Epidemiology and clinico-investigative study of organisms causing vaginal discharge

Patient characteristics and factors contributing to recurrence of bacterial vaginosis presented in primary care

BACKGROUND

Bacterial vaginosis (BV) is a common problem in primary care. BV symptoms often have a negative impact on patients' quality of life and may predispose to gynaecological problems. Some patients experience recurring episodes of BV. This study's objective is to identify possible factors that may be associated with BV recurrence and describe the characteristics of these patients and interventions performed by general practitioners.

METHODS

In this retrospective cohort study, we used data from a primary care registration network in the Netherlands in the period 2015-2020. We analysed differences between patients with recurrent BV and patients with a single episode of BV in terms of characteristics and interventions performed by general practitioners.

RESULTS

We found that patients with recently prescribed antibiotics, and a medical history of sexually transmitted infections and/or Candidiasis significantly more often presented with recurrent BV. Patients with recurrent BV had more remote consultations and less in-person consultations than single-episode patients. The reason for encounter was more often a request for medication. Regarding GPs' diagnostic and therapeutic interventions, microbiological tests were more frequently performed in recurrent BV patients. Moreover, most patients in both groups were prescribed oral metronidazole most frequently.

CONCLUSIONS

Our findings might help GPs to better recognise patients at risk of recurrence. GPs could re-evaluate their approach to the diagnosis and treatment of recurrent BV, opting for in-person consultation and using standardised diagnostic criteria and microbiological testing in patients with recurrent complaints. Antibiotic use for other conditions in these patients may lead to new BV episodes.

Efficacy of Acacia nilotica Linn. Pod's Sitz Bath plus Vaginal Pessary in Syndromic Management of Abnormal Vaginal Discharge: A Randomized Controlled Trial

Objectives

Abnormal vaginal discharge (Sayalan al-Rahim) is a common public health problem that significantly disrupts the health-related quality of life (HRQoL). Syndromic management infers the concurrent treatment of two or more infections. Hence, a comparative, single-blind study was planned to determine the efficacy of Acacia (Acacia nilotica Linn.) pod's sitz bath (Abzan) plus vaginal pessary (Farzaja) vs. placebo in abnormal vaginal discharge syndromic management, its associated symptoms, and women's HRQoL.

Methods

Diagnosed patients (n = 66) were randomly divided into Acacia (n = 33) and placebo (n = 33) group. Acacia group received Sitz bath with Acacia pod powder (30g) solution followed by vaginal cotton pessary (5 ml of the same solution) once daily for 10 days. The placebo group received palm sugar powder (30g) solution for Sitz bath plus vaginal cotton pessary same as the Acacia group. Primary outcomes included clinical cure assessed with VAS for symptoms and Modified McCormack Pain Scale (McPS) for pelvic tenderness. The secondary outcomes included were the EQ-5D-5 L questionnaire, TSQM questionnaire, sachet count, and microbiological cure. Overall, therapeutic cure included clinical and microbiological cure after treatment.

Results

The overall therapeutic cure for bacterial vaginosis, cervicitis, and uncomplicated pelvic inflammatory disease was 100% (n = 7/7), 45.45% (n = 10/22), and 71.42% (n = 5/7), respectively, in the Acacia group, while in the placebo group none of the patients had responded. The VAS score for symptoms was significantly reduced in Acacia than in the placebo group. At each follow-up, the improvement in the EQ-5D-5 L level of HRQoL was significantly higher in the Acacia group than in the placebo group.

Conclusion

Acacia would be an effective and safe alternative in syndromic management of abnormal vaginal discharge, associated symptoms, and improved women's HRQoL. Trial registration. This trial was registered in the Clinical Trials Registry of Indian Trials Website and given the identification no. CTRI/2018/02/012175 (dated: 27/02/2018).

Inadequacies in service delivery for the diagnosis and treatment of vaginitis and vaginosis in Nairobi, Kenya

Vulvovaginal candidiasis (VVC), a common cause of vaginitis, affects 75% of women in their lifetime. In Kenya, vaginitis/VVC is managed using the vaginal discharge syndrome guidelines. We assessed how frequently healthcare workers consider the diagnosis of vaginitis/VVC in symptomatic women, and adherence to the syndromic guidelines, outpatient records at Nairobi City County health facilities, of non-pregnant symptomatic females aged ≥15 years were abstracted. Descriptive statistics were applied, and analysis of determinants of practice determined using multivariable logistic regression models. Of 6,516 patients, 4,236 (65%) (inter-facility range 11-92%) had vaginitis of which 1,554 (37%) were considered VVC (inter-facility range 0-99%). Vaginitis was associated with facility, adjusted odds ratio (aOR) 2.80 (95% confidence interval (CI) 1.64-4.76) and aOR 0.03 (95% CI 0.02-0.04); and month, aOR 0.33 (95% CI 0.25-0.43). Vaginal examination was in 53% (inter-facility range 0-98%). Adherence to syndromic treatment was 56% (inter-facility range 0-83%), better with older patients (aOR 7.73, 95% CI 3.31-18.07). Vaginitis and VVC are commonly diagnosed in symptomatic patients in Nairobi; adherence to the syndromic guidelines is low and differs across the health facilities. Interventions to improve adherence are needed.

Recent Advances in Presentation, Diagnosis and Treatment for Mixed Vaginitis

Mixed vaginitis is the simultaneous presence of at least two types of vaginitis, contributing to an abnormal vaginal milieu and leading to vaginal symptoms and signs. However, associations between symptoms and the type of mixed vaginitis have not been clearly elucidated, and research on mixed vaginitis is still in the preliminary stage. Therefore, the pathogenic mechanism of mixed vaginitis remains understudied. Mixed vaginitis generally involves the formation of mixed biofilms. The study of polymicrobial interactions and mixed biofilms will provide a new idea for the understanding of mixed vaginitis. Moreover, this review summarizes some effective management and laboratory diagnosis of mixed vaginitis to avoid inappropriate therapy, recurrence, and reinfection. It is of high clinical importance to obtain relevant clinical data to improve clinical knowledge about mixed vaginitis.

Prospective trial for the clinical efficacy of anogenital skin care with miconazole nitrate-containing soap for diaper candidiasis

Anogenital skin care for the elderly remains an umbrella term concerning protective and non-interventional regimens, particularly for ordinary diaper users. Our recent investigation has demonstrated the preventive effect of daily anogenital washing with miconazole nitrate-containing soap to the development of diaper candidiasis. We extended this work to cover our hypothesis as to whether the miconazole soap has a therapeutic benefit in genital candidiasis. The study outline includes: (i) the enrollment of 21 bedridden inpatients (84 ± 9 years; eight men and 13 women) who were diagnosed clinically and mycologically with genital candidiasis, and who had never received topical and/or systemic antifungal agents; (ii) administration of anogenital washing with 0.75% miconazole-containing soap once daily for 4 weeks; and (iii) assessment of clinical symptoms and detection of Candida materials by culture and microscopic examination. As assessed by clinical symptom scoring for incontinence-associated dermatitis (IAD), the ratio of patients with severe to moderate symptoms dramatically decreased by 2 weeks and 10 of 21 patients became symptom-free at 4 weeks. The IAD clinical severity score was significantly decreased at 4 weeks. Compared with the baseline positivity, both microscopic and cultured Candida-positive rates were significantly decreased at 4 weeks after washing. All culture-detected fungi were Candida albicans. Severe adverse events did not occur in all participants. Individual medical and risk factors had no significant correlation with clinical severity and duration of candidiasis on variance analysis. In conclusion, topical washing with miconazole soap is a safe and reliable non-medical approach for soothing diaper-associated genital candidiasis in bedridden inpatients in whom it is difficult to perform prompt medical examination.

Análise de prescrições de antimicrobianos na Atenção Primária à Saúde

RESUMO Objetivo Avaliar receitas com prescrição de antimicrobianos retidas nas unidades de saúde da Atenção Primária de uma capital da região Nordeste do Brasil. Método Estudo avaliativo, analítico. Foram utilizadas as informações da central de distribuição de medicamentos essenciais e as receitas com prescrição de antimicrobianos. Resultados Foram analisadas 2.232 receitas, nas quais o metronidazol (250 mg) foi prescrito em 28% das receitas avaliadas, a forma farmacêutica “comprimido” em 30,7% e a forma de administração “oral” em 78,2%. Nas receitas prescritas por enfermeiros, 80,7% destinavam-se para usuários com infecção sexualmente transmissível. Com exceção da forma farmacêutica, somente 34,7% das receitas estavam em concordância com as recomendações do protocolo de Enfermagem. Há, ainda, inexistência de informações sobre a concentração (43,7%), a posologia (39,9%) e o tempo de tratamento (36,8%). Conclusão As receitas com prescrição de antimicrobianos avaliadas não seguem com precisão as orientações da Resolução nº 20/2011, e nem do protocolo de Enfermagem instituído.

Comparative Study on the Vaginal Flora and Incidence of Asymptomatic Vaginosis among Healthy Women and in Women with Infertility Problems of Reproductive Age

INTRODUCTION

The normal vaginal flora is highly complex, dominated by lactobacilli of doderlein that plays a vital role in maintaining the women's health and inhibits other pathogenic microorganisms. Fluctuation in local environment or exposure to any exogenous and endogenous sources changes the vaginal flora over a period of time. Disruption of the vaginal ecosystem changes the microflora of the healthy vagina, altering the pH and predisposing to lower reproductive tract infections. The change in the microflora of the female genital tract by pathogenic organisms may ascend from vagina to upper genital tract and may cause infertility. Although several studies demonstrate a higher prevalence of bacterial vaginosis in infertile population. The role of vaginal microbiome in infertility is not clear and need to be explored further.

AIM

To compare the vaginal flora and analyse the incidence of asymptomatic vaginosis among healthy women and in women with infertility problems.

MATERIALS AND METHODS

A cross-sectional study was conducted over a period of six months at Sri Lakshmi Narayana Medical College and Hospital Puducherry, India. A total of 200 high vaginal swabs were collected from Group 1 which included 84 healthy women with regular menstrual cycles without any gynaecological disorder and from Group 2, 116 women with infertility problems attending fertility clinic within the age group of 18 to 45 years. All swabs were subjected to routine aerobic, anaerobic and fungal culture. Saline wet mount was performed for the detection of clue cells and Trichomonas vaginalis, 10% KOH was performed for demonstration of budding yeast cells and pseudo hyphae, Gram's staining to determine the presence of yeast cells, leucocytes and bacterial morphotypes. The smear was also graded using Nugent scoring system.

RESULTS

The vaginal flora of Group 1 was dominated by Lactobacillus (40, 27.8 %) followed by Micrococcus (22, 15.3 %), Enterococcus (16, 11.1%), Coagulase negative Staphylococcus spp. (12, 8.3%). Whereas in Group 2, the most dominant flora was Candida spp. (30, 26.5 %), Enterococcus (26, 23%) followed by Gram negative bacilli such as E. coli (16, 14.1 %). The percentage of Lactobacillus in Group 2 women with infertility problems was relatively low (4, 3.5%). Asymptomatic vaginosis was present in 32 (27.6 %) of Group 2 women compared to Group 1 women were only 6 (7.1%) had asymptomatic vaginosis.

CONCLUSION

Women with infertility problems showed higher prevalence of asymptomatic vaginosis and abundance of Bacterial Vaginosis (BV) associated bacteria compared to healthy women. Hence, this study recommends the screening of vaginal flora as a routine for all women, especially in women undergoing infertility treatment and also suggests the importance of vaginal culture and sensitivity in routine practice.