Evolving issues in understanding and treating bacterial vaginosis

Factors associated with bacterial vaginosis in women with homosexual, bisexual and heterosexual practices

BACKGROUND

The factors associated with bacterial vaginosis in women with homosexual, bisexual and heterosexual practices are still poorly explored. Thus, the aim of this study was to analyze the factors associated with bacterial vaginosis in women with different sexual practices.

METHODS

Cross-sectional study that included 453 women, 149 Women with Homosexual practice (WSW); 80 bisexual Women (WSWM) and 224 Women with heterosexual practice (WSM). The diagnosis of bacterial vaginosis was performed by microscopic examination of the vaginal smears stained by Gram method and classified according to the Nugent et al. (1991) score. Data analysis was performed by Cox multiple regression.

RESULTS

Bacterial vaginosis was associated to years of education among WSW (0.91 [95% CI 0.82‒0.99]; p = 0.048) and non-white skin color (2.34 [95% CI 1.05‒5.19]; p = 0.037) between WSWM. Changing partners in the last 3-months (2.09 [95% CI 1.14‒3.82]; p = 0.017), inconsistent use of condoms (2.61 [95% CI 1.10‒6.20]; p = 0.030) and positive diagnosis of Chlamydia trachomatis (2.40 [95% CI 1.01‒5.73]; p = 0.048) were associated with bacterial vaginoses only in WSH.

CONCLUSIONS

The factors associated to bacterial vaginosis differ between different sexual practices, suggesting that the type of sexual partner may influence the risk of developing this classic dysbiosis.

Systematic Review: The Neovaginal Microbiome

OBJECTIVE

To review neovaginal colonization and inflammatory patterns, and factors that may impact this.

METHODS

A systematic review of the neovaginal microbiome was conducted in concordance with PRISMA guidelines through October 2021.

RESULTS

Thirteen articles were included, totaling 458 patients. Neovaginal constructions were most commonly performed with penile and scrotal skin grafts, sigmoid segments, and peritoneal grafts. The neovaginal microflora identified were generally polymicrobial and shared similarities with the native tissue. Nine studies identified Lactobacillus: 5/6 for penile skin, 1/3 for sigmoid, 1/1 for peritoneum, and 2/3 for other graft types, suggesting that the neovagina may support Lactobacillus either innately, via rectal migration or oral probiotic supplementation. A polymicrobial, bacterial vaginosis-like environment was found in nine studies. Inflammatory markers were also described: 2/6 for penile skin, 2/3 for sigmoid, 0/1 for peritoneum, and 1/3 for other graft types. Scant data were available on the impact of postsurgical duration, oral hormones, dilating, sexual practices, or douching on the neovaginal microbiome.

CONCLUSION

Understanding and optimizing the polymicrobial neovaginal microenvironment may improve surgical outcomes, specifically inflammatory, pain, and infectious. Future research should focus on standardizing testing and classification systems, and treating neovaginal dysbiosis.

Prevalence of bacterial vaginosis and factors associated among women who have sex with women

OBJECTIVE

to describe the prevalence of bacterial vaginosis and factors associated among women who have sex with women.

METHOD

cross-sectional, descriptive and analytical study with 150 women. The vaginal microbiota profile was analyzed by microscopic examination of vaginal swabs according to the Gram method. Endocervical samples were collected with cytobrush for the investigation of endocervicitis by Chlamydia trachomatis. The polymerase chain reaction was used to diagnosis Human Papillomavirus infection. Socio-demographic data, sexual behavior and clinical history were obtained through an interview. Logistic regression was performed to identify risk factors independently associated with bacterial vaginosis.

RESULTS

among the 150 participants, 71 (47.3%) presented some alteration in the vaginal microbiota, 54 (36.0%) bacterial vaginosis and 12 (8.0%) Flora II. The variable independently associated with bacterial vaginosis was the use of sexual accessories [2.37(1.13-4.97), p=0.022].

CONCLUSION

the high prevalence of bacterial vaginosis among women who have sex with women indicates the need for screening this population and association between use of sexual accessories and this disease suggests the possibility of transmission of sexual fluids between the partners during the sexual act, which demonstrates the need for educational actions on sexual and reproductive health.

Prevalence of Mycoplasma genitalium and Mycoplasma hominis in urogenital tract of Brazilian women

BACKGROUND

The role of Mycoplasma hominis and M. genitalium in urogenital tract infections remains unknown. Furthermore these mollicutes present a complex relationship with the host immune response. The role of inflammatory cytokines in infections also makes them good candidates to investigate bacterial vaginosis and mycoplasma genital infections. Therefore, the aim of this study was to detect the above-mentioned mollicutes by quantitative Polymerase Chain Reaction (qPCR) methodologies in vaginal swabs and dosage of cytokines.

METHODS

Vaginal swabs and peripheral blood were collected from 302 women, including healthy individuals. The molecular findings were correlated with some individual behavioral variables, clinical and demographic characteristics, presence of other important microorganisms in vaginal swabs, and levels of interleukin (IL)-1β and IL-6.

RESULTS

M. hominis and M. genitalium were detected in 31.8% and 28.1% of samples, respectively. The qPCR results were associated with clinical signs and symptoms of the infections studied. The frequency of Trichomonas vaginalis, Gardnerella vaginalis, Neisseria gonorrhoeae and Chlamydia trachomatis was 3.0%, 21.5%, 42.4%, and 1.7% respectively. Increased levels of IL-1β were associated with the presence of M. hominis and signs and/or symptoms of the genital infection of women studied.

CONCLUSION

IL-1β production was associated with the detection of M. hominis by qPCR. The sexual behavior of women studied was associated with the detection of mycoplasma and other agents of genital infections.

High-dose vaginal metronidazole for recurrent bacterial vaginosis--a pilot study

OBJECTIVE

The purpose of this study was to evaluate high-dose intravaginal metronidazole, with or without miconazole, in enhancing cure rates in women with recurrent BV.

MATERIALS AND METHODS

A total of 43 women with symptomatic recurrent BV were enrolled in a 4-arm study comparing 500 mg versus 750 mg of metronidazole, with or without miconazole, intravaginally for 7 days. Test of cure by saline wet mount and 10% potassium chloride microscopy, pH, Gram stain for Nugent score, and yeast culture were performed 3 times after treatment: 3 to 7 days, 30 to 35 days, and 60 to 70 days.

RESULTS

Overall cure rate for the entire group was 92.6% at visit 2, 62.1% at visit 3, and 51.4% at visit 4. At visit 2, there was no difference in cure rates among patients who received metronidazole 750 mg ± miconazole daily (90.5%) compared with metronidazole 500 mg ± miconazole daily (85%). At visit 3, there was a significant improvement in cure rates among patients who received metronidazole 750 mg ± miconazole daily (78.9%) compared with metronidazole 500 mg ± miconazole daily (44.4%) (p < .05). At visit 4, a significant difference in clinical cure rates persisted among patients who received metronidazole 750 mg ± miconazole daily (68.4%) compared with of metronidazole 500 mg ± miconazole daily (33.3%; p < .05). Poor responses (Nugent score > 4 or pH > 4.4) at the first visit alter treatment-predicted recurrence. The addition of miconazole did not enhance BV response rates.

CONCLUSIONS

Cure rates for BV were high in this refractory cohort and seemed dose dependent.

Efficacy of orally applied probiotic capsules for bacterial vaginosis and other vaginal infections: a double-blind, randomized, placebo-controlled study

OBJECTIVE

To assess the efficacy of orally administered capsules containing the probiotics Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 (Lactogyn, JGL, Rijeka, Croatia) compared to placebo in otherwise healthy women diagnosed with bacterial vaginosis.

STUDY DESIGN

Randomized, double-blind, multicentric, placebo-controlled trial, including a total of 544 subjects. Included were women older than 18 years of age, diagnosed with vaginal infection. Subjects received either probiotic (395 subjects or 72.6%) or identical-looking placebo capsules (149 subjects or 27.4%,) per day over a period of 6 weeks. Six and 12 weeks after the beginning of the study, subjects underwent two additional gynecological examinations and their vaginal swabs were evaluated by a clinical cytologist.

RESULTS

Mean follow-up period after the baseline visit was 44 days. After this period, restitution to balanced vaginal microbiota was reported in 40 subjects (26.9%) in the placebo group, compared to 243 subjects (61.5%) in the probiotic group. Differences between groups were statistically significant at p<0.001. After the additional 6 weeks of follow up, normal vaginal microbiota were still present in more than half (51.1%) of subjects in the probiotic group, but only in around one-fifth (20.8%) of subjects who were taking placebo (p<0.001).

CONCLUSION

Oral probiotics could be an alternative, side effect-free treatment for one of the most common indications in gynecology, combining the good aspects of both metronidazole and vaginal capsules.

Costs and effectiveness of neonatal male circumcision

OBJECTIVE

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.

DESIGN

We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty.

SETTING

United States.

PARTICIPANTS

Birth cohort of men and women.

INTERVENTION

Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited).

OUTCOMES MEASURED

Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections.

RESULTS

Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses.

CONCLUSION

Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Probiotics for the treatment of bacterial vaginosis

BACKGROUND

The dominance of lactobacilli in healthy vaginal microbiota and its depletion in bacterial vaginosis (BV) has given rise to the concept of oral or vaginal instillation of probiotic Lactobacillus strains for the management of this condition.

OBJECTIVES

To ascertain the efficacy of probiotics in the treatment of BV.

SEARCH STRATEGY

We searched electronic databases irrespective of publication status or language. These included: Cochrane Central Register of Controlled Trials (CENTRAL), the HIV/AIDS and STD Cochrane Review Groups' specialized registers, the Cochrane Complementary Medicine Field's Register of Controlled Trials, MEDLINE (1966 to 2008), EMBASE (1980 to 2007), ISI science citation index (1955 to 2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature (1982 to 2007).We handsearched of specialty journals, conference proceedings and publications list on the website of the International Scientific Association of Probiotics and Prebiotics (http://www.isapp.net/default.asp).For unpublished studies or ongoing trials, we contacted authors from relevant publications, nutraceutical companies and probiotic-related scientific associations. We searched electronic databases on ongoing clinical trials.

SELECTION CRITERIA

Randomized controlled trials using probiotics for the treatment of women of any age diagnosed with bacterial vaginosis, regardless of diagnostic method used. The probiotic preparation could be single or "cocktail" of strains, any preparation type/dosage/route of administration. Studies comparing probiotics with placebo, probiotics used in conjunction with conventional antibiotics compared with placebo or probiotics alone compared with conventional antibiotics were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We screened titles and abstracts , obtained full reports of relevant trialsand independently appraised them for eligibility. A data extraction form was used to extract data from the four included studies. For dichotomous outcomes, odds ratios (OR) and 95% confidence intervals (CI) were derived for each study using RevMan (versions 4.2 and 5). We did not perform meta-analysis due to significant differences in the probiotic preparations and trial methodologies.

MAIN RESULTS

Analysis suggests beneficial outcome of microbiological cure with the oral metronidazole/probiotic regimen (OR 0.09 (95% CI 0.03 to 0.26)) and the probiotic/estriol preparation (OR 0.02, (95% CI 0.00 to 0.47)). For the probiotic/estriol preparation, the OR and 95% CI for physician-reported resolution of symptoms was OR 0.04 (95% CI 0.00 to 0.56).

AUTHORS' CONCLUSIONS

The results do not provide sufficient evidence for or against recommending probiotics for the treatment of BV. The metronidazole/probiotic regimen and probiotic/estriol perparation appear promising but well-designed randomized controlled trials with standardized methodologies and larger patient size are needed.

Microflora of the penile skin-lined neovagina of transsexual women

Background

The microflora of the penile skin-lined neovagina in male-to-female transsexuals is a recently created microbial niche which thus far has been characterized only to a very limited extent. Yet the knowledge of this microflora can be considered as essential to the follow-up of transsexual women. The primary objective of this study was to map the neo-vaginal microflora in a group of 50 transsexual women for whom a neovagina was constructed by means of the inverted penile skin flap technique. Secondary objectives were to describe possible correlations of this microflora with multiple patients' characteristics, such as sexual orientation, the incidence of vaginal irritation and malodorous vaginal discharge.

Results

Based on Gram stain the majority of smears revealed a mixed microflora that had some similarity with bacterial vaginosis (BV) microflora and that contained various amounts of cocci, polymorphous Gram-negative and Gram-positive rods, often with fusiform and comma-shaped rods, and sometimes even with spirochetes. Candida cells were not seen in any of the smears.

On average 8.6 species were cultured per woman. The species most often found were: Staphylococcus epidermidis, Streptococcus anginosus group spp., Enterococcus faecalis, Corynebacterium sp., Mobiluncus curtisii and Bacteroides ureolyticus. Lactobacilli were found in only one of 30 women

There was no correlation between dilatation habits, having coitus, rinsing habits and malodorous vaginal discharge on the one hand and the presence of a particular species on the other. There was however a highly significant correlation between the presence of E. faecalis on the one hand and sexual orientation and coitus on the other (p = 0.003 and p = 0.027 respectively).

Respectively 82%, 58% and 30% of the samples showed an amplicon after amplification with M. curtisii, Atopobium vaginae and Gardnerella vaginalis primer sets.

Conclusion

Our study is the first to describe the microflora of the penile skin-lined neovagina of transsexual women. It reveals a mixed microflora of aerobe and anaerobe species usually found either on the skin, in the intestinal microflora or in a BV microflora.

Vulvar discharge syndrome in loosely housed Finnish pigs: prevalence and evaluation of vaginoscopy, bacteriology and cytology

A total of 21 sow herds were randomly chosen to determine the prevalence of vulvar discharge syndrome (VDS) in loosely housed sows. The median VDS prevalence was low as expected, 0% (range 0-4.5%). Nine of the 655 animals examined (1.4%, 95% CI 0.5-2.3) displayed signs of VDS in 21 non-problem herds. In addition, five VDS problem farms were visited to gather more animals affected with the syndrome in order to estimate which methods of examination are useful. Altogether, 19 VDS animals and 19 healthy controls were found, inspected and sampled. Ten of the VDS animals (53%) and three of the controls (16%) were positive in bacterial culture (p = 0.04) taken with a guarded swab from the anterior vagina. In addition, 94% of VDS animals had a positive vaginoscopic examination result and the corresponding figure in the control sows was 28% (p < 0.0002). Cytological smears were classified as positive in 37% of the case sows and in 5% of the control sows (p = 0.04). Detection of vulvar discharge was associated with vaginoscopic examination findings (p = 0.0005) and with bacteriology (p = 0.04), but not with leucocyte counts (p = 0.07). Susceptibility testing was performed on pure bacterial cultures. Totally, 7 (44%) of 16 isolates were considered to be resistant or showed intermediate susceptibility to at least one of the antimicrobial agents tested (sulpha-trimethoprim and ampicillin). In conclusion, we found vaginoscopy and bacteriology as valid tools in diagnosis of VDS and susceptibility testing of antimicrobial treatments was found to be indicated.

Activity of a Lactobacillus acidophilus–Based Douche for the Treatment of Bacterial Vaginosis

OBJECTIVES

Bacterial vaginosis is characterized by alteration of the normal vaginal microflora, in which a mixed anaerobic bacterial flora becomes prevalent over the population of lacobacilli. Because administration of probiotics might be of some utility in restoring a normal flora, the present study aimed to evaluate the effect of a Lactobacillus acidophilus-strain-based douche on the vaginal environment in bacterial vaginosis.

PATIENTS AND METHODS

In an open-label pilot evaluation, 40 women with bacterial vaginosis as defined by Amsel's criteria were treated for 6 days with a douche containing L. acidophilus. Vaginal smears were collected from the patients and analyzed according to Nugent's criteria at the time of diagnosis, after 6 days of treatment, and again at 20 days after the last treatment. At the same times, determination of vaginal pH and a Whiff test were performed.

RESULTS

The Nugent score decreased significantly from bacterial vaginosis or an intermediate flora toward a normal flora during treatment, and remained low during the follow-up period for almost all of the patients, indicating bacterial vaginosis in 52.5% and in 7.5% of the patients before treatment and at follow-up, respectively. After treatment, significant decreases in vaginal pH were observed, to less than pH 4.5 in 34/40 women, and the odor test became negative in all of the patients.

CONCLUSIONS

In this preliminary study, treatment of bacterial vaginosis with a vaginal douche containing a strain of L. acidophilus contributed to the restoration of a normal vaginal environment.

A pilot study of vaginal flora changes with randomization to cessation of douching

OBJECTIVES

The objectives of this study were to determine whether women who douche regularly would enter a randomized trial of douching cessation or continuation, whether they would adhere to the assigned behavior, and whether there was a dramatic impact on vaginal flora.

GOAL

The goal of this study was to determine the feasibility of a large, definitive trial of douching cessation.

STUDY DESIGN

Women who douched at least weekly and who had either bacterial vaginosis or normal flora by Gram stain were assigned at random either to continue douching or to stop for 8 weeks. Vaginal Gram stains were obtained every 7 days from each woman.

RESULTS

Forty-eight women were randomized. Those assigned to continue reported douching during 77% of study weeks; those assigned to stop denied douching in 94% of weeks. No dramatic differences in flora were observed between women in the continue versus stop groups.

CONCLUSION

A large randomized trial of douching cessation is feasible.

Thein vitroeffect of hydrogen peroxide on vaginal microbial communities

This study presents a series of experiments carried out in order to elucidate the role of H2O2 in antimicrobial activity of lactobacilli. Vaginal swabs were collected from 60 premenopausal women and checked for pH and Nugent score, and Lactobacillus species were cultured, phenotyped and genotyped. The main outcome measures involved: (1) species of vaginal lactobacilli most effective in liberating H2O2, (2) minimal microbicidal concentrations of added H2O2, (3) kinetics of H2O2 liberation in relation to oxygen tension, (4) antimicrobial activity of pure H2O2 versus one produced by selected vaginal lactobacilli and the total activity of their culture supernatants. Results showed that H2O2 was liberated especially by: Lactobacillus delbrueckii, Lactobacillus acidophilus, Lactobacillus crispatus, Lactobacillus johnsonii and L. gasseri. Hydrogen peroxide reached concentrations from 0.05 to 1.0 mM, which under intensive aeration increased even up to 1.8 mM. Microorganisms related to vaginal pathologies show varied resistance to the action of pure H2O2. Most potent inhibitory activity against bacteria and yeasts was presented by Lactobacillus culture supernate producing H2O2, followed by the nonproducing strain and pure H2O2. To conclude - the antimicrobial activity of lactobacilli is a summation of various inhibitory mechanisms in which H2O2 plays some but not a crucial role, in addition to other substances.

Clinical study comparing probiotic Lactobacillus GR-1 and RC-14 with metronidazole vaginal gel to treat symptomatic bacterial vaginosis

Bacterial vaginosis (BV) is particularly common in black women, and in Nigeria it is often caused by Mycoplasma, as well as Atopobium, Prevotella and Gardnerella sp. Antimicrobial metronidazole oral therapy is poorly effective in eradicating the condition and restoring the Lactobacillus microbiota in the vagina. In this study, 40 women diagnosed with BV by discharge, fishy odor, sialidase positive test and Nugent Gram stain scoring, were randomized to receive either two dried capsules containing Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 each night for 5 days, or 0.75% metronidazole gel, applied vaginally twice a day (in the morning and evening). Follow-up at day 6, 15 and 30 showed cure of BV in significantly more probiotic treated subjects (16, 17 and 18/20, respectively) compared to metronidazole treatment (9, 9 and 11/20: P=0.016 at day 6, P=0.002 at day 15 and P=0.056 at day 30). This is the first report of an effective (90%) cure of BV using probiotic lactobacilli. Given the correlation between BV and HIV, and the high risk of the latter in Nigeria, intravaginal use of lactobacilli could provide women with a self-use therapy, similar to over-the-counter anti-yeast medication, for treatment of urogenital infections.

A preliminary survey of Atopobium vaginae in women attending the Dunedin gynaecology out-patients clinic: is the contribution of the hard-to-culture microbiota overlooked in gynaecological disorders?

Preliminary studies have indicated that the recently described bacterium Atopobium vaginae may have an association with bacterial vaginosis (BV). Fifty-five women attending the gynaecology out-patient's clinic were tested for the presence of this micro-organism, Gardnerella vaginalis, Mobiluncus and Bacteroides species by polymerase chain reaction (PCR)-based assays. The frequency of detection was 40%. PCR detection of Gardnerella vaginalis with A. vaginae, occurred in 50% of A. vaginae-positive cases. Due to the high detection rate of A. vaginae we believe that it is important to determine whether this and other hard-to-culture microorganisms have a role in gynaecological disorders.