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Mitchell CM. Assessment and Treatment of Vaginitis. Obstet Gynecol 2024:00006250-990000000-01111. [PMID: 38991218 DOI: 10.1097/aog.0000000000005673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/11/2024] [Indexed: 07/13/2024]
Abstract
Vaginitis is the presenting symptom at millions of office visits each year in the United States. Although treatment of sporadic cases is often straightforward, recurrent cases present both diagnostic and treatment challenges. Molecular diagnostic tests are likely superior to in-office microscopy for most clinicians and most cases. In both recurrent bacterial vaginosis and recurrent vulvovaginal candidiasis, national treatment guidelines recommend an extended treatment duration with one of the first-line agents. In cases in which such treatment is not successful, vaginal boric acid is likely the cheapest and easiest alternative option. New antifungal medications offer additional but limited treatment options. Probiotics are not recommended for prevention of vulvovaginal candidiasis; however, vaginal products containing Lactobacillus crispatus may have promise for recurrent bacterial vaginosis. Trichomoniasis should be treated with a 1-week course of metronidazole; this is the only sexually transmitted infection for which treatment recommendations vary by sex. In cases in which patients do not respond to initial treatment, the diagnosis should be reconsidered, and other potential causes such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia should be considered.
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Affiliation(s)
- Caroline M Mitchell
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and the Vulvovaginal Disorders Program, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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Duarte G, Linhares IM, Kreitchmann R, Tristão ADR, Traina E, Canti I, Takimura M, Andrade JQ. Vulvovaginitis in pregnant women. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-FPS03. [PMID: 38765512 PMCID: PMC11075393 DOI: 10.61622/rbgo/2024fps03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
• The balanced vaginal microbiome is the main factor defending the vaginal environment against infections. Lactobacilli play a key role in this regard, maintaining the vaginal pH within the normal range (3.8 to 4.5). •Hormonal and immune adaptations resulting from pregnancy influence changes in the vaginal microbiome during pregnancy. •An altered vaginal microbiome predisposes to human immunodeficiency virus (HIV) infection. •Bacterial vaginosis is the main clinical expression of an imbalanced vaginal microbiome. •Vulvovaginal candidiasis depends more on the host's conditions than on the etiological agent. •Trichomonas vaginalis is a protozoan transmitted during sexual intercourse. •The use of probiotics is not approved for use in pregnant women.
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Affiliation(s)
- Geraldo Duarte
- Faculdade de Medicina de Ribeirão Preto Universidade de São Paulo Ribeirão PretoSP Brazil Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Iara Moreno Linhares
- Faculdade de Medicina Universidade de São Paulo São PauloSP Brazil Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Regis Kreitchmann
- Universidade Federal de Ciências da Saúde de Porto Alegre Porto AlegreRS Brazil Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Andréa da Rocha Tristão
- Faculdade de Medicina de Botucatu Universidade Estadual Paulista BotucatuSP Brazil Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Evelyn Traina
- Escola Paulista de Medicina Universidade Federal de São Paulo São PauloSP Brazil Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Ivete Canti
- Universidade Federal do Rio Grande do Sul Porto AlegreRS Brazil Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcos Takimura
- Universidade Positivo CuritibaPR Brazil Universidade Positivo, Curitiba, PR, Brazil
| | - Joelma Queiroz Andrade
- Faculdade de Medicina Universidade de São Paulo São PauloSP Brazil Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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3
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Carter KA, France MT, Rutt L, Bilski L, Martinez-Greiwe S, Regan M, Brotman RM, Ravel J. Sexual transmission of urogenital bacteria: whole metagenome sequencing evidence from a sexual network study. mSphere 2024; 9:e0003024. [PMID: 38358269 PMCID: PMC10964427 DOI: 10.1128/msphere.00030-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 02/16/2024] Open
Abstract
Sexual transmission of the urogenital microbiota may contribute to adverse sexual and reproductive health outcomes. The extent of sexual transmission of the urogenital microbiota is unclear as prior studies largely investigated specific pathogens. We used epidemiologic data and whole metagenome sequencing to characterize urogenital microbiota strain concordance between participants of a sexual network study. Individuals who screened positive for genital Chlamydia trachomatis were enrolled and referred their sexual contacts from the prior 60-180 days. Snowball recruitment of sexual contacts continued for up to four waves. Vaginal swabs and penile urethral swabs were collected for whole metagenome sequencing. We evaluated bacterial strain concordance using inStrain and network analysis. We defined concordance as ≥99.99% average nucleotide identity over ≥50% shared coverage; we defined putative sexual transmission as concordance between sexual contacts with <5 single-nucleotide polymorphisms per megabase. Of 138 participants, 74 (54%) were female; 120 (87%) had genital chlamydia; and 43 (31%) were recruited contacts. We identified 115 strain-concordance events among 54 participants representing 25 bacterial species. Seven events (6%) were between sexual contacts including putative heterosexual transmission of Fannyhessea vaginae, Gardnerella leopoldii, Prevotella amnii, Sneathia sanguinegens, and Sneathia vaginalis (one strain each), and putative sexual transmission of Lactobacillus iners between female contacts. Most concordance events (108, 94%) were between non-contacts, including eight female participants connected through 18 Lactobacillus crispatus and 3 Lactobacillus jensenii concordant strains, and 14 female and 2 male participants densely interconnected through 52 Gardnerella swidsinskii concordance events.IMPORTANCEEpidemiologic evidence consistently indicates bacterial vaginosis (BV) is sexually associated and may be sexually transmitted, though sexual transmission remains subject to debate. This study is not capable of demonstrating BV sexual transmission; however, we do provide strain-level metagenomic evidence that strongly supports heterosexual transmission of BV-associated species. These findings strengthen the evidence base that supports ongoing investigations of concurrent male partner treatment for reducing BV recurrence. Our data suggest that measuring the impact of male partner treatment on F. vaginae, G. leopoldii, P. amnii, S. sanguinegens, and S. vaginalis may provide insight into why a regimen does or does not perform well. We also observed a high degree of strain concordance between non-sexual-contact female participants. We posit that this may reflect limited dispersal capacity of vaginal bacteria coupled with individuals' comembership in regional transmission networks where transmission may occur between parent and child at birth, cohabiting individuals, or sexual contacts.
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Affiliation(s)
- Kayla A. Carter
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael T. France
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lindsay Rutt
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lisa Bilski
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | | | - Mary Regan
- School of Nursing, University of Maryland, Baltimore, Maryland, USA
| | - Rebecca M. Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Muzny CA, Sobel JD. Understanding and Preventing Recurring Bacterial Vaginosis: Important Considerations for Clinicians. Int J Womens Health 2023; 15:1317-1325. [PMID: 37581202 PMCID: PMC10423565 DOI: 10.2147/ijwh.s383333] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/29/2023] [Indexed: 08/16/2023] Open
Abstract
Bacterial vaginosis (BV) is the most common vaginal infection worldwide. It is associated with an increased risk of acquisition of HIV and other sexually transmitted infections (STIs) as well as pelvic inflammatory disease and adverse birth outcomes. During BV, a polymicrobial biofilm forms on the surface of the vaginal mucosa. However, the exact etiology of BV remains controversial which has impeded significant advances in diagnosis, treatment, and prevention. Despite 30-day cure rates approaching 80% in BV-infected women treated with 7 days of oral metronidazole, recurrence within 12 months is common. This article provides a current review of the epidemiology, pathogenesis, diagnosis, and treatment of recurrent BV for practicing clinicians who commonly see women with this recurrent vaginal infection. Regarding management, we focus primarily on antimicrobial measures that may be effective. Future areas of research in this field are also discussed.
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Affiliation(s)
- Christina A Muzny
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jack D Sobel
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
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Zinsli KA, Srinivasan S, Balkus JE, Chambers LC, Lowens MS, Morgan J, Rowlinson E, Robinson TS, Romano SS, Munch MM, Manhart LE, Fredricks DN. Bacterial vaginosis-associated bacteria in cisgender men who have sex with women: prevalence, association with non-gonococcal urethritis and natural history. Sex Transm Infect 2023; 99:317-323. [PMID: 36601742 PMCID: PMC10241981 DOI: 10.1136/sextrans-2022-055494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Bacterial vaginosis-associated bacterium 2 (BVAB2), Mageeibacillus indolicus and Sneathia spp are highly predictive of bacterial vaginosis (BV) in cisgender women. They have been associated with non-gonococcal urethritis (NGU) in cisgender men in some but not all populations. We evaluated this association in a cross-sectional study of cisgender men who have sex with women only (MSW). METHODS MSW without gonorrhoea attending a sexual health clinic (SHC) from 2014 to 2018 completed a computer-assisted self-interview, clinical interview and examination. NGU was defined as ≥5 polymorphonuclear leucocytes/high-power field in urethral exudates plus either urethral symptoms or visible discharge. Urine was tested for Chlamydia trachomatis and Mycoplasma genitalium using Aptima (Hologic) and for BVAB2, M. indolicus, Sneathia spp, Trichomonas vaginalis, Ureaplasma urealyticum, Haemophilus influenzae, herpes simplex virus and adenovirus using quantitative PCR. RESULTS Of 317 MSW age 17-71, 67 (21.1%) had Sneathia spp, 36 (11.4%) had BVAB2, and 17 (5.4%) had M. indolicus at enrolment. Having ≥3 partners in the past 2 months was the only characteristic that was more common among MSW with than those without these bacteria (BVAB2: 47% vs 23%, M. indolicus: 53% vs 24%, Sneathia spp: 42% vs 22%; p≤0.03 for all). One-hundred seventeen men (37%) were diagnosed with NGU at enrolment. There was no significant association of BVAB2, M. indolicus or Sneathia spp with NGU (adjusted OR=0.59, 95% CI 0.14 to 2.43; aOR=3.40, 95% CI 0.68 to 17.06; aOR=0.46, 95% CI 0.16 to 1.27). Of 109 MSW with monthly samples, 34 (31.2%) had one of the bacteria at one or more follow-up visits, 22 of which were co-colonised with >1. Median persistence over 6 months did not differ significantly (BVAB2=30.5 days, IQR=28-87; M. indolicus=87 days, IQR=60-126; Sneathia spp=70 days, IQR=30-135; p≥0.20 for each comparison). CONCLUSIONS Neither BVAB2, M. indolicus nor Sneathia spp were associated with increased risk of prevalent NGU in MSW attending an SHC.
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Affiliation(s)
- Kaitlin A Zinsli
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jennifer E Balkus
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Laura C Chambers
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - M Sylvan Lowens
- HIV/STD Program, Public Health - Seattle & King County, Seattle, Washington, USA
| | - Jennifer Morgan
- HIV/STD Program, Public Health - Seattle & King County, Seattle, Washington, USA
| | - Emily Rowlinson
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Tashina S Robinson
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Sarah S Romano
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Matthew M Munch
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Lisa E Manhart
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - David N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Ziogou A, Ziogos E, Giannakodimos I, Giannakodimos A, Sifakis S, Ioannou P, Tsiodras S. Bacterial Vaginosis and Post-Operative Pelvic Infections. Healthcare (Basel) 2023; 11:healthcare11091218. [PMID: 37174760 PMCID: PMC10178576 DOI: 10.3390/healthcare11091218] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Bacterial vaginosis (BV) represents a condition in which the normal protective Lactobacilli, especially those that produce H2O2, are replaced by high quantities of facultative anaerobes, leading to gynecologic and obstetric post-operative complications. BV is an important cause of obstetric and gynecological adverse sequelae and it could lead to an increased risk of contracting sexually transmitted infections such as gonorrhea, genital herpes, Chlamydia, Trichomonas, and human immunodeficiency virus. Herein, we reviewed bacterial vaginosis and its association with post-operative pelvic infections. In Obstetrics, BV has been associated with increased risk of preterm delivery, first-trimester miscarriage in women undergoing in vitro fertilization, preterm premature rupture of membranes, chorioamnionitis, amniotic fluid infections, postpartum and postabortal endomyometritis as well as postabortal pelvic inflammatory disease (PID). In gynecology, BV increases the risk of post-hysterectomy infections such as vaginal cuff cellulitis, pelvic cellulitis, pelvic abscess, and PID. BV is often asymptomatic, can resolve spontaneously, and often relapses with or without treatment. The American College of Obstetricians and Gynecologists recommends testing for BV in women having an increased risk for preterm delivery. Women with symptoms should be evaluated and treated. Women with BV undergoing gynecological surgeries must be treated to reduce the frequency of post-operative pelvic infections. Metronidazole and clindamycin are the mainstays of therapy. Currently, there is no consensus on pre-surgery screening for BV; decisions are made on a case-by-case basis.
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Affiliation(s)
- Afroditi Ziogou
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Eleftherios Ziogos
- Department of Gynecology and Obstetrics, University Hospital of Heraklion, 71110 Heraklion, Greece
| | - Ilias Giannakodimos
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Alexios Giannakodimos
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Petros Ioannou
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Sotirios Tsiodras
- School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Fourth Department of Internal Medicine, Attikon General Hospital, 12462 Athens, Greece
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Abstract
Vaginal symptoms are one of the most common reasons women consult with physicians and can significantly impact quality of life. The differential diagnosis of vaginal discharge includes physiologic discharge, vaginitis, cervicitis, and pelvic inflammatory disease (PID). Vaginitis is inflammation of the vagina, most commonly caused by bacterial vaginosis (BV), vulvovaginal candidiasis, and trichomoniasis infections. Cervicitis is an inflammation of the cervix and typically caused by Chlamydia trachomatis and Neisseria gonorrhoeae. PID is infection of the female upper genital tract, involving the uterus, fallopian tubes, ovaries, and/or pelvic peritoneum and usually caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and bacterial vaginosis-associated pathogens. A pelvic exam should be performed for any woman presenting with vaginal discharge to confirm the diagnosis and rule out an upper tract infection. BV and vulvovaginal candidal infections only require treatment if symptomatic and do not require partner therapy, whereas treatment and partner therapy is recommended for sexually transmitted illnesses, such as trichomoniasis, chlamydia and gonorrhea. Vaginitis may be uncomfortable, but rarely leads to serious long-term consequence, but pelvic inflammatory disease can lead to serious long-term sequelae, including increased risk for ectopic pregnancy, infertility, and chronic pelvic pain.
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Affiliation(s)
- Swati Shroff
- Internal Medicine, Thomas Jefferson University, Jefferson Women's Primary Care, 700 Walnut Street 2nd Floor, Philadelphia, PA 19106, USA.
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Waltmann A, Thomas C, Duncan JA. The role of the genital microbiota in the acquisition and pathogenesis of sexually transmitted infections. Curr Opin Infect Dis 2023; 36:35-48. [PMID: 36729748 PMCID: PMC10500551 DOI: 10.1097/qco.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW There are an estimated 374 million new sexually transmitted infections (STIs) worldwide every year. Our review article examines the current evidence of how STI acquisition, transmission, and pathogenesis is impacted upon by the genital microbiota, with a focus on epidemiological, biochemical, and immunological features. RECENT FINDINGS At least in women, a genital microbiota dominated by lactobacilli has long been considered optimal for reproductive health, while depletion of lactobacilli may lead to a genital microenvironment dominated by anaerobic pathogens, which can manifest clinically as bacterial vaginosis. Recent research efforts have characterized genital microbiota composition in greater resolution, sometimes at species-level, using proteomics, metabolomics, and deep sequencing. This has enhanced our understanding of how specific microbiota members influence acquisition or clinical manifestation of STI pathogen infection. Other advances include a steady, though still slow, increase in the number of studies that sought to determine the genital (penile or urethral) microbiota of males and how it may impact that of their female partners' genital microbiota and risk of STI acquisition. Altogether, these data enabled us to explore the concept that genital microbiota may be sexually transmitted and influence pathogenesis and clinical presentation of other STI. SUMMARY With STI infection rates increasing worldwide, it is important now more than ever to find novel STI prevention strategies. Understanding if and how the genital microbiota is a modifiable risk factor for STI transmission, acquisition, and clinical manifestation may prove to be an important strategy in our efforts to curb morbidity in at risk populations.
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Affiliation(s)
- Andreea Waltmann
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cynthia Thomas
- Graduate Program, Department of Microbiology and Immunology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Joseph A Duncan
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Institute for Global Health & Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Pharmacology, School of Medicine, University of North Carolina, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Muacevic A, Adler JR. Bacterial Vaginosis: A Comprehensive Narrative on the Etiology, Clinical Features, and Management Approach. Cureus 2022; 14:e31314. [PMID: 36514655 PMCID: PMC9735379 DOI: 10.7759/cureus.31314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Due to the intricate balance of the vaginal microbiota's ecology, bacterial vaginosis is documented in one-third of females globally at various times of their lives. It is a typical reason for unusual vaginal discharge and is linked to various health problems. Gardnerella vaginalis is one of the anaerobic microorganisms linked to bacterial vaginosis. bacterial vaginosis is diagnosed by Amsel's criteria as well as comparisons among Amsel's criteria, Nugent's criteria, and Hay/Ison's criteria. To scan and assess the degree of dysbiosis within the vaginal microbiome, researchers have upped their game by combining cutting-edge molecular methods, with a focus on how specific microbial populations fluctuate in comparison to a healthy condition. A clue cell can be detected on a simple wet mount of vaginal secretions. Despite receiving regular antibiotic therapy, a substantial risk of treatment failure and bacterial vaginosis recurrence persists. Researchers have revealed positive treatment effects and reduced the infection of the female reproductive system with harmful bacteria.
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Muzny CA, Balkus J, Mitchell C, Sobel JD, Workowski K, Marrazzo J, Schwebke JR. Diagnosis and Management of Bacterial Vaginosis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines. Clin Infect Dis 2022; 74:S144-S151. [PMID: 35416968 DOI: 10.1093/cid/ciac021] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In preparation for the 2021 Centers for Disease Control and Prevention (CDC) sexually transmitted infections (STIs) treatment guidelines, the CDC convened an advisory group in 2019 to examine recent literature addressing updates in the epidemiology, diagnosis, and management of STIs. This article summarizes recent data in each of these key topic areas as they pertain to bacterial vaginosis (BV), the most common cause of vaginal discharge. The evidence reviewed primarily focused on updates in the global epidemiology of BV, risk factors for BV, data supportive of sexual transmission of BV-associated bacteria, BV molecular diagnostic tests, and novel treatment regimens. Additionally, recent literature on alcohol abstinence in the setting of 5-nitroimidazole use was reviewed.
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Affiliation(s)
- Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Sexually Transmitted Disease Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jennifer Balkus
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Caroline Mitchell
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jack D Sobel
- Division of Infectious Diseases, Wayne State University, Detroit, Michigan, USA
| | - Kimberly Workowski
- Division of Sexually Transmitted Disease Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jeanne Marrazzo
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jane R Schwebke
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Muzny CA, Sobel JD. The Role of Antimicrobial Resistance in Refractory and Recurrent Bacterial Vaginosis and Current Recommendations for Treatment. Antibiotics (Basel) 2022; 11:500. [PMID: 35453251 PMCID: PMC9024683 DOI: 10.3390/antibiotics11040500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 12/03/2022] Open
Abstract
Bacterial vaginosis (BV), the most common cause of vaginal discharge, is characterized by a shift in the vaginal microbiota from Lactobacillus species dominance to a diverse array of facultative and strict anaerobic bacteria which form a multi-species biofilm on vaginal epithelial cells. The rate of BV recurrence after therapy is high, often >60%. The BV biofilm itself likely contributes to recurrent and refractory disease after treatment by reducing antimicrobial penetration. However, antimicrobial resistance in BV-associated bacteria, including those both within the biofilm and the vaginal canal, may be the result of independent, unrelated bacterial properties. In the absence of new, more potent antimicrobial agents to eradicate drug-resistant pathogenic vaginal microbiota, treatment advances in refractory and recurrent BV have employed new strategies incorporating combination therapy. Such strategies include the use of combination antimicrobial regimens as well as alternative approaches such as probiotics and vaginal fluid transfer. Our current recommendations for the treatment of refractory and recurrent BV are provided.
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Affiliation(s)
- Christina A. Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Jack D. Sobel
- Division of Infectious Diseases, Wayne State University, Detroit, MI 48202, USA;
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12
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Abstract
Up to 50% of women receiving first-line antibiotics for bacterial vaginosis (BV) experience recurrence within 12 weeks. Evidence suggests that reinfection from an untreated regular sexual partner contributes to recurrence. We conducted a pilot study of 34 heterosexual couples to describe the impact of concurrent partner treatment on the composition of the genital microbiota over a 12-week period. We also determined the acceptability and tolerability of concurrent partner treatment and obtained preliminary estimates of the efficacy of the intervention to inform a randomized controlled trial (RCT). Women received first-line antibiotic treatment for BV (i.e., oral metronidazole or intravaginal clindamycin), and their male partner received oral metronidazole, 400 mg, and 2% clindamycin cream applied topically to penile skin, both twice daily for 7 days. The genital microbiota was characterized at three anatomical sites (women, vaginal; men, cutaneous penile and first-pass urine [representing the urethra]) using 16S rRNA gene sequencing. Immediately posttreatment, concurrent partner treatment significantly reduced the abundance of BV-associated bacteria (false-discovery rate [FDR] corrected P value < 0.05) and altered the overall microbiota composition of all three anatomical sites (P = 0.001). Suppression of BV-associated bacteria was sustained in the majority (81%) of women over the 12-week period (FDR P value < 0.05), despite BV-associated bacteria reemerging at both genital sites in men. In this cohort of women at high risk for recurrence, five recurred within 12 weeks of treatment (17%; 95% confidence interval [CI], 6 to 34%). Importantly, men tolerated and adhered to combination therapy. Our findings provide support for an RCT of combined oral and topical male partner treatment for BV. IMPORTANCE Recurrence of BV following standard treatment is unacceptably high. Posttreatment recurrence is distressing for women, and it imposes a considerable burden on the health care system. Recurrences result in multiple presentations to clinical services and repeated antibiotic use, and the associated obstetric and gynecological sequelae are significant. New treatments to improve long-term BV cure are urgently needed. Here, we used 16S rRNA gene sequencing to investigate changes in the microbiota composition at three genital sites (vagina, penile skin, and male urethra) of heterosexual couples undergoing concurrent partner treatment for bacterial vaginosis (BV). We found that concurrent partner treatment immediately and significantly altered the composition of the genital microbiota of both partners, with a reduction in BV-associated bacteria seen at all three sites. BV cure at 12 weeks posttreatment was higher than expected. These microbiological data provide evidence for continued investigation of partner treatment as a strategy to improve BV cure.
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13
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Vodstrcil LA, Muzny CA, Plummer EL, Sobel JD, Bradshaw CS. Bacterial vaginosis: drivers of recurrence and challenges and opportunities in partner treatment. BMC Med 2021; 19:194. [PMID: 34470644 PMCID: PMC8411528 DOI: 10.1186/s12916-021-02077-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/28/2021] [Indexed: 12/16/2022] Open
Abstract
Bacterial vaginosis (BV) is the most common vaginal dysbiosis to affect women globally, yet an unacceptably high proportion of women experience BV recurrence within 6 months of recommended antibiotic therapy. The low rate of sustained cure highlights our limited understanding of the pathogenesis of BV recurrence, which has been attributed to possible persistence and re-emergence of BV-associated bacteria (BVAB) or a BV-associated biofilm following antimicrobials and/or reinfection occurring from sexual partners.There is a robust body of evidence to support the exchange of bacteria between partners during sexual activity, and while the hypothesis that women treated for BV are subsequently reinfected with BVAB following sex with an untreated sexual partner is not new, failure of past partner treatment trials has eroded confidence in this concept. If reinfection is a key driver of recurrence, current antimicrobial regimens directed to women alone are unlikely to achieve a high level of sustained cure, and the approach of partner treatment to reduce reinfection is justified. In this manuscript, we present the molecular and epidemiological evidence that underlies the hypothesis that BV is sexually transmitted, and summarise why research that continues to consider sexual partnerships is necessary. We also outline the significant barriers and challenges that we have identified while undertaking partner treatment studies, and we discuss the factors that impact on our ability to determine their effectiveness.Ultimately, the pathogenesis of BV recurrence is likely to be multifaceted and not attributable to a single mechanism in all women. If we are to achieve sustained cure for women, it is likely that combined and individualised approaches to eradicate BVAB, support an optimal vaginal microbiome, and prevent reinfection from partners will be required.
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Affiliation(s)
- Lenka A Vodstrcil
- Central Clinical School - Melbourne Sexual Health Centre, Monash University, 580 Swanston St, Carlton, Victoria, 3053, Australia.
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.
| | - Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Erica L Plummer
- Central Clinical School - Melbourne Sexual Health Centre, Monash University, 580 Swanston St, Carlton, Victoria, 3053, Australia
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
| | - Jack D Sobel
- Division of Infectious Diseases, Wayne State University, Detroit, MI, USA
| | - Catriona S Bradshaw
- Central Clinical School - Melbourne Sexual Health Centre, Monash University, 580 Swanston St, Carlton, Victoria, 3053, Australia
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
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14
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Schwebke JR, Lensing SY, Lee J, Muzny CA, Pontius A, Woznicki N, Aguin T, Sobel JD. Treatment of Male Sexual Partners of Women With Bacterial Vaginosis: A Randomized, Double-Blind, Placebo-Controlled Trial. Clin Infect Dis 2021; 73:e672-e679. [PMID: 33383580 DOI: 10.1093/cid/ciaa1903] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We aimed to determine if treatment of male sexual partners of women with recurrent bacterial vaginosis (BV) with oral metronidazole 2×/day for 7 days (ie, multidose metronidazole) significantly decreased BV recurrence rates in the female. METHODS This was a multicenter, 2-arm, double-blind, placebo-controlled study. Women with recurrent BV and current diagnosis of BV by Amsel and Nugent were enrolled. Multidose metronidazole for 7 days was dispensed to women. Male partners were randomized to placebo versus multidose metronidazole for 7 days and asked to refrain from unprotected sex for 14 days. Female follow-up visits were conducted at day 21 and 8 and 16 weeks. Male follow-up visits occurred at days 14-21. BV cure was defined as 0-2 Amsel criteria and Nugent score 0-6 in the female partner with the primary endpoint at 16 weeks. RESULTS 214 couples were enrolled. In the intent-to-treat population, there was no significant difference between treatment arms for the primary outcome. BV treatment failure occurred in 81% and 80% of women in the metronidazole and placebo arms through the third follow-up visit, respectively (P > .999). However, women whose male partners adhered to study medication were less likely to fail treatment (adjusted relative risk, .85; 95% CI, .73-.99; P = .035). This finding persisted in post hoc comparisons in the metronidazole arm. CONCLUSIONS Overall, this study did not find that male partner treatment with multidose metronidazole significantly reduces BV recurrence in female partners, although women whose partners adhered to multidose metronidazole were less likely to fail treatment. CLINICAL TRIALS REGISTRATION (NCT02209519).
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Affiliation(s)
- Jane R Schwebke
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shelly Y Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Angela Pontius
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nicole Woznicki
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Tina Aguin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
| | - Jack D Sobel
- Division of Infectious Diseases, Wayne State University, Detroit, Michigan, USA
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15
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Vodstrcil LA, Bradshaw CS. Does Partner Treatment Impact on Bacterial Vaginosis Cure? Clin Infect Dis 2021; 73:e680-e682. [PMID: 33411901 DOI: 10.1093/cid/ciaa1907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lenka A Vodstrcil
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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16
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 793] [Impact Index Per Article: 264.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for
sexually transmitted infections (STIs) were updated by CDC after consultation
with professionals knowledgeable in the field of STIs who met in Atlanta,
Georgia, June 11–14, 2019. The information in this report updates the
2015 guidelines. These guidelines discuss 1) updated recommendations for
treatment of Neisseria gonorrhoeae, Chlamydia trachomatis,
and Trichomonas vaginalis; 2) addition of
metronidazole to the recommended treatment regimen for pelvic inflammatory
disease; 3) alternative treatment options for bacterial vaginosis; 4) management
of Mycoplasma genitalium; 5) human papillomavirus vaccine
recommendations and counseling messages; 6) expanded risk factors for syphilis
testing among pregnant women; 7) one-time testing for hepatitis C infection; 8)
evaluation of men who have sex with men after sexual assault; and 9) two-step
testing for serologic diagnosis of genital herpes simplex virus. Physicians and
other health care providers can use these guidelines to assist in prevention and
treatment of STIs.
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17
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Joseph RJ, Ser HL, Kuai YH, Tan LTH, Arasoo VJT, Letchumanan V, Wang L, Pusparajah P, Goh BH, Ab Mutalib NS, Chan KG, Lee LH. Finding a Balance in the Vaginal Microbiome: How Do We Treat and Prevent the Occurrence of Bacterial Vaginosis? Antibiotics (Basel) 2021; 10:719. [PMID: 34203908 PMCID: PMC8232816 DOI: 10.3390/antibiotics10060719] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/27/2021] [Accepted: 06/10/2021] [Indexed: 12/30/2022] Open
Abstract
Bacterial vaginosis (BV) has been reported in one-third of women worldwide at different life stages, due to the complex balance in the ecology of the vaginal microbiota. It is a common cause of abnormal vaginal discharge and is associated with other health issues. Since the first description of anaerobic microbes associated with BV like Gardnerella vaginalis in the 1950s, researchers have stepped up the game by incorporating advanced molecular tools to monitor and evaluate the extent of dysbiosis within the vaginal microbiome, particularly on how specific microbial population changes compared to a healthy state. Moreover, treatment failure and BV recurrence rate remain high despite the standard antibiotic treatment. Consequently, researchers have been probing into alternative or adjunct treatments, including probiotics or even vaginal microbiota transplants, to ensure successful treatment outcomes and reduce the colonization by pathogenic microbes of the female reproductive tract. The current review summarizes the latest findings in probiotics use for BV and explores the potential of vaginal microbiota transplants in restoring vaginal health.
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Affiliation(s)
- Rebecca Jane Joseph
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
| | - Hooi-Leng Ser
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
| | - Yi-He Kuai
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
| | - Loh Teng-Hern Tan
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Johor Bahru 80100, Malaysia;
| | | | - Vengadesh Letchumanan
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
| | - Lijing Wang
- Vascular Biology Research Institute, Guangdong Pharmaceutical University, Guangzhou 510006, China;
| | - Priyia Pusparajah
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
| | - Bey-Hing Goh
- Biofunctional Molecule Exploratory Research Group (BMEX), School of Pharmacy, Monash University Malaysia, Bandar Sunway 47500, Malaysia;
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Nurul-Syakima Ab Mutalib
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
- UKM Medical Molecular Biology Institute (UMBI), UKM Medical Centre, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Kok-Gan Chan
- Division of Genetics and Molecular Biology, Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur 50603, Malaysia
- International Genome Centre, Jiangsu University, Zhenjiang 212013, China
| | - Learn-Han Lee
- Novel Bacteria and Drug Discovery Research Group (NBDD), Microbes and Bioresource Research Strength (MBRS), Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway 47500, Malaysia; (R.J.J.); (H.-L.S.); (Y.-H.K.); (L.T.-H.T.); (V.L.); (P.P.); (N.-S.A.M.)
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18
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Sobel JD, Sobel R. Current and emerging pharmacotherapy for recurrent bacterial vaginosis. Expert Opin Pharmacother 2021; 22:1593-1600. [PMID: 33750246 DOI: 10.1080/14656566.2021.1904890] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Given the frequency of recurrent bacterial vaginosis (RBV), enhancing treatment and preventing recurrence have become the central target of pharmacotherapy today. Antimicrobial failure is occurring at a time when knowledge of pathogenesis of bacterial vaginosis (BV) and RBV is incomplete, limiting rational treatment modification. AREAS COVERED The current manuscript reviews pathogenesis of RBV and the performance of available antimicrobials as well as attempts employed to enhance activity and pharmacologic strategies to reduce BV recurrence and refractory vaginal disease. The authors also provide their expert perspectives on the subject area, including their outlook for the future. EXPERT OPINION In the face of an empty pipeline of new antibiotics, strategies have emerged to enhance existing antibiotic efficacy, which include modifying drug dose, treatment duration, long-term prophylactic regimens, and use of biofilm disrupting agents. It is likely that future effective therapy will include several simultaneous and consecutive treatment components, including combinations of antibiotics, antibiofilm agents, and probiotics. Measures to prevent sexual transmission and reinfection are also essential.
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Affiliation(s)
- Jack D Sobel
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, United States
| | - Ryan Sobel
- Department of Obstetrics and Gynecology, Jefferson Medical College, Philadelphia, United States
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19
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Vodstrcil LA, Plummer EL, Doyle M, Fairley CK, McGuiness C, Bateson D, Hocking JS, Law MG, Petoumenos K, Donovan B, Chow EPF, Bradshaw CS. Treating male partners of women with bacterial vaginosis (StepUp): a protocol for a randomised controlled trial to assess the clinical effectiveness of male partner treatment for reducing the risk of BV recurrence. BMC Infect Dis 2020; 20:834. [PMID: 33176727 PMCID: PMC7661182 DOI: 10.1186/s12879-020-05563-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/30/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Bacterial vaginosis (BV) is estimated to affect 1 in 3 women globally and is associated with obstetric and gynaecological sequelae. Current recommended therapies have good short-term efficacy but 1 in 2 women experience BV recurrence within 6 months of treatment. Evidence of male carriage of BV-organisms suggests that male partners may be reinfecting women with BV-associated bacteria (henceforth referred to as BV-organisms) and impacting on the efficacy of treatment approaches solely directed to women. This trial aims to determine the effect of concurrent male partner treatment for preventing BV recurrence compared to current standard of care. METHODS StepUp is an open-label, multicentre, parallel group randomised controlled trial for women diagnosed with BV and their male partner. Women with clinical-BV defined using current gold standard diagnosis methods (≥3 Amsel criteria and Nugent score (NS) = 4-10) and with a regular male partner will be assessed for eligibility, and couples will then be consented. All women will be prescribed oral metronidazole 400 mg twice daily (BID) for 7 days, or if contraindicated, a 7-day regimen of topical vaginal 2% clindamycin. Couples will be randomised 1:1 to either current standard of care (female treatment only), or female treatment and concurrent male partner treatment (7 days of combined antibiotics - oral metronidazole tablets 400 mg BID and 2% clindamycin cream applied topically to the glans penis and upper shaft [under the foreskin if uncircumcised] BID). Couples will be followed for up to 12 weeks to assess BV status in women, and assess the adherence, tolerability and acceptability of male partner treatment. The primary outcome is BV recurrence defined as ≥3 Amsel criteria and NS = 4-10 within 12 weeks of enrolment. The estimated sample size is 342 couples, to detect a 40% reduction in BV recurrence rates from 40% in the control group to 24% in the intervention group within 12 weeks. DISCUSSION Current treatments directed solely to women result in unacceptably high rates of BV recurrence. If proven to be effective the findings from this trial will directly inform the development of new treatment strategies to impact on BV recurrence. TRIAL REGISTRATION The trial was prospectively registered on 12 February 2019 on the Australian and New Zealand Clinical Trial Registry (ACTRN12619000196145, Universal Trial Number: U1111-1228-0106, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376883&isReview=true ).
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Affiliation(s)
- Lenka A Vodstrcil
- Central Clinical School, Monash University, Carlton, VIC, 3053, Australia.
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia.
| | - Erica L Plummer
- Central Clinical School, Monash University, Carlton, VIC, 3053, Australia
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia
| | - Michelle Doyle
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia
| | - Christopher K Fairley
- Central Clinical School, Monash University, Carlton, VIC, 3053, Australia
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia
| | - Colette McGuiness
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia
| | - Deborah Bateson
- Family Planning New South Wales, Ashfield, 2131, Australia
- Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Camperdown, 2006, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, University of Melbourne, Parkville, 3010, Australia
| | - Matthew G Law
- The Kirby Institute, University of New South Wales, Sydney, 2052, Australia
| | - Kathy Petoumenos
- The Kirby Institute, University of New South Wales, Sydney, 2052, Australia
| | - Basil Donovan
- The Kirby Institute, University of New South Wales, Sydney, 2052, Australia
| | - Eric P F Chow
- Central Clinical School, Monash University, Carlton, VIC, 3053, Australia
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Carlton, VIC, 3053, Australia.
- Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, 3053, Australia.
- Centre for Epidemiology and Biostatistics, Melbourne School of Population & Global Health, University of Melbourne, Parkville, 3010, Australia.
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20
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Bohbot JM, Brami G, Goubard A, Harvey T. [Ten questions about bacterial vaginosis]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2020; 48:693-702. [PMID: 32438010 DOI: 10.1016/j.gofs.2020.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Indexed: 06/11/2023]
Abstract
The physiopathology of bacterial vaginosis (BV), the ultimate stage of vaginal dysbiosis, has benefited from recent advances in molecular biology, highlighting, among others, the important role of A. vaginae. Certain immunological specificities (variants of TLR4, elevation of IL-1β, for example) explain the variations in the prevalence of this infection, the poor clinical and cellular inflammatory response and the promoting influence of BV on the acquisition and progression of some sexually transmitted infections. These advances do not fully elucidate the causes of the high rate of recurrences. Some risk factors for relapses of BV have been identified such as tobacco use, stress or hygienic errors have been associated to relapses of BV. However, other paths are beginning to be explored such as the role of sexual transmission, the resistance of certain bacteria associated to BV to nitroimidazoles or the lack of efficacy of conventional treatments on dysbiosis itself. Taking into acount this vaginal dysbiosis appears to be important or even essential to better control the natural history of HPV-hr infection or improve the success rate of IVF, for example. Despite heterogeneous results, the use of probiotics as a complement to conventional treatments (nitroimidazoles, dequalinium chloride) has demonstrated a preventive effect on BV recurrences. Further studies are needed to customize the contribution of probiotics (or synbiotics) according to the individual specificities of the vaginal microbiome.
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Affiliation(s)
- J-M Bohbot
- Institut Fournier, 25, boulevard Saint-Jacques, 75014 Paris, France.
| | - G Brami
- Institut Fournier, 25, boulevard Saint-Jacques, 75014 Paris, France
| | - A Goubard
- Institut Fournier, 25, boulevard Saint-Jacques, 75014 Paris, France
| | - T Harvey
- Maternité des Diaconnesses, 12-18, rue du Sergent Bauchat, 75012 Paris, France
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21
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Mehta SD, Zhao D, Green SJ, Agingu W, Otieno F, Bhaumik R, Bhaumik D, Bailey RC. The Microbiome Composition of a Man's Penis Predicts Incident Bacterial Vaginosis in His Female Sex Partner With High Accuracy. Front Cell Infect Microbiol 2020; 10:433. [PMID: 32903746 PMCID: PMC7438843 DOI: 10.3389/fcimb.2020.00433] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022] Open
Abstract
Background: We determined the predictive accuracy of penile bacteria for incident BV in female sex partners. In this prospective cohort, we enrolled Kenyan men aged 18–35 and their female sex partners aged 16 and older. We assessed BV at baseline, 1, 6, and 12 months. Incident BV was defined as a Nugent score of 7–10 at a follow-up visit, following a Nugent score of 0–6 at baseline. Amplification of the V3–V4 region of the bacterial 16S rRNA gene was performed on meatal and glans/coronal sulcus swab samples. Majority vote classifier combined the decisions of three machine learning classification algorithms (Random Forest, Support Vector Machine, K Nearest Neighbor). We report the estimate cross-validation predictive accuracy for incident BV based on baseline penile taxa. Results: The incidence of BV was 31% among 168 couples in which the woman did not have BV at baseline: 37.3% if the man was uncircumcised vs. 26.3% if the man was circumcised. Incident BV occurred at 1 month (n = 23), 6 months (n = 20), 12 months (n = 9). The predictive capacity of meatal taxa was high: sensitivity (80.7%), specificity (74.6%), accuracy (77.5%), area under the curve (88.8%). Variable importance ranking identified meatal taxa that in the vagina are associated with BV: Parvimonas, Lactobacillus iners, L. crispatus, Dialister, Sneathia sanguinegens, and Gardnerella vaginalis were among the top 10 most predictive taxa. The accuracy of glans/coronal sulcus taxa to predict incident BV was comparable to meatal taxa accuracy, but with greater variability. Conclusions: Baseline penile microbiota accurately predicted BV incidence in women who did not have BV at baseline, with more than half of incident infections observed at 6- to 12- months after penile microbiome assessment. These results suggest interventions to manipulate the penile microbiome may reduce BV incidence in sex partners, and that potential treatment (antibiotic or live biotherapeutic) will need to be effective in reducing or altering bacteria at both the glans/coronal sulcus and urethral sites (as represented by the meatus). The temporal association clarifies that concordance of penile microbiome with the vaginal microbiome of sex partners is not merely reflecting the vaginal microbiome, but can contribute to it.
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Affiliation(s)
- Supriya D Mehta
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | - Dan Zhao
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | - Stefan J Green
- Sequencing Core, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | | | | | - Runa Bhaumik
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | - Dulal Bhaumik
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | - Robert C Bailey
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
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22
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Onywera H, Williamson AL, Ponomarenko J, Meiring TL. The Penile Microbiota in Uncircumcised and Circumcised Men: Relationships With HIV and Human Papillomavirus Infections and Cervicovaginal Microbiota. Front Med (Lausanne) 2020; 7:383. [PMID: 32850898 PMCID: PMC7406686 DOI: 10.3389/fmed.2020.00383] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 06/19/2020] [Indexed: 12/14/2022] Open
Abstract
While the human microbiota especially that of the gut, cervix, and vagina continue to receive great attention, very little is currently known about the penile (glans, coronal sulcus, foreskin, and shaft) microbiota. The best evidences to date for the potential role of the penile microbiota in human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) acquisition have come from studies examining medical male circumcision. We are still at the foothills of identifying specific penile bacteria that could be associated with increased risk of STI/HIV acquisition. In this review, we summarize the available literature on the human penile microbiota and how it is impacted by circumcision. We also discuss the potential role of penile microbiota in STIs and its impact on cervicovaginal microbiota. Taken together, the findings from the penile microbiota studies coupled with observational studies on the effect of male circumcision for reduction of STI/HIV infection risk suggest that specific penile anaerobic bacteria such as Prevotella spp. potentially have a mechanistic role that increases the risk of genital infections and syndromes, including bacterial vaginosis in sexual partners. Although penile Corynebacterium and Staphylococcus have been associated with healthy cervicovaginal microbiota and have been found to increase following male circumcision, further investigations are warranted to ascertain the exact roles of these bacteria in the reproductive health of men and women. This review aims to address existing gaps and challenges and future prospects in the penile microbiota research. The information described here may have translational significance, thereby improving reproductive health and management of STI/HIV.
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Affiliation(s)
- Harris Onywera
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Medical Virology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,Center for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Medical Virology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,SAMRC Gynaecological Cancer Research Centre, University of Cape Town, Cape Town, South Africa
| | - Julia Ponomarenko
- Center for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology, Barcelona, Spain.,University of Pompeu Fabra, Barcelona, Spain
| | - Tracy L Meiring
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Medical Virology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Wigan R, Vaughn C, Vodstrcil L, Doyle M, Kaiser M, McGuiness C, Bradshaw CS, Bilardi JE. "It's just an issue and you deal with it… you just deal with it, you move on and you do it together.": Men's experiences of bacterial vaginosis and the acceptability of male partner treatment. PLoS One 2020; 15:e0235286. [PMID: 32598394 PMCID: PMC7323956 DOI: 10.1371/journal.pone.0235286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/11/2020] [Indexed: 01/28/2023] Open
Abstract
Bacterial vaginosis (BV) is a common vaginal infection among women of reproductive age. Increasing evidence suggests BV may be sexually transmitted indicating a potential role for the treatment of sexual partners. If partner treatment reduces BV recurrence in women, real-world success will depend on sexual partners’ willingness to accept it. However, a lack of data exists on the acceptability of partner treatment among sexual partners, and no data exists on male partners’ experience of BV specifically. The aim of this study was to explore male partners’ views and experience of BV and their attitudes toward associated partner treatment. A social constructionist approach informed the framework of this study. Semi structured interviews were conducted with eleven men who participated in a BV partner treatment trial. Interviews were transcribed verbatim and analysed thematically. In the absence of symptoms in themselves, BV had little impact on men beyond their concerns for their partner’s health and self-esteem. Acceptance of treatment was largely a demonstration of care and support. While all participants had accepted treatment, men surmised the primary reasons other men may reject treatment as being: if they felt BV had “nothing to do with them”, which was related to not wanting to be viewed as having a ‘problem’ and exacerbated by norms of masculinity and STI-related stigma; lack of a diagnostic test to indicate if a male “had BV”; and a casual or less established relationship. Men’s attitudes to BV and partner treatment were primarily influenced by the nature of their relationships. The ambiguous aetiology of BV appears to attenuate STI related stigma and questions of infidelity.
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Affiliation(s)
- Rebecca Wigan
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
| | - Cathy Vaughn
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lenka Vodstrcil
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Michelle Doyle
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Marti Kaiser
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Collette McGuiness
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Catriona S. Bradshaw
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jade E. Bilardi
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
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Abstract
Vaginitis is defined as inflammation or infection of the vagina and is associated with a spectrum of symptoms, including vulvovaginal itching, burning, irritation, dyspareunia, "fishy" vaginal odor, and abnormal vaginal discharge. Vaginal symptoms are some of the most frequent reasons for patient visits to obstetrician-gynecologists () and may have important consequences in terms of discomfort and pain, days lost from school or work, sexual functioning, and self-image (). Distinguishing vaginal from vulvar symptoms is important to direct evaluation and treatment. The purpose of this document is to provide updated evidence-based guidance for the diagnosis and treatment of the common causes of vaginitis in nonpregnant patients. Information on the treatment of vaginitis in patients with human immunodeficiency virus (HIV) is covered elsewhere (). Guidelines are subject to change. For the most up-to-date information on vaginitis diagnosis and treatment, see the Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases webpage, which is available at https://www.cdc.gov/std/.
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Noncandidal vaginitis: a comprehensive approach to diagnosis and management. Am J Obstet Gynecol 2020; 222:114-122. [PMID: 31513780 DOI: 10.1016/j.ajog.2019.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 08/16/2019] [Accepted: 09/03/2019] [Indexed: 11/20/2022]
Abstract
Vaginitis is one of the most common causes of patient visits to gynecologists, primary care providers, and urgent care centers. However, many women leave without a clear diagnosis or experience recurrent symptoms despite treatment. The 3 most common etiologies of vaginitis are trichomonas, bacterial vaginosis, and vulvovaginal candidiasis, which account for an estimated 70% of cases. The remaining 30% may be related to other causes of vaginitis, including atrophic vaginitis, desquamative inflammatory vaginitis, and vaginal erosive disease. The purpose of this review is to describe the noncandidal causes of acute and recurrent vaginitis, with the goal of improving the likelihood of accurate diagnosis as well as efficient and effective therapy. We excluded candidal vaginitis from our review because there was a recently published review on this topic in the Journal. The clinical presentation and evaluation of patients with symptoms of vaginitis can be triaged into 1 of 2 diagnostic pathways: noninflammatory and inflammatory vaginitis. The most common noninflammatory cause is bacterial vaginosis. Features such as irritation, purulent discharge, and the presence of polymorphonuclear neutrophils are more suggestive of an inflammatory process. Trichomoniasis is the most common cause of inflammatory vaginitis. Other well-described forms of inflammatory vaginitis include atrophic vaginitis, desquamative inflammatory vaginitis, and erosive disease. We present a review of the pathogenesis, symptoms, examination findings, diagnostic testing, and treatment for each of these causes of noncandidal vaginitis.
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Coudray MS, Madhivanan P. Bacterial vaginosis-A brief synopsis of the literature. Eur J Obstet Gynecol Reprod Biol 2020; 245:143-148. [PMID: 31901667 PMCID: PMC6989391 DOI: 10.1016/j.ejogrb.2019.12.035] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 12/09/2019] [Accepted: 12/23/2019] [Indexed: 12/12/2022]
Abstract
Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Approximately 50 % of women are symptomatic and experience vaginal malodor, discharge, itching and increased vaginal pH. BV can increase the risk of contracting many sexually transmitted infections (STIs) such as human immunodeficiency virus (HIV), Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV) and herpes simplex virus-2 (HSV-2). Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term. The purpose of this review is to summarize current literature on the epidemiology of BV and highlight areas of deficiency in current clinical practice with respect to BV. BV recurrence rates are high, approximately 80 % three months after effective treatment. Furthermore, in some instances treatment is ineffective and BV persists. Literature also documents the relationship between BV and human papillomavirus (HPV). HPV is the most common sexually transmitted infection among young adult women while BV is the most common cause of vaginal symptoms among women of reproductive age. BV is associated with high levels of anaerobic organisms which can damage the vaginal epithelium and increase the risk of HPV infection. Recent research also highlights the role of the vaginal microbiome in BV. The results of this review warrant further exploration into the etiology of BV as well as exploration of more long-term effective treatment and the investigation of prognostic indicators. Additionally, the need for a standard definition of recurrent and persistent BV is recognized.
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Affiliation(s)
- Makella S Coudray
- Department of Epidemiology, Stempel College of Public Health and Social Work, Florida International University, USA.
| | - Purnima Madhivanan
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, USA; Internal Medicine, Division of Infectious Diseases, College of Medicine, University of Arizona, Tuscon, Arizona, USA; Public Health Research Institute of India, Mysore, Karnataka, India; Family & Community Medicine, College of Medicine, University of Arizona, Tuscon, Arizona, USA
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27
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Abstract
Sexually transmitted diseases (STDs) continue to be underrecognized leading to devastating health and economic consequences. Emergency clinicians play an important role in diagnosing and managing STDs and in improving health care outcomes for both the patient and their partners. In addition, antibiotic resistance and emerging infections continue to challenge providers in clinical practice. This review focuses on the cause, history, physical examination, diagnostic studies, and treatment strategies for bacterial vaginosis, chlamydia, genital herpes, gonorrhea, human papillomavirus, granuloma inguinale, Lymphogranuloma Venereum, Mycoplasma genitalium, syphilis, and trichomoniasis.
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Affiliation(s)
- Camiron L Pfennig
- Prisma Health, University of South Carolina School of Medicine Greenville, 701 Grove Road, Greenville, SC 29605, USA.
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Vodstrcil LA, Plummer ME, Fairley CK, Tachedjian G, Law MG, Hocking JS, Worthington MK, Grant MM, Okoko N, Bradshaw CS. Combined oral contraceptive pill-exposure alone does not reduce the risk of bacterial vaginosis recurrence in a pilot randomised controlled trial. Sci Rep 2019; 9:3555. [PMID: 30837554 PMCID: PMC6401172 DOI: 10.1038/s41598-019-39879-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/01/2019] [Indexed: 12/17/2022] Open
Abstract
We conducted a pilot open-label randomised controlled trial of combined (oestrogen-progesterone) oral contraceptive pill (COCP)-exposure aimed to examine its effect on BV-recurrence following first-line antibiotics compared to antibiotics alone. Ninety-five women with symptomatic BV were prescribed antibiotic therapy, randomised to COCP-exposure (intervention) or current non-hormonal contraceptive practices (control) and followed monthly for six-months or until BV-recurrence. Modified intention-to-treat methods requiring either ≥1 clinical (primary/Amsel-outcome) or ≥1 microbiological (secondary/Nugent-outcome) BV-recurrence assessment were applied to determine cumulative recurrence rates. Secondary Cox regression analyses assessed factors associated with recurrence in all women. 92/95 women randomised provided baseline requirements. BV-recurrence rates were similar in women randomised to the COCP (primary/Amsel-outcome: 10/100PY, 95%CI: 6,19/100PY) compared to controls (14/100PY, 95%CI: 9, 21/100PY, p = 0.471). In secondary analyses sex with the same pre-treatment regular sexual partner (RSP; Amsel: Adjusted Hazard Ratio [AHR] = 3.13, 95%CI: 1.41, 6.94, p = 0.005; Nugent: AHR = 2.97, 95%CI: 1.49, 5.83, p = 0.002) and BV-history (Amsel: AHR = 3.03, 95%CI: 1.14, 6.28; Nugent: AHR = 2.78, 95%CI: 1.22, 6.33) were associated with increased BV-recurrence. This pilot RCT of COCP-exposure did not improve BV cure but found sex with an RSP and BV-history were associated with recurrence, although impacted by sample size and attrition. These data indicate reinfection from an untreated RSP and persistence of BV-associated bacteria are integral to the pathogenesis of recurrence and may overwhelm potential beneficial effects of hormonal contraception on the vaginal microbiota.
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Affiliation(s)
- Lenka A Vodstrcil
- Central Clinical School, Monash University, Melbourne, 3004, Australia.
- Melbourne Sexual Health Centre, Alfred Hospital, Carlton, 3053, Australia.
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, 3010, Australia.
| | - Ms Erica Plummer
- Central Clinical School, Monash University, Melbourne, 3004, Australia
- Melbourne Sexual Health Centre, Alfred Hospital, Carlton, 3053, Australia
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, 3004, Australia
- Melbourne Sexual Health Centre, Alfred Hospital, Carlton, 3053, Australia
| | - Gilda Tachedjian
- Burnet Institute, Melbourne, 3004, Australia
- Department of Microbiology, Monash University, Clayton, 3168, Australia
- Department of Microbiology and Immunology, University of Melbourne, at the Peter Doherty Institute of Infection and Immunity, Melbourne, 3000, Australia
- School of Science, College of Science, Engineering and Health, RMIT University, Melbourne, 3000, Australia
| | - Matthew G Law
- Kirby Institute, University of New South Wales, Kensington, 2052, Australia
| | - Jane S Hocking
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, 3010, Australia
| | | | - Ms Mieken Grant
- Melbourne Sexual Health Centre, Alfred Hospital, Carlton, 3053, Australia
| | - Nita Okoko
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, 3010, Australia
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Melbourne, 3004, Australia
- Melbourne Sexual Health Centre, Alfred Hospital, Carlton, 3053, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, 3010, Australia
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Affiliation(s)
- Jorma Paavonen
- From the Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki (J.P.); and the Department of Medicine, University of British Columbia, Vancouver, Canada (R.C.B.)
| | - Robert C Brunham
- From the Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki (J.P.); and the Department of Medicine, University of British Columbia, Vancouver, Canada (R.C.B.)
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Abstract
Cervicovaginal microbiota play a critical role in women's health and reproductive outcomes. Despite being one of the simplest commensal bacterial communities in the human body, we are only beginning to appreciate its complex dynamic nature and important role in host immune modulation. In this review, we discuss the "optimal" cervicovaginal bacterial community composition, the impact of microbiota on gynecologic and obstetric outcomes, and the hurdles to developing a deeper mechanistic understanding of the function of the cervicovaginal microbiome. We then describe efforts to durably alter microbial composition in this compartment by promotion of Lactobacillus colonization with probiotics, modulation of vaginal pH, hormonal administration, and the eradication of pathogenic bacteria with antibiotics. Finally, we draw on lessons learned from the deeply investigated gut microbiome to suggest future avenues of research into host-pathogen interactions in the female genital tract.
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31
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Abstract
Bacterial vaginosis is a common vaginal infection that causes discharge, odor, and irritation. It can predispose women to sexually transmitted infections (STIs) including HIV. Recurrent bacterial vaginosis may require prolonged treatment to return the vaginal flora to a normal predominately lactobacilli-dominated environment.
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32
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Plummer EL, Vodstrcil LA, Danielewski JA, Murray GL, Fairley CK, Garland SM, Hocking JS, Tabrizi SN, Bradshaw CS. Combined oral and topical antimicrobial therapy for male partners of women with bacterial vaginosis: Acceptability, tolerability and impact on the genital microbiota of couples - A pilot study. PLoS One 2018; 13:e0190199. [PMID: 29293559 PMCID: PMC5749747 DOI: 10.1371/journal.pone.0190199] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/07/2017] [Indexed: 12/14/2022] Open
Abstract
Objectives Recurrence following recommended treatment for bacterial vaginosis is unacceptably high. While the pathogenesis of recurrence is not well understood, recent evidence indicates re-infection from sexual partners is likely to play a role. The aim of this study was to assess the acceptability and tolerability of topical and oral antimicrobial therapy in male partners of women with bacterial vaginosis (BV), and to investigate the impact of dual-partner treatment on the vaginal and penile microbiota. Methods Women with symptomatic BV (Nugent Score of 4–10 and ≥3 Amsel criteria) and their regular male sexual partner were recruited from Melbourne Sexual Health Centre, Melbourne, Australia. Women received oral metronidazole 400mg twice daily (or intra-vaginal 2% clindamycin cream, if contraindicated) for 7-days. Male partners received oral metronidazole 400mg twice daily and 2% clindamycin cream topically to the penile skin twice daily for 7-days. Couples provided self-collected genital specimens and completed questionnaires at enrolment and then weekly for 4-weeks. Genital microbiota composition was determined by 16S rRNA gene sequencing. Changes in genital microbiota composition were assessed by Bray-Curtis index. Bacterial diversity was measured by the Shannon Diversity Index. Results Twenty-two couples were recruited. Sixteen couples (76%) completed all study procedures. Adherence was high; most participants took >90% of prescribed medication. Medication, and particularly topical clindamycin in males, was well tolerated. Dual-partner treatment had an immediate and sustained effect on the composition of vaginal microbiota (median Bray-Curtis score day 0 versus day 8 = 0.03 [IQR 0–0.15], day 0 vs day 28 = 0.03 [0.02–0.11]). We observed a reduction in bacterial diversity of the vaginal microbiota and a decrease in the prevalence and abundance of BV-associated bacteria following treatment. Treatment had an immediate effect on the composition of the cutaneous penile microbiota (median Bray-Curtis score day 0 vs day 8 = 0.09 [0.04–0.17]), however this was not as pronounced at day 28 (median Bray-Curtis score day 0 vs day 28 = 0.38 [0.11–0.59]). A decrease in the prevalence and abundance of BV-associated bacteria in the cutaneous penile microbiota was observed immediately following treatment at day 8. Conclusion Combined oral and topical treatment of male partners of women with BV is acceptable and well tolerated. The combined acceptability and microbiological data presented in this paper supports the need for larger studies with longer follow up to characterize the sustained effect of dual partner treatment on the genital microbiota of couples and assess the impact on BV recurrence.
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Affiliation(s)
- Erica L. Plummer
- Department of Molecular Microbiology, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Lenka A. Vodstrcil
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer A. Danielewski
- Department of Molecular Microbiology, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Gerald L. Murray
- Department of Molecular Microbiology, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Christopher K. Fairley
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Suzanne M. Garland
- Department of Molecular Microbiology, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Microbiology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Jane S. Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Sepehr N. Tabrizi
- Department of Molecular Microbiology, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Microbiology, The Royal Children’s Hospital, Melbourne, Victoria, Australia
| | - Catriona S. Bradshaw
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- * E-mail:
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Unemo M, Bradshaw CS, Hocking JS, de Vries HJC, Francis SC, Mabey D, Marrazzo JM, Sonder GJB, Schwebke JR, Hoornenborg E, Peeling RW, Philip SS, Low N, Fairley CK. Sexually transmitted infections: challenges ahead. THE LANCET. INFECTIOUS DISEASES 2017; 17:e235-e279. [PMID: 28701272 DOI: 10.1016/s1473-3099(17)30310-9] [Citation(s) in RCA: 447] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/13/2017] [Accepted: 03/30/2017] [Indexed: 12/30/2022]
Abstract
WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Henry J C de Vries
- STI Outpatient Clinic, Public Health Service of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Suzanna C Francis
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - David Mabey
- Clinical Research Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeanne M Marrazzo
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Gerard J B Sonder
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands; Division of Infectious Diseases, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jane R Schwebke
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Elske Hoornenborg
- STI Outpatient Clinic, Public Health Service of Amsterdam, Amsterdam, Netherlands
| | - Rosanna W Peeling
- Clinical Research Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan S Philip
- Disease Prevention and Control Population Health Division, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.
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34
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Muzny CA, Schwebke JR. Pathogenesis of Bacterial Vaginosis: Discussion of Current Hypotheses. J Infect Dis 2017; 214 Suppl 1:S1-5. [PMID: 27449868 DOI: 10.1093/infdis/jiw121] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In April 2015, the Division of Microbiology and Infectious Diseases of the National Institute of Allergy and Infectious Diseases hosted an experts technical consultation on bacterial vaginosis (BV), where data regarding controversies over the pathogenesis of BV were discussed. The discussion on the epidemiology and pathogenesis of BV is presented here, and several hypotheses on its pathogenesis are critiqued. Rigorous hypothesis-driven studies are needed to ultimately determine the cause of BV. This information is vital for the prevention and control of this important infection and its adverse public health consequences.
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Affiliation(s)
- Christina A Muzny
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
| | - Jane R Schwebke
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham
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35
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Bradshaw CS, Sobel JD. Current Treatment of Bacterial Vaginosis-Limitations and Need for Innovation. J Infect Dis 2017; 214 Suppl 1:S14-20. [PMID: 27449869 DOI: 10.1093/infdis/jiw159] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Practitioners and patients alike widely recognize the limitations of current therapeutic approaches to the treatment of bacterial vaginosis (BV). Options remain extremely limited, and our inability to prevent the frequently, often relentless symptomatic recurrences of BV and to reduce serious sequelae such as preterm delivery, remains an acknowledged but unresolved shortcoming. Our incomplete understanding of the pathophysiology of this unique form of vaginal dysbiosis has been a significant impediment to developing optimal treatment and prevention approaches. New drugs have not been forthcoming and are not likely to be available in the immediate future; hence, reliance on the optimal use of available agents has become essential as improvised often unproven regimens are implemented. In this review, we will explore the limitations of currently recommended therapies, with a particular focus on the contribution of reinfection and pathogen persistence to BV recurrence, and the development of interventions that target these mechanisms. Ultimately, to achieve sustained cure and effectiveness against BV-associated sequelae, it is possible that we will need approaches that combine antimicrobials with biofilm-disrupting agents and partner treatments in those at risk of reinfection.
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Affiliation(s)
- Catriona S Bradshaw
- Melbourne Sexual Health Centre Central Clinical School, Monash University, Clayton, Australia
| | - Jack D Sobel
- Division of Infectious Diseases, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
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36
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Bilardi JE, Walker SM, Temple-Smith MJ, McNair RP, Mooney-Somers J, Vodstrcil LA, Bellhouse CE, Fairley CK, Bradshaw CS. Women view key sexual behaviours as the trigger for the onset and recurrence of bacterial vaginosis. PLoS One 2017; 12:e0173637. [PMID: 28278277 PMCID: PMC5344463 DOI: 10.1371/journal.pone.0173637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/23/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Bacterial vaginosis (BV) affects a third of women of reproductive age in the US and there is increasing evidence to suggest it may be sexually transmitted. This study aimed to extend and validate the findings of our earlier smaller qualitative study by exploring in detail women's views and experiences of the triggering factors associated with BV onset and recurrence. METHODS Women aged 20-49, who had experienced one or more symptomatic episode of BV within 6 months, were opportunistically recruited to complete a 38-item questionnaire on their experience of BV. RESULTS 103 women completed the questionnaire. Women were significantly more likely to report sexual than lifestyle factors triggered BV onset and recurrence (p<0.001). The top 3 factors women attributed to both BV onset and recurrence were identical-and all sexual. They included, in order: 1) unprotected sex; 2) sex with a new male partner; and 3) sex in general. The main lifestyle factors nominated included stress, diet, menstruation and the use of feminine hygiene products. While many women felt their BV had been transmitted through sexual contact (54%) and developed as a result of sexual activity (59%), few considered BV a sexually transmitted infection (STI) (10%). Despite this 57% felt partners should also be treated for BV. CONCLUSION These data concur with our earlier qualitative findings that women believe BV is triggered by sexual activity. While many women felt BV was sexually transmitted and supported partner treatment, they did not consider BV an STI. This contradiction is likely due to information conveyed to women based on current guidelines. In the absence of highly effective BV treatments, this study highlights the need for guidelines to indicate there is scientific uncertainty around the pathogenesis of BV and to contain clear health messages regarding the evidence for practices shown to be associated with a reduced risk of BV (i.e. consistent condom use.
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Affiliation(s)
- Jade E. Bilardi
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sandra M. Walker
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Ruth P. McNair
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julie Mooney-Somers
- Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Lenka A. Vodstrcil
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Clare E. Bellhouse
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher K. Fairley
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Catriona S. Bradshaw
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Victoria, Australia
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Price MJ, Ades AE, Soldan K, Welton NJ, Macleod J, Simms I, DeAngelis D, Turner KM, Horner PJ. The natural history of Chlamydia trachomatis infection in women: a multi-parameter evidence synthesis. Health Technol Assess 2016; 20:1-250. [PMID: 27007215 DOI: 10.3310/hta20220] [Citation(s) in RCA: 256] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The evidence base supporting the National Chlamydia Screening Programme, initiated in 2003, has been questioned repeatedly, with little consensus on modelling assumptions, parameter values or evidence sources to be used in cost-effectiveness analyses. The purpose of this project was to assemble all available evidence on the prevalence and incidence of Chlamydia trachomatis (CT) in the UK and its sequelae, pelvic inflammatory disease (PID), ectopic pregnancy (EP) and tubal factor infertility (TFI) to review the evidence base in its entirety, assess its consistency and, if possible, arrive at a coherent set of estimates consistent with all the evidence. METHODS Evidence was identified using 'high-yield' strategies. Bayesian Multi-Parameter Evidence Synthesis models were constructed for separate subparts of the clinical and population epidemiology of CT. Where possible, different types of data sources were statistically combined to derive coherent estimates. Where evidence was inconsistent, evidence sources were re-interpreted and new estimates derived on a post-hoc basis. RESULTS An internally coherent set of estimates was generated, consistent with a multifaceted evidence base, fertility surveys and routine UK statistics on PID and EP. Among the key findings were that the risk of PID (symptomatic or asymptomatic) following an untreated CT infection is 17.1% [95% credible interval (CrI) 6% to 29%] and the risk of salpingitis is 7.3% (95% CrI 2.2% to 14.0%). In women aged 16-24 years, screened at annual intervals, at best, 61% (95% CrI 55% to 67%) of CT-related PID and 22% (95% CrI 7% to 43%) of all PID could be directly prevented. For women aged 16-44 years, the proportions of PID, EP and TFI that are attributable to CT are estimated to be 20% (95% CrI 6% to 38%), 4.9% (95% CrI 1.2% to 12%) and 29% (95% CrI 9% to 56%), respectively. The prevalence of TFI in the UK in women at the end of their reproductive lives is 1.1%: this is consistent with all PID carrying a relatively high risk of reproductive damage, whether diagnosed or not. Every 1000 CT infections in women aged 16-44 years, on average, gives rise to approximately 171 episodes of PID and 73 of salpingitis, 2.0 EPs and 5.1 women with TFI at age 44 years. CONCLUSIONS AND RESEARCH RECOMMENDATIONS The study establishes a set of interpretations of the major studies and study designs, under which a coherent set of estimates can be generated. CT is a significant cause of PID and TFI. CT screening is of benefit to the individual, but detection and treatment of incident infection may be more beneficial. Women with lower abdominal pain need better advice on when to seek early medical attention to avoid risk of reproductive damage. The study provides new insights into the reproductive risks of PID and the role of CT. Further research is required on the proportions of PID, EP and TFI attributable to CT to confirm predictions made in this report, and to improve the precision of key estimates. The cost-effectiveness of screening should be re-evaluated using the findings of this report. FUNDING The Medical Research Council grant G0801947.
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Affiliation(s)
- Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - A E Ades
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Soldan
- Public Health England (formerly Health Protection Agency), Colindale, London, UK
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - John Macleod
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Ian Simms
- Public Health England (formerly Health Protection Agency), Colindale, London, UK
| | - Daniela DeAngelis
- Public Health England (formerly Health Protection Agency), Colindale, London, UK.,Medical Research Council Biostatistics Unit, Cambridge, UK
| | | | - Paddy J Horner
- School of Social and Community Medicine, University of Bristol, Bristol, UK.,Bristol Sexual Health Centre, University Hospital Bristol NHS Foundation Trust, Bristol, UK
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Recent Biomarker-Confirmed Unprotected Vaginal Sex, But Not Self-reported Unprotected Sex, Is Associated With Recurrent Bacterial Vaginosis. Sex Transm Dis 2016; 43:172-6. [PMID: 26859804 DOI: 10.1097/olq.0000000000000414] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Self-reported unprotected vaginal sex seems to increase risk of bacterial vaginosis (BV). However, the validity of self-reports is questionable, given their inconsistency with more objective measures of recent semen exposure such as detection of prostate-specific antigen (PSA). We examined whether recent unprotected sex, as measured both by PSA detection on vaginal swabs and by self-report, was associated with increased BV recurrence. METHODS We analyzed randomized trial data from nonpregnant, BV-positive adult women recruited from a sexually transmitted disease clinic. Participants received BV therapy at enrollment and were scheduled to return after 4, 12, and 24 weeks. Bacterial vaginosis (by Nugent score) and PSA were measured at each visit. We used Cox proportional hazards models to examine the association between PSA positivity and recurrent BV. We also evaluated associations between self-reported unprotected sex (ever/never since the last visit and in the last 48 hours, analyzed separately) and recurrent BV. RESULTS Prostate-specific antigen and BV results were available for 96 women who contributed 226 follow-up visits. Prostate-specific antigen positivity was associated with increased BV recurrence (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.28-4.21). In contrast, we observed no significant increase in BV recurrence among women self-reporting unprotected sex since the last visit (aHR, 1.63; 95% CI, 0.77-3.43) or in the last 48 hours (aHR, 1.28; 95% CI, 0.70-2.36). CONCLUSIONS Estimates from earlier studies linking self-reported unprotected sex and BV may be biased by misclassification. Biomarkers can improve measurement of unprotected sex, a critical exposure variable in sexual health research.
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Amaya‐Guio J, Viveros‐Carreño DA, Sierra‐Barrios EM, Martinez‐Velasquez MY, Grillo‐Ardila CF. Antibiotic treatment for the sexual partners of women with bacterial vaginosis. Cochrane Database Syst Rev 2016; 10:CD011701. [PMID: 27696372 PMCID: PMC6458027 DOI: 10.1002/14651858.cd011701.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Bacterial vaginosis (BV) is an infection that has a prevalence between 10% to 50% worlwide. BV results in an imbalance of the normal vaginal flora. Microorganisms associated with BV have been isolated from the normal flora of the male genital tract, and their presence could be related to the recurrence of BV after antibiotic treatment. Therefore, the treatment of sexual partners could decrease the recurrence of infection and possibly the burden of the disease. OBJECTIVES To assess the effectiveness in women and the safety in men of concurrent antibiotic treatment for the sexual partners of women treated for BV. SEARCH METHODS We searched the Cochrane Sexually Transmitted Infections Group Specialized Register (23 July 2016), CENTRAL (1991 to 23 July 2016), MEDLINE (1946 to 23 July 2016), Embase (1974 to 23 July 2016), LILACS (1982 to 23 July 2016), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (23 July 2016), ClinicalTrials.gov (23 July 2016) and the Web of Science™ (2001 to 23 July 2016). We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. SELECTION CRITERIA Randomized controlled trials (RCTs) that compared the concurrent use of any antibiotic treatment with placebo, no intervention or any other intervention by the sexual partners of women treated for BV. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Seven RCTs (1026 participants) met our inclusion criteria, and pharmaceutical industry funded four of these trials. Five trials (854 patients) compared any antibiotic treatment of sexual partners with placebo. Based on high quality evidence, antibiotic treatment does not increase the rate of clinical or symptomatic improvement in women during the first week (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.96 to 1.03; 712 participants, four studies; RR 1.06, 95% CI 1.00 to 1.12; 577 patients, three studies, respectively), between the first and fourth week (RR 1.02, 95% CI 0.94 to 1.11; 590 participants, three studies; RR 0.93, 95% CI 0.84 to 1.03; 444 participants, two studies; respectively) or after the fourth week (RR 0.98, 95% CI 0.90 to 1.07; 572 participants, four studies; RR 1.03, 95% CI 0.90 to 1.17; 296 participants, two studies; respectively). Antibiotic treatment does not led to a lower recurrence during the first and fourth week (RR 1.28, 95% CI 0.68 to 2.43; 218 participants, one study; low quality evidence) or after the fourth week of treatment (RR 1.00, 95% CI 0.67 to 1.52; 372 participants, three studies; low quality evidence) in women, but increases the frequency of adverse events (most frequently gastrointestinal symptoms) reported by sexual partners (RR 2.55, 95% CI 1.55 to 4.18; 477 participants, three studies; low quality evidence). Two trials (172 participants) compared any antibiotic treatment for sexual partners with no intervention. When we compared it with no intervention, the effects of antibiotic treatment on recurrence rate after the fourth week (RR 1.71, 95% CI 0.65 to 4.55; 51 participants, one study), clinical improvement between the first and fourth week (RR 0.93, 95% CI 0.70 to 1.25; 152 participants, two studies) and symptomatic improvement after the fourth week (RR 0.66, 95% CI 0.39 to 1.11; 70 participants, one study) were imprecise and there were no differences between groups. We downgraded the quality of the evidence to low or very low. AUTHORS' CONCLUSIONS High quality evidence shows that antibiotic treatment for sexual partners of women with BV, compared with placebo, does not increase the rate of clinical or symptomatic improvement during the first, between the first and fourth or after the fourth week into the women. Low quality evidence suggests that antibiotic treatment does not led to a lower recurrence rate during the first and fourth or after the fourth week of treatment into the women, but increases the frequency of adverse events reported by sexual partners. Finally, compared with no intervention, antibiotic treatment does not decrease the recurrence rate after the fourth week and does not increase the frequency of clinical or symptomatic improvement between the first and fourth or after the fourth week into the women, respectively.
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Affiliation(s)
- Jairo Amaya‐Guio
- Faculty of Medicine, Universidad Nacional de ColombiaDepartment of Obstetrics and GynecologyBogotaColombia
| | | | | | | | - Carlos F Grillo‐Ardila
- Faculty of Medicine, Universidad Nacional de ColombiaDepartment of Obstetrics and GynecologyBogotaColombia
- Faculty of Medicine, Universidad Nacional de ColombiaClinical Research InstituteBogotaColombia
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Price MJ, Ades AE, Welton NJ, Simms I, Macleod J, Horner PJ. Proportion of Pelvic Inflammatory Disease Cases Caused by Chlamydia trachomatis: Consistent Picture From Different Methods. J Infect Dis 2016; 214:617-24. [PMID: 27260786 PMCID: PMC4957435 DOI: 10.1093/infdis/jiw178] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 04/27/2016] [Indexed: 11/27/2022] Open
Abstract
Background. Pelvic inflammatory disease (PID) is a leading cause of both tubal factor infertility and ectopic pregnancy. Chlamydia trachomatis is an important risk factor for PID, but the proportion of PID cases caused by C. trachomatis is unclear. Estimates of this are required to evaluate control measures. Methods. We consider 5 separate methods of estimating age-group-specific population excess fractions (PEFs) of PID due to C. trachomatis, using routine data, surveys, case-control studies, and randomized controlled trials, and apply these to data from the United Kingdom before introduction of the National Chlamydia Screening Programme. Results. As they are informed by randomized comparisons and national exposure and outcome estimates, our preferred estimates of the proportion of PID cases caused by C. trachomatis are 35% (95% credible interval [CrI], 11%–69%) in women aged 16–24 years and 20% (95% CrI, 6%–38%) in women aged 16–44 years in the United Kingdom. There is a fair degree of consistency between adjusted estimates of PEF, but all have wide 95% CrIs. The PEF decreases from 53.5% (95% CrI, 15.6%–100%) in women aged 16–19 years to 11.5% (95% CrI, 3.0%–25.7%) in women aged 35–44 years. Conclusions. The PEFs of PID due to C. trachomatis decline steeply with age by a factor of around 5-fold between younger and older women. Further studies of the etiology of PID in different age groups are required.
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Affiliation(s)
- Malcolm J Price
- Institute of Applied Health Research, University of Birmingham
| | - A E Ades
- School of Social and Community Medicine, University of Bristol
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol
| | - Ian Simms
- Bristol Sexual Health Centre, University Hospital Bristol NHS Foundation Trust, United Kingdom
| | - John Macleod
- School of Social and Community Medicine, University of Bristol
| | - Paddy J Horner
- School of Social and Community Medicine, University of Bristol Public Health England, London
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41
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Bilardi J, Walker S, Mooney-Somers J, Temple-Smith M, McNair R, Bellhouse C, Fairley C, Chen M, Bradshaw C. Women's Views and Experiences of the Triggers for Onset of Bacterial Vaginosis and Exacerbating Factors Associated with Recurrence. PLoS One 2016; 11:e0150272. [PMID: 26930414 PMCID: PMC4773144 DOI: 10.1371/journal.pone.0150272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/11/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Bacterial vaginosis (BV) is the most common vaginal infection affecting women of childbearing age. While the aetiology and transmissibility of BV remain unclear, there is strong evidence to suggest an association between BV and sexual activity. This study explored women's views and experiences of the triggers for BV onset and factors associated with recurrence. METHODS A descriptive, social constructionist approach was chosen as the framework for the study. Thirty five women of varying sexual orientation who had experienced recurrent BV in the past five years took part in semi-structured interviews. RESULTS The majority of women predominantly reported sexual contact triggered the onset of BV and sexual and non-sexual factors precipitated recurrence. Recurrence was most commonly referred to in terms of a 'flare-up' of symptoms. The majority of women did not think BV was a sexually transmitted infection however many reported being informed this by their clinician. Single women who attributed BV onset to sex with casual partners were most likely to display self-blame tendencies and to consider changing their future sexual behaviour. Women who have sex with women (WSW) were more inclined to believe their partner was responsible for the transmission of or reinfection with BV and seek partner treatment or change their sexual practices. CONCLUSION Findings from this study strongly suggest women believe that BV onset is associated with sexual activity, concurring with epidemiological data which increasingly suggest BV may be sexually transmitted. Exacerbating factors associated with recurrence were largely heterogeneous and may reflect the fact it is difficult to determine whether recurrence is due to persistent BV or a new infection in women. There was however evidence to suggest possible transmission and reinfection among WSW, reinforcing the need for new approaches to treatment and management strategies including male and female partner treatment trials.
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Affiliation(s)
- Jade Bilardi
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Sandra Walker
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Julie Mooney-Somers
- Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Meredith Temple-Smith
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth McNair
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Clare Bellhouse
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Christopher Fairley
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Marcus Chen
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Catriona Bradshaw
- Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Mendling W, Weissenbacher ER, Gerber S, Prasauskas V, Grob P. Use of locally delivered dequalinium chloride in the treatment of vaginal infections: a review. Arch Gynecol Obstet 2015; 293:469-84. [PMID: 26506926 PMCID: PMC4757629 DOI: 10.1007/s00404-015-3914-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/12/2015] [Indexed: 12/12/2022]
Abstract
Background Vaginal infections are responsible for a large proportion of gynaecological outpatient visits. Those are bacterial vaginosis (BV), vulvovaginal candidosis (VVC), aerobic vaginitis (AV) associated with aerobic bacteria, and mixed infections. Usual treatments show similar acceptable short-term efficacy, but frequent recurrences and increasing microbial resistance are unsolved issues. Furthermore, vaginal infections are associated with a variety of serious adverse outcomes in pregnancy and generally have a major impact on quality of life. Identifying the correct therapy can be challenging for the clinician, particularly in mixed infections. Findings Dequalinium chloride (DQC) is an anti-microbial antiseptic agent with a broad bactericidal and fungicidal activity. Systemic absorption after vaginal application of DQC is very low and systemic effects negligible. Vaginal DQC (Fluomizin®vaginal tablets) has been shown to have equal clinical efficacy as clindamycin in the treatment of BV. Its broad antimicrobial activity makes it appropriate for the treatment of mixed vaginal infections and in case of uncertain diagnosis. Moreover, resistance of pathogens is unlikely due to its multiple mode of action, and vaginal DQC provides also a reduced risk for post-treatment vaginal infections. Conclusions Vaginal DQC (10 mg) as 6-day therapy offers a safe and effective option for empiric therapy of different vaginal infections in daily practice. This review summarizes the available and relevant pharmacological and clinical data for the therapy of vaginal infections with vaginal DQC and provides the rationale for its use in daily gynaecologic practice.
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Affiliation(s)
- Werner Mendling
- German Center for Infections in Gynecology and Obstetrics, Wuppertal, Germany.
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43
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Muzny CA, Schwebke JR. Biofilms: An Underappreciated Mechanism of Treatment Failure and Recurrence in Vaginal Infections. Clin Infect Dis 2015; 61:601-6. [PMID: 25935553 PMCID: PMC4607736 DOI: 10.1093/cid/civ353] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/26/2015] [Indexed: 12/13/2022] Open
Abstract
Biofilms are microbial communities of surface-attached cells embedded in a self-produced extracellular matrix. They are of major medical significance because they decrease susceptibility to antimicrobial agents and enhance the spread of antimicrobial resistance. Biofilm-associated bacterial and fungal microorganisms have increasingly been recognized to play a role in multiple infectious diseases, particularly in their persistence and recurrence. More recently, biofilms have also been implicated in vaginal infections, notably bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC), particularly in the setting of treatment failure and recurrence. The purpose of this review is to discuss the impact of biofilms on the management and treatment of BV and recurrent VVC and highlight the need for additional research and development of novel therapeutics targeting pathogenic vaginal biofilms.
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Affiliation(s)
- Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham
| | - Jane R Schwebke
- Division of Infectious Diseases, University of Alabama at Birmingham
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Bradshaw CS, Brotman RM. Making inroads into improving treatment of bacterial vaginosis - striving for long-term cure. BMC Infect Dis 2015. [PMID: 26219949 PMCID: PMC4518586 DOI: 10.1186/s12879-015-1027-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Bacterial vaginosis (BV) is one of the great enigmas in women's health, a common condition of unknown aetiology, which is associated with significant morbidity and unacceptably high recurrence rates. While it remains unclear whether BV recurrence is predominantly due to failure of current antibiotic regimens to eradicate BV-associated bacteria (BVAB) and biofilm, a failure of some women to re-establish a resilient Lactobacillus-dominant vaginal microbiota, reinfection from sexual partners, or a combination of these factors, it is inherently challenging to make significant inroads towards this goal. In this review, we will outline why BV is such a clinical and epidemiologic conundrum, and focus on several key approaches that we believe merit discussion and clinical research, including strategies to: i) prevent reinfection (partner treatment trials), ii) boost favourable vaginal Lactobacillus species and promote a Lactobacillus-dominant vaginal microbiome (hormonal contraceptive and probiotic trials) and iii) disrupt vaginal BV-associated biofilm.
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Affiliation(s)
- Catriona S Bradshaw
- Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, VIC, 3053, Australia. .,Central Clinical School, Monash University, Melbourne, VIC, Australia.
| | - Rebecca M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.
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45
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Liu CM, Hungate BA, Tobian AAR, Ravel J, Prodger JL, Serwadda D, Kigozi G, Galiwango RM, Nalugoda F, Keim P, Wawer MJ, Price LB, Gray RH. Penile Microbiota and Female Partner Bacterial Vaginosis in Rakai, Uganda. mBio 2015; 6:e00589. [PMID: 26081632 PMCID: PMC4471566 DOI: 10.1128/mbio.00589-15] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/17/2015] [Indexed: 12/15/2022] Open
Abstract
UNLABELLED Bacterial vaginosis (BV) is a common vaginal bacterial imbalance associated with risk for HIV and poor gynecologic and obstetric outcomes. Male circumcision reduces BV-associated bacteria on the penis and decreases BV in female partners, but the link between penile microbiota and female partner BV is not well understood. We tested the hypothesis that having a female partner with BV increases BV-associated bacteria in uncircumcised men. We characterized penile microbiota composition and density (i.e., the quantity of bacteria per swab) by broad-coverage 16S rRNA gene-based sequencing and quantitative PCR (qPCR) in 165 uncircumcised men from Rakai, Uganda. Associations between penile community state types (CSTs) and female partner's Nugent score were assessed. We found seven distinct penile CSTs of increasing density (CST1 to 7). CST1 to 3 and CST4 to 7 were the two major CST groups. CST4 to 7 had higher prevalence and abundance of BV-associated bacteria, such as Mobiluncus and Dialister, than CST1 to 3. Men with CST4 to 7 were significantly more likely to have a female partner with a high Nugent score (P = 0.03). Men with two or more extramarital partners were significantly more likely to have CST4 to 7 than men with only marital partners (CST4 to 7 prevalence ratio, 1.84; 95% confidence interval [CI], 1.16 to 2.92). Female partner Nugent BV is significantly associated with penile microbiota. Our data support the exchange of BV-associated bacteria through intercourse, which may explain BV recurrence and persistence. IMPORTANCE Bacterial vaginosis (BV) is sexually associated but not considered a sexually transmitted disease. Our findings suggest that the uncircumcised penis is an important niche for BV-associated genital anaerobes. In addition, we found a link between extramarital sexual relationships and BV-associated bacteria in men, which parallels earlier findings of the association between sexual activity and BV in women. This suggests the sexual transmissibility of BV-associated bacteria. Reducing bacterial exchange by barrier methods and managing carriage of BV-associated bacteria in men may decrease BV persistence and recurrence in women.
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Affiliation(s)
| | - Bruce A Hungate
- Center for Ecosystem Science and Society and Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona, USA
| | - Aaron A R Tobian
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | | | | | | | | | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA
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46
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Amaya-Guio J, Martinez-Velasquez MY, Viveros-Carreño DA, Sierra-Barrios EM, Grillo-Ardila CF. Antibiotic treatment for the sexual partners of women with bacterial vaginosis. Cochrane Database Syst Rev 2015. [DOI: 10.1002/14651858.cd011701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
Vaginal and vulvar disorders are among the leading causes for women to visit a health care professional. Therefore, it is important to have a basic understanding of these diseases. Although rarely life threatening, these disorders can impact significantly a woman's sexual function and sense of well-being.
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Affiliation(s)
- Andrea Prabhu
- Division of Women's Health, Department of Obstetrics and Gynecology, University of Washington, Box 356460, Seattle, WA 98195, USA.
| | - Carolyn Gardella
- Division of Women's Health, Department of Obstetrics and Gynecology, University of Washington, Box 356460, Seattle, WA 98195, USA; Department of Gynecology, VA Puget Sound Medical Center, 1600 South Columbian Way, Seattle, WA 98108, USA
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48
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Muzny CA, Schwebke JR. Editorial commentary: women who have sex with women: a unique population for studying the pathogenesis of bacterial vaginosis. Clin Infect Dis 2015; 60:1054-6. [PMID: 25516182 DOI: 10.1093/cid/ciu1132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Christina A Muzny
- Division of Infectious Diseases, University of Alabama at Birmingham
| | - Jane R Schwebke
- Division of Infectious Diseases, University of Alabama at Birmingham
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49
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Vodstrcil LA, Walker SM, Hocking JS, Law M, Forcey DS, Fehler G, Bilardi JE, Chen MY, Fethers KA, Fairley CK, Bradshaw CS. Incident Bacterial Vaginosis (BV) in Women Who Have Sex With Women Is Associated With Behaviors That Suggest Sexual Transmission of BV. Clin Infect Dis 2014; 60:1042-53. [DOI: 10.1093/cid/ciu1130] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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50
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Powell AM, Nyirjesy P. Recurrent vulvovaginitis. Best Pract Res Clin Obstet Gynaecol 2014; 28:967-76. [DOI: 10.1016/j.bpobgyn.2014.07.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
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