Bacterial Vaginosis:

Assessment of the Performance of the Aptima Bacterial Vaginosis Assay Over a 3-Month Period in a French Hospital

Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge. BV represents a dysbiosis with the acquisition of a diverse community of anaerobic bacteria and a reduction in lactobacilli burden. Our objective was to evaluate the Aptima BV assay kit for the diagnosis of BV. From May to August 2019, we enrolled outpatients and inpatients, including nonpregnant women above 18 with vaginosis symptoms, consulting at Nantes University hospital. The Aptima BV assay measures the loads of Gardnerella vaginalis, Atopobium vaginae, and Lactobacillus species in relation to overall bacterial load. The Aptima BV assay was compared to Nugent scoring (NS). A total of 456 women were enrolled, and 347 patients met the inclusion criteria with data available for the analysis. NS was used to classify the samples and 144 (41.5%) samples were classified as normal (NS = 0-3), 45 (13%) as BV (NS = 7-10), 38 (11%) presented an intermediate vaginal microbiota (3 < NS < 7), 79 (22.7%) had various bacteria (excluding vaginal flora), 29 (8.3%) had insufficient bacterial density, and 12 (3.5%) had a predominance of yeasts. The Aptima BV kit displayed a sensitivity of 91.1% and specificity of 94.4% with a positive predictive value (PPV) of 83.7% and a negative predictive (NPV) value of 97.1%. The results of this monocentric retrospective study show that Aptima BV kit has a good diagnostic correlation compared to standard of care for dysbiotic diagnosis cases. IMPORTANCE The possibility exists of the involvement of a new molecular test in the routine algorithm of bacterial vaginosis diagnosis in microbiology laboratories. This manuscript reports on our experience, and we propose an organization combining Nugent scoring and molecular testing, especially for intermediate Nugent scores.

No. 211-Screening and Management of Bacterial Vaginosis in Pregnancy

OBJECTIVE

To review the evidence and provide recommendations on screening for and management of bacterial vaginosis in pregnancy.

OPTIONS

The clinical practice options considered in formulating the guideline.

OUTCOMES

Outcomes evaluated include antibiotic treatment efficacy and cure rates, and the influence of the treatment of bacterial vaginosis on the rates of adverse pregnancy outcomes such as preterm labour and delivery and preterm premature rupture of membranes.

EVIDENCE

Medline, EMBASE, CINAHL, and Cochrane databases were searched for articles, published in English before the end of June 2007 on the topic of bacterial vaginosis in pregnancy.

VALUES

The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Guideline implementation will assist the practitioner in developing an approach to the diagnosis and treatment of bacterial vaginosis in pregnant women. Patients will benefit from appropriate management of this condition.

VALIDATION

These guidelines have been prepared by the Infectious Diseases Committee of the SOGC, and approved by the Executive and Council of the SOGC.

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada.

RECOMMENDATIONS

There is currently no consensus as to whether to screen for or treat bacterial vaginosis in the general pregnant population in order to prevent adverse outcomes, such as preterm birth.

Bacterial vaginosis: An insight into the prevalence, alternative treatments regimen and it's associated resistance patterns

Bacterial Vaginosis (BV) is a complex polymicrobial infection of vagina that shifts the paradigms of vaginal flora from lactobacilli to opportunistic pathogens. BV is catagorized by greyish white discharge, pH greater than 4.5. It results in the preterm labor, abortion, pelvic inflammatory disorders, post cesarean infections. BV is associated with Sexually Transmitted Diseases (STDs) or immune deficiency disorders like Human Immunodeficiency Virus, Human Papilloma Virus, Herpes Simplex Virus 1 and 2, and Neisseria gonorrhoeae. The prevalence rate is about 21.2 million (29.2%) worldwide. BV is more frequent in black females as compared to white females, independent of geographical distribution. Globally, BV is treated with the current recommended antibiotic therapy including Metronidazole and Clindamycin. The recurrence rates are 76% and occur within 06 months of treatment due to antibiotic resistance against pathogenic bacteria and their biofilms. The antibiotic resistance is a global health issue which directs the attentions towards other treatments. One of these is the treatment of sex partners, thus helping to stop the recurrence rates in females. However, this method does not show any positive results. Probiotic therapy is an incorporation of Lactobacilli orally or intravaginally for the recolonization of healthy microbes. This therapy has exhibited promising results but some studies revealed that Probiotic therapy does not control the recurrence rate. The other methods are in trials period and none of them are used clinically or commercially available for the treatment. The thermoplastic polyurethane (TPU) intravaginal rings contain lactic acid and metronidazole showed promising results in trials of BV treatment. The vaginal acidifiers are used as an alternative method to maintain the vaginal pH but the process of douching is a major limitation. The activated charcoal is used to treat BV patients in clinical trials showed decrease in the pH with only 3.1% loss of lactobacilli. Phage therapy is a reemerging field to overcome the bacterial resistance. They are host specific and easier to handle. They can be used naturally, synthetically; phage cocktails and phage-antibiotics combination can be used. Phages show auspicious results for the treatment of bacterial infections as compared to antibiotics as they also treat biofilms. This is one of the promising therapy in future to treat infections with no side effects. Phage therapy can be used in pharmaceuticals according to Food and Drug Administration (FDA) guidelines. Taken together, it is suggested that large funding is required by pharmaceutical sector or government for further investigation of bacteriophages to be used against BV pathogenesis.

Secnidazole: next-generation antimicrobial agent for bacterial vaginosis treatment

Secnidazole is a next-generation 5-nitroimidazole approved for more than three decades in Europe, Asia, South America and Africa and recently in the USA as a single-dose (2 g) treatment of bacterial vaginosis (BV). Secnidazole is characterized by potent in vitro antimicrobial activity against BV-associated pathogens, as well as prolonged terminal elimination half-life and systemic exposure. These characteristics form the basis of effective and safe treatment of BV with a 2-g single-dose secnidazole regimen, which was recently confirmed in double-blind, placebo-controlled clinical trials conducted in the USA. The option to treat BV with single-dose secnidazole not only cures the primary infection but also may diminish risks of serious sequelae of untreated or undertreated infection.

Is bacterial vaginosis a disease?

Bacterial vaginosis (BV) has been described as a disease, a disorder, a vaginal inflammation, an infection, a microbial dysbiosis, a condition, and in some women, a normal situation. In order to fit the definition of a disease, BV would have to be a disorder of function that produces specific signs or symptoms or affects the vagina in an aberrant way. Yet, there is little consistency in patients reporting signs and symptoms when BV is diagnosed, nor the appearance of aberrations to the vagina. If BV is not a disease, there are implications for its management and coverage of treatment costs, and for the conclusions drawn in a multitude of previous studies. It is time for BV to be redefined and for the various subsets to be given a separate terminology with specific methods of diagnosis and appropriate treatment and preventive strategies.

Vulvovaginite : Dépistage et prise en charge de la trichomonase, de la candidose vulvovaginale et de la vaginose bactérienne

OBJECTIF

Analyser les données probantes et formuler des recommandations quant au dépistage et à la prise en charge de la candidose vulvovaginale, de la trichomonase et de la vaginose bactérienne.

ISSUES

Parmi les issues évaluées, on trouve l'efficacité de l'antibiothérapie, les taux de guérison en ce qui concerne les infections simples et compliquées, et les implications de ces pathologies pendant la grossesse. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE, EMBASE, CINAHL et The Cochrane Library en juin 2013 au moyen d'un vocabulaire contrôlé (p. ex. « vaginitis », « trichomoniasis », « vaginal candidiasis ») et de mots clés (p. ex. « bacterial vaginosis », « yeast », « candidiasis », « trichomonas vaginalis », « trichomoniasis », « vaginitis », « treatment ») appropriés. Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date, mais les résultats ont été limités aux documents rédigés en anglais ou en français. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en mai 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

VALEURS

La qualité des résultats est évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Identifying metabolite markers for preterm birth in cervicovaginal fluid by magnetic resonance spectroscopy

INTRODUCTION

Preterm birth (PTB) may be preceded by changes in the vaginal microflora and metabolite profiles.

OBJECTIVES

We sought to characterise the metabolite profile of cervicovaginal fluid (CVF) of pregnant women by 1H NMR spectroscopy, and assess their predictive value for PTB.

METHODS

A pair of high-vaginal swabs was obtained from pregnant women with no evidence of clinical infection and grouped as follows: asymptomatic low risk (ALR) women with no previous history of PTB, assessed at 20-22 gestational weeks, g.w., n = 83; asymptomatic high risk (AHR) women with a previous history of PTB, assessed at both 20-22 g.w., n = 71, and 26-28 g.w., n = 58; and women presenting with symptoms of preterm labor (PTL) (SYM), assessed at 24-36 g.w., n = 65. Vaginal secretions were dissolved in phosphate buffered saline and scanned with a 9.4 T NMR spectrometer.

RESULTS

Six metabolites (lactate, alanine, acetate, glutamine/glutamate, succinate and glucose) were analysed. In all study cohorts vaginal pH correlated with lactate integral (r = -0.62, p < 0.0001). Lactate integrals were higher in the term ALR compared to the AHR (20-22 g.w.) women (p = 0.003). Acetate integrals were higher in the preterm versus term women for the AHR (20-22 g.w.) (p = 0.048) and SYM (p = 0.003) groups; and was predictive of PTB < 37 g.w. (AUC 0.78; 95 % CI 0.61-0.95), and delivery within 2 weeks of the index assessment (AUC 0.84; 95 % CI 0.64-1) in the SYM women, whilst other metabolites were not.

CONCLUSION

High CVF acetate integral of women with symptoms of PTL appears predictive of preterm delivery, as well as delivery within 2 weeks of presentation.

Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis

OBJECTIVE

To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.

OUTCOMES

OUTCOMES evaluated include the efficacy of antibiotic treatment, cure rates for simple and complicated infections, and the implications of these conditions in pregnancy.

EVIDENCE

Published literature was retrieved through searches of MEDLINE, EMBASE, CINAHL, and The Cochrane Library in June 2013 using appropriate controlled vocabulary (e.g., vaginitis, trichomoniasis, vaginal candidiasis) and key words (bacterial vaginosis, yeast, candidiasis, trichomonas vaginalis, trichomoniasis, vaginitis, treatment). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to May 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I) 2. Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2) 3. Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2) 4. Cure rates are equal at up to 88% for trichomoniasis treated with oral metronidazole 2 g once or 500 mg twice daily for 7 days. Partner treatment, even without screening, enhances cure rates. (I-A) 5. Current evidence of the efficacy of alternative therapies for bacterial vaginosis (probiotics, vitamin C) is limited. (I) Recommendations 1. Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A) 2. Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A) 3. Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D) 4. Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A) 5. In pregnancy, treatment of symptomatic Trichomonas vaginalis with oral metronidazole is warranted for the prevention of preterm birth. (I-A) 6. Bacterial vaginosis should be diagnosed using either clinical (Amsel's) or laboratory (Gram stain with objective scoring system) criteria. (II-2A) 7. Symptomatic bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days. Alternatives include vaginal metronidazole gel and oral or vaginal clindamycin cream. (I-A) 8. Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences. (I-A).

Does midtrimester Nugent score or high vaginal pH predict gestational age at delivery in women at risk for recurrent preterm birth?

OBJECTIVE

To estimate whether bacterial vaginosis, as defined by either Nugent score or vaginal pH, predicts gestational age at delivery in women at risk for recurrent preterm birth.

STUDY DESIGN

Planned secondary analysis of a randomized cerclage trial in women with prior spontaneous preterm birth 17⁰(/)⁷-33⁶(/)⁷ weeks. Vaginal Gram stain and pH were collected at the initial study visit. Women not assigned to cerclage, either because they did not experience cervical shortening <25 mm or because they were randomly assigned to no cerclage, were studied.

RESULTS

Seven hundred eighty-six women had complete delivery gestational age, Gram stain, and pH results. The diagnosis of bacterial vaginosis by either Nugent score ≥ 7 or by pH ≥ 5 was not associated with earlier birth.

CONCLUSION

The presence of bacterial vaginosis at 16-21⁶(/)⁷ weeks does not predict gestational age at birth in women at risk for recurrent preterm birth.

Detection of Ureaplasma biovars and polymerase chain reaction-based subtyping of Ureaplasma parvum in women with or without symptoms of genital infections

Ureaplasma parvum colonises human mucosal surfaces, primarily in the urogenital and respiratory tracts, causing a wide spectrum of diseases, from non-gonococcal urethritis to pneumonitis in immunocompromised hosts. Although the basis for these diverse clinical outcomes is not yet understood, it has been suggested that only certain strains of these micro-organisms are disease-associated. The aim of this study was to determine the distribution of Ureaplasma biovars and U. parvum serovars and to estimate their possible association with age, absence of lactobacilli, clinical symptoms and antibiotic resistance. DNA was extracted by endocervical, vaginal and urethral samples obtained from 158 women positive for U. urealyticum by culture and were biotyped by polymerase chain reaction (PCR) targeting the multiple-banded gene. Parvo biovar (biovar 1) was found in 136 (86%) and T960 biovar (biovar 2) in 22 (14%) patients. Among the different serovars of U. parvum, we found that serovar 3/14 was present maximally in the 21-25-year-old age group, while T960 biovar was distributed with quite similar frequency in women of 26-30 and >40 years of age. In this study, U. parvum serovar 3/14 and T960 biovar were found to be significantly associated with symptomatic patients and a loss of lactobacilli, while, on the contrary, U. parvum serovar 6 was significantly correlated with asymptomatic women and normal vaginal flora. The most active antibiotic for the majority of Ureaplasma isolates was tetracycline. These preliminary data show the possibility of distinguishing between the more or less virulent strains of Ureaplasma, with important consequences for therapeutic treatment.

Screening and management of bacterial vaginosis in pregnancy

OBJECTIVE

To review the evidence and provide recommendations on screening for and management of bacterial vaginosis in pregnancy.

OPTIONS

The clinical practice options considered in formulating the guideline.

OUTCOMES

Outcomes evaluated include antibiotic treatment efficacy and cure rates, and the influence of the treatment of bacterial vaginosis on the rates of adverse pregnancy outcomes such as preterm labour and delivery and preterm premature rupture of membranes.

EVIDENCE

Medline, EMBASE, CINAHL, and Cochrane databases were searched for articles, published in English before the end of June 2007 on the topic of bacterial vaginosis in pregnancy.

VALUES

The evidence obtained was rated using the criteria developed by the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Guideline implementation will assist the practitioner in developing an approach to the diagnosis and treatment of bacterial vaginosis in pregnant women. Patients will benefit from appropriate management of this condition.

VALIDATION

These guidelines have been prepared by the Infectious Diseases Committee of the SOGC, and approved by the Executive and Council of the SOGC.

SPONSORS

The Society of Obstetricians and Gynaecologists of Canada.

Atopobium vaginae triggers an innate immune response in an in vitro model of bacterial vaginosis

Bacterial vaginosis is the most common vaginal disorder among women of reproductive age. The pathogenesis of bacterial vaginosis is poorly understood, but is defined by a transition in the vaginal flora from the predominant Lactobacillus species to other bacterial species such as Atopobium vaginae and Gardnerella vaginalis. This change is associated with an increase in vaginal cytokine secretion. We hypothesize that vaginal epithelial cells respond to bacterial vaginosis-associated bacteria by triggering an innate immune response. We observed that vaginal epithelial cells secreted interleukin-6 and interleukin-8 in response to Atopobium vaginae and Gardnerella vaginalis, but not to Lactobacillus crispatus. Atopobium vaginae induced increased levels of interleukin-6 and interleukin-8 transcripts, as well as increased transcripts for the antimicrobial peptide beta-defensin 4. This innate immune response required live bacteria capable of protein synthesis in direct contact with vaginal epithelial cells. The response of vaginal epithelial cells was mediated by Toll-like receptor 2, required the adaptor protein MyD88, and involved activation of the NFkappaB signaling pathway. These results suggest that Atopobium vaginae stimulates an innate immune response from vaginal epithelial cells, leading to localized cytokine and defensin production, and possibly contributes to the pathogenesis of bacterial vaginosis.

Mycoplasmas and ureaplasmas as neonatal pathogens

The genital mycoplasmas represent a complex and unique group of microorganisms that have been associated with a wide array of infectious diseases in adults and infants. The lack of conclusive knowledge regarding the pathogenic potential of Mycoplasma and Ureaplasma spp. in many conditions is due to a general unfamiliarity of physicians and microbiology laboratories with their fastidious growth requirements, leading to difficulty in their detection; their high prevalence in healthy persons; the poor design of research studies attempting to base association with disease on the mere presence of the organisms in the lower urogenital tract; the failure to consider multifactorial aspects of diseases; and considering these genital mycoplasmas only as a last resort. The situation is now changing because of a greater appreciation of the genital mycoplasmas as perinatal pathogens and improvements in laboratory detection, particularly with regard to the development of powerful molecular nucleic acid amplification tests. This review summarizes the epidemiology of genital mycoplasmas as causes of neonatal infections and premature birth; evidence linking ureaplasmas with bronchopulmonary dysplasia; recent changes in the taxonomy of the genus Ureaplasma; the neonatal host response to mycoplasma and ureaplasma infections; advances in laboratory detection, including molecular methods; and therapeutic considerations for treatment of systemic diseases.

Bacterial vaginosis in pregnancy: diagnosis, screening, and management

Bacterial vaginosis is the most common lower genital tract infection among women of reproductive age. It has been associated with a number of significant obstetric and gynecologic complications, such as preterm labor and delivery, preterm premature rupture of membranes, spontaneous abortion, chorioamnionitis, postpartum endometritis, postcesarean delivery wound infections, postsurgical infections, and subclinical pelvic inflammatory disease. This article focuses on bacterial vaginosis in pregnancy, and discusses approaches to diagnosis, screening, and management.

Successful treatment of bacterial vaginosis with a policarbophil-carbopol acidic vaginal gel: results from a randomised double-blind, placebo-controlled trial

OBJECTIVE

We evaluated the efficacy of a mucoadhesive vaginal gel (MVG, Miphil) with acidic-buffering properties in bacterial vaginosis (BV).

STUDY DESIGN

Double-blind, placebo-controlled, 12-week trial.

SUBJECTS

A total of 45 non-pregnant women with BV were enrolled in the trial. Patients were treated with MVG 2.5 g or the corresponding placebo (P) daily for the first week and then every 3 days for the following 5 weeks (treatment phase) in a 2:1 ratio. All patients were followed for an additional 6 weeks without treatments (follow-up phase). Clinical cure was defined as absence of vaginal discharge, vaginal pH <4.5, a negative fish odour test and a Nugent score <7.

RESULTS

At week 6, 28 out of 30 women (93%) in the MVG group were clinically cured in comparison with only 1 out of 15 (6%) in the P group (P=0.0001). At week 12, 86% of MVG treated women remained cured in comparison with 8% in P group (P=0.0001). At baseline, the vaginal pH was 6.1+/-0.7 in the MVG and 5.5+/-0.7 in the P group. Vaginal pH significantly (P=0.003) decreased to 4.3+/-0.3 in the MVG group. In P group non-significant modifications of vaginal pH were observed (5.1+/-0.5).

CONCLUSION

Our results demonstrated that this MVG is an effective treatment of BV.

Inhibition of vaginal lactobacilli by a bacteriocin-like inhibitor produced by Enterococcus faecium 62-6: potential significance for bacterial vaginosis

Objective: Bacterial vaginosis (BV) is characterized by a shift in vaginal tract ecology, which includes a decrease in the concentration and/or prevalence of facultative lactobacilli. Currently, mechanisms which could account for the disappearance of lactobacilli are not well understood. The objective of this study was to determine whether vaginal streptococci/enterococci can produce bacteriocin-like inhibitors antagonistic to vaginal lactobacilli.

Methods: Seventy strains of vaginal streptococci or enterococci were tested for antagonistic activities against vaginal lactobacilli using the deferred antagonism technique.

Results: One strain, Enterococcus faecium 62-6, which strongly inhibited growth of lactobacilli was selected for further characterization. The spectrum of inhibitory activity of strain 62-6 included Gram-positive organisms from the vaginal environment, although native lactobacilli from the same host were resistant to inhibitor action. Following growth inMRSbroth the strain 62-6 inhibitor was shown to be heat- (100℃, 30 minutes), cold- (4℃, less than 114 days) and pH- (4–7) stable. The sensitivity of inhibitor-containing supernatants to pepsin and α-chymotrypsin suggested an essential proteinaceous component. The inhibitor was sensitive to lipase but resistant to lysozyme. Dialysis of inhibitor-containing culture supernatants suggested a molecular mass greater than 12 000 Da. All physicochemical properties were consistent with its classification as a bacteriocin-like inhibitor. Kinetic assays demonstrated a sharp onset of inhibitor production coinciding with a concentration of 62-6 of 10⁷ cfu/ml, suggesting that production may be regulated by quorum sensing.

Conclusions: These results may have clinical significance as a novel mechanism to account for the decline of vaginal Lactobacillus populations and contribute to both the establishment and recurrence of BV.

Diagnosis of Bacterial Vaginosis During Pregnancy

OBJECTIVE.: To evaluate the sensitivity and specificity of the score and each one of the clinical criteria (pH, potassium hydroxide (KOH) test for amines, and clue cells) in relation to the Amsel's method. MATERIALS AND METHODS.: One hundred ninety vaginal exudates from pregnant women were studied from April to August 1997. The patients were examined in the Lower Genital Tract and Colposcopy Clinics of the Obstetrics Division at the University Hospital de Clínicas at the University of Buenos Aires, Argentina.The diagnosis of bacterial vaginosis (BV) was made by the presence of three or more of the following criteria: homogeneous vaginal discharge, pH >/= 4.5, positive KOH test for amines, and microscopic presence of clue cells. We also used the microscopic observation of coccobacilli forms in Gram stain (Nugent's method), diagnosing BV with a score >/= 7. RESULTS.: Nugent's method showed a sensitivity of 97% and specificity of 98%. The presence of clue cells showed a sensitivity of 92% and specificity of 97%. The sensitivity of the pH and KOH test for amines was 87% and 81%, whereas the respective specificity was 45% and 99%. CONCLUSIONS.: Because Nugent's method showed a very good specificity and sensitivity, it can be used as another method in the diagnosis of BV. The presence of clue cells diagnosed BV with better sensitivity and specificity than the other clinical criteria. In this way, we recommend the microscopic exam by Gram stain, using Nugent's method or the presence of clue cells, for diagnosing BV.

Preventing Adverse Sequelae of Bacterial Vaginosis

BACKGROUND

The cause of bacterial vaginosis remains poorly understood. Recent evidence strengthens the association between bacterial vaginosis and serious medical complications.

GOAL

To review the evidence linking bacterial vaginosis with adverse pregnancy outcomes, complications after gynecologic procedures, and HIV infection, and to identify prevention strategies.

METHODS

In March 1999, the Centers for Disease Control and Prevention organized a conference to accomplish this goal.

RESULTS

Better understanding is needed concerning the etiology, epidemiology, and natural history of bacterial vaginosis. More efficacious treatment of bacterial vaginosis and strategies to reduce maternal complications associated with bacterial vaginosis, such as premature rupture of the fetal membranes, chorioamnionitis, premature labor and delivery, postdelivery endometritis, and postpartum infant complications should be developed. Recent evidence shows that screening and treatment of bacterial vaginosis before abortion reduces postabortion pelvic inflammatory disease, and that anaerobic coverage during hysterectomy reduces postoperative complications. Better understanding concerning the relation of bacterial vaginosis to acquisition of sexually transmitted diseases and HIV infection are needed as well as possible prevention strategies.

CONCLUSIONS

A national prevention effort should be guided by the results of research that addresses current knowledge gaps.

Bacterial vaginosis

Bacterial vaginosis represents a unique upheaval of the complex vaginal bacterial flora with disappearance of lactobacilli and overgrowth of Gardnerella vaginalis and resident anaerobic vaginal bacteria. Little progress has occurred in identifying causal factors, although the pathophysiology of this syndrome is better understood. Although symptoms are easily recognizable, obstetric and gynecologic complications continue to increase in number. Bacterial vaginosis is far more than a nuisance infection. Problems with diagnosis continue to dominate clinical practice, although new tests have been introduced. Therapeutic options have increased, although recurrent disease remains common, and management of this common complication constitutes a major challenge.

Systemic absorption of clindamycin after intravaginal administration of clindamycin phosphate ovule or cream

The absolute bioavailability of clindamycin phosphate vaginal ovule with comparison to a reference treatment of clindamycin phosphate sterile solution, as well as the relative bioavailability of the ovule compared to clindamycin phosphate vaginal cream, was evaluated in 12 healthy adult female volunteers. Subjects were randomly assigned to receive either the ovule or cream formulation intravaginally for 3 consecutive days during the two-way crossover portion of the study. During a third treatment period, all subjects received 100 mg of clindamycin as a 4-minute intravenous infusion of clindamycin phosphate sterile solution (10 mg/mL). Clindamycin concentrations in serum were assayed by a high-performance liquid chromatography method with detection by mass spectrometry. Pharmacokinetic analyses of the serum data indicated low systemic absorption of clindamycin from the vaginal cream (about 4%), consistent with results of previous bioavailability studies. Following intravaginal administration of the clindamycin phosphate ovule, systemic absorption averaged 30%, which was approximately sevenfold greater than after dosing with the vaginal cream. The higher drug absorption for the ovule may be related to differences in formulation effects on the vaginal membrane. Nevertheless, systemic exposure to clindamycin from the ovule is still considerably lower than from a therapeutic oral dose.

Vulvovaginitis in healthy women

Vulvovaginal symptoms are extremely common and result in millions of visits to practitioners' offices, STD clinics and emergency rooms. Vaginal infections or infectious vaginitis is responsible for only a minority of symptoms and is readily diagnosed. Epidemiology, diagnosis and therapy of vaginitis is reviewed.

The role of bacterial vaginosis in infection after major gynecologic surgery

PURPOSE

Previous studies have reported an association between bacterial vaginosis (BV) and postoperative fever and infection. This prospective study investigated whether the intermediate or definite stages of BV are risk factors for postoperative infection after major gynecologic surgery.

METHODS

Vaginal cultures were obtained preoperatively from 175 women undergoing gynecologic surgery. The diagnostic criteria for BV were based on Nugent's standardized method of Gram stain interpretation. Postoperative fever was defined as at least one temperature equal to 101.0 degrees F or greater, or two or more temperatures more than 6 hours apart equal to 100.4 degrees F or greater.

RESULTS

Thirty-six percent of the positive-BV group developed a postoperative fever, compared with 20% of the Lactobacillus-predominant group and 12% of the intermediate-BV group (P = 0.017). The differences between the positive-BV group and the Lactobacillus-predominant group, and between the positive-BV group and the intermediate-BV group, with respect to postoperative fever, were statistically significant (P = 0.045 and P = 0.007, respectively). The difference between the intermediate-BV group and the Lactobacillus-predominant group was not statistically significant (P = 0.28).

CONCLUSIONS

Although the association between BV and postoperative febrile morbidity could be a spurious result of confounding with other variables, it may be prudent for the surgeon to identify patients with BV and treat them preoperatively.

A commensal symbiosis between Prevotella bivia and Peptostreptococcus anaerobius involves amino acids: potential significance to the pathogenesis of bacterial vaginosis

In both batch and continuous culture, Peptostreptococcus anaerobius was able to grow in vaginal defined medium with Prevotella bivia, but not in pure culture. Growth of P. anaerobius was increased by 238% (P < 0.001) in peptone-supplemented vaginal defined medium conditioned by prior growth of P. bivia. Analysis of P. bivia culture supernatants showed a net accumulation of amino acids and subsequent growth of P. anaerobius in the conditioned supernatants resulted generally in amino acid utilization. Supplementation of peptone-supplemented vaginal defined medium with amino acids in concentrations similar to those available after prior growth with P. bivia were growth-stimulatory (246%, P=0.006) for P. anaerobius. Increased availability of amino acids by P. bivia is proposed as a mechanism to support the observed in vitro commensal symbiosis between P. bivia and P. anaerobius.

Bacterial vaginosis: association with adverse pregnancy outcome

Bacterial vaginosis is the most common lower genital tract infection encountered among women of reproductive age. This condition can best be considered as a vaginal syndrome associated with an alteration of the normal vaginal flora rather than an infection specific to any one microorganism. Bacterial vaginosis is a clinical condition with a complex microbiology that is characterized by a reduced concentration of a normally abundant Lactobacillus species along with high concentrations of gram-negative and anaerobic bacteria, particularly, Gardnerella vaginalis and Mobiluncus, Bacteroides, Prevotella, and Mycoplasma species. The exact make up of the microorganisms and their relative concentration vary among women who have this condition. Although it was previously regarded as a harmless condition, recent work has linked bacterial vaginosis to numerous upper genital tract complications such as preterm labor and preterm delivery, preterm premature rupture of the membranes, chorioamnionitis, and postpartum endometritis. The findings from recent prospective randomized trials suggest that treatment of bacterial vaginosis in certain women who are at high risk for preterm delivery decreases the rate of preterm birth.

The relationship between bacterial vaginosis and preterm birth. A review

Bacterial vaginosis is currently the most prevalent form of vaginal infection of reproductive age women. The etiology of bacterial vaginosis has not yet been defined. However, clear criteria for diagnosis and treatment have been established in the absence as well as in presence of pregnancy. Recent data show an association between bacterial vaginosis and preterm labor and delivery. This review outlines the role of bacterial vaginosis in preterm birth and other pregnancy complications.

Bacterial vaginosis-associated microflora and effects of topical intravaginal clindamycin

OBJECTIVES

The goals of this study were as follows: (1) to further define the microbiologic characteristics of bacterial vaginosis in nonpregnant women, (2) to evaluate the in vivo activity of topical intravaginal clindamycin and reference this activity to clinical cure, and (3) to evaluate for clindamycin-related emergence of species.

STUDY DESIGN

Vaginal microflora was identified and quantified from 33 women with bacterial vaginosis at enrollment and 4 to 7 days after treatment with placebo or three different dosages of clindamycin administered twice daily for 5 days in a double-blind, randomized trial.

RESULTS

Clindamycin eradicated and/or decreased counts of major bacterial vaginosis-associated microflora such as Gardnerella, gram-negative and gram-positive anaerobes, and Mycoplasma hominis; this was correlated with cure in 22 of 24 (92%) women. Altered flora (nonlactobacilli) among some of the women who received clindamycin appeared to be transient and without apparent adverse effects.

CONCLUSION

Microbial (and clinical) results support use of clindamycin as effective treatment of bacterial vaginosis.

The microbiology of bacterial vaginosis

A group of microorganisms are present concurrently in high concentrations in the vaginas of women with bacterial vaginosis. The major members of the group are Gardnerella vaginalis, anaerobic gram-negative rods belonging to the genera Prevotella, Porphyromonas and Bacteroides, Peptostreptococcus species, Mycoplasma hominis, Ureaplasma urealyticum, and often Mobiluncus species. Facultative species of Lactobacillus are present in lower concentrations and are less prevalent in bacterial vaginosis than in women with a normal vaginal examination. The exact microbe(s) responsible for bacterial vaginosis is unknown whether among the organisms listed above or an unknown agent. The high concentrations of anaerobic gram-negative rods, peptostreptococci, and other opportunistic pathogens in the lower genital tract place women with bacterial vaginosis at increased risk for genital infections and adverse pregnancy outcomes.

Pelvic inflammatory disease. Current diagnostic criteria and treatment guidelines

Pelvic inflammatory disease (PID) is a common infection in women of reproductive age. PID is actually a spectrum of disease, beginning with cervicitis and progressing to endometritis and eventually salpingitis. Sequelae include ectopic pregnancy, infertility, chronic pelvic pain, hydrosalpinx, and tubo-ovarian abscess. Neisseria gonorrhoeae and Chlamydia trachomatis are the primary causes of PID. Chlamydial infection may be asymptomatic, and the resulting salpingitis is often referred to as "silent PID." Polymicrobial infection with other organisms (eg, anaerobes, facultative aerobes) may be initiated by gonorrhea, chlamydial infection, or both. Early recognition of infection, prompt institution of appropriate antibiotic therapy, and proper follow-up are important to prevent the sequelae of PID. Patient education is essential to reduce the incidence of PID.

Vaginal infection and preterm labour

OBJECTIVE

To study the vaginal flora of women in preterm labour (PTL) and determine whether the presence of specific vaginal microflora is significantly associated with onset of PTL.

DESIGN

A comprehensive prospective study of the vaginal microflora of women in early labour comparing women in PTL with term controls. Microbiological assessment included cultures for aerobic and anaerobic bacteria, yeasts, genital mycoplasmas and Trichomonas vaginalis. Multiple logistic regression analysis was used to adjust for confounding obstetric and demographic variables.

SETTING

The Queen Victoria Hospital, Adelaide.

PATIENTS

428 Women in PTL compared to 568 women in labour at term.

MAIN OUTCOME MEASURE

PTL and preterm prelabour rupture of membranes (PPROM) in relation to specific vaginal microflora.

RESULTS

After multiple logistic regression analysis, two distinct bacteriological groupings were associated with PTL less than 37 weeks gestation, namely, the bacterial vaginosis group of organisms, Gardnerella vaginalis and Bacteroides spp., and a group of enteropharyngeal organisms, E. coli, Klebsiella spp., Haemophilus spp. and S. aureus. G. vaginalis was found in 12% of women in PTL compared to 6% at term [regression odds ratio (ROR) 1.8, 95% confidence intervals (CI) 1.1-3.1] whereas Bacteroides spp. were detected in 45% of women in PTL compared with 35% at term (ROR 1.6, CI 1.2-2.1). The prevalence of G. vaginalis (17%) and Bacteroides spp. (50%) was even higher in women in PTL less than 34 weeks gestation. The enteropharyngeal group of organisms were more commonly present in women in PTL less than 37 weeks (E. coli 10% vs 6%, ROR 1.4, CI 0.8-2.4; Klebsiella spp. 3% vs less than 1%, ROR 5.4, CI 1.1-26.7; Haemophilus spp. 2% vs less than 1%, ROR 5.5, CI 1.1-28.6; S. aureus 6% vs 4%, ROR 1.8, CI 0.9-3.3) and were isolated even more frequently in women in PTL less than 34 weeks (E. coli 15%; Klebsiella spp. 4%; S. aureus 7%). Bacteroides spp., Klebsiella spp., and Haemophilus spp. were all found to be associated with PPROM.

CONCLUSION

There are two distinct bacteriological groupings commonly found in women in PTL, especially in PTL less than 34 weeks gestation. These bacteriological groups are women with bacterial vaginosis in pregnancy and women who demonstrate enteropharyngeal bacteria in the vagina.

The detection of Gardnerella vaginalis DNA sequences in uncultured clinical specimens with cloned G. vaginalis DNA as probes

Cloned Gardnerella vaginalis DNA were selected from a plasmid DNA library constructed with partially restriction endonuclease Hind III-digested genomic DNA of G. vaginalis to serve as DNA probe in detecting G. vaginalis. The level of detection was determined to be approximately 10,000 cells by slot-blot DNA hybridization. This probe DNA will not cross-hybridize with DNA of a number of non-Gardnerella micro-organisms commonly found in female genital tract. The DNA probe-based hybridization test may become a useful tool for the identification of G. vaginalis in uncultured clinical specimens.