Bacterial Vaginosis

Benha University Hospital, Egypt E-mail: [email protected]

Non-specific vaginitis: Haemophilus vaginalis Gardnerella vaginitis: Gardnerella vaginalis Anaerobic vaginosis: Gardnerella vaginalis & anaerobic bacteria Bacterial vaginosis: polymicrobial alteration in vaginal flora causing an increase in vaginal

BV is the most common cause of vaginal discharge in young women of reproductive age. Prevalence between

Polymicrobial: G. vaginalis (coccobacilli, surface pathogen), Anaerobic bacteria (Bacteroids, Mobiluncus, Prevotella) & Mycoplasma hominis. There is synergistic relationship between the acquired organisms.

Their metabolism produces volatile amines & organic acids other than lactic acids leading to smell & increase pH. Mobiluncus produce trimethylamine giving the smell of rotting fish. Mobiluncus & Bacteroids produce succinate (Keto-acid) which raises vaginal pH. Absence of lactic acid & the

Gram stain b= bacteroids, c= mobilincus, g= gardenerlla, p=peptostreptococci

Electron micrograph of Mobiluncus

1. Increase vaginal pH: Semen, after menstruation when estradiol levels increase. 2. Decrease lactobacilli: Douching, change of sexual partner (change of vaginal environment), episodes of candida .

3. Smoking: suppresses the immune system facilitating infection. 4. IUCD: 5. Black ethnic groups 6. Lesbians •It is not STD: Treatment of the husband is not beneficial in preventing recurrence of BV.

The reason for the alteration in flora is unclear. 1.Hormonal changes: the mechanism is unclear 2.Enzymatic changes: Mucinase & siallidase are elevated in vaginal discharge of BV. Breaking down the mucosal barrier

Up to half the women diagnosed with BV are asymptomatic. .Discharge: thin, homogenous, whitish-grey, frothy & fishy. Absence of discharge does not imply the absence of BV. It is not accepted as a reliable indicator on its own as it is neither sensitive nor specific to BV.(Deborah et al,2003)

1.pH of discharge: 5.7 A low pH virtually excludes BV. An elevated pH is the most sensitive but least specific as an increase can also associated with menstruation, recent

2.Whiff test (amine test). Addition of 10% KOH to a sample of vaginal discharge produces fishy odor. It has a positive

3.Wet film (drop of vaginal secretion & drop of saline): clue cells (epithelial cells covered by coccobacilli, borders are indistinct), No WBC. It is the single most sensitive & specific criterion for BV. , but it is operator dependent. Debris & degenerated cells may be

4. Gram stain: 90% sensitivity, highly sensitive & specific (Gr. Variable c.bacilli, no WBC, no lactobacilli). Scoring systems which weight numbers of lactobacilli & numbers of G vaginalis & Mobiluncus. It is simple & objective method. However

5.Rapid tests: .Diamine test: rapid, sensitive & specific .Proline aminopeptidase test (Pip Activity test Card) .A card test for detection of elevated pH & trimethylamine (FemExam test card) .DNA probe based test for high concentration of G. vaginalis

. Pap. smear: clue cells. Limited clinical utility because of low sensitivity .Culture: It is not recommended as a diagnostic tools

•Amsel’s criteria 3 of the following: .Homogenous discharge. .pH> 4.5. . Amine test. .Clue cells. •Gram stain alone corresponds well to Amsel’s criteria & to the presence of the associated bacteria.

Gynecological 1. Psychological disturbance 2. PID: The microorganisms of BV & PID are similar. There is 10 fold-increased risk of PID in females with BV. 3. Tubal infertility: 1/3 of

4. Post-hysterectomy vaginal cuff infection. 5. Uretheral syndrome. 6. HIV susceptibility infection. The presence of BV increases susceptibility to HIV infection

Obstetric 1. Miscarriage: Women with BV had a higher rate of first trimester miscarriage than those with normal vaginal flora. Recurrent first trimester miscarriage has not been associated with BV.

The incidence of late miscarriage (1323 w) is higher in women with BV. 2. Postabortal sepsis. The use of antibiotic prophylaxis before surgical termination of

3.Preterm labour. The earlier in pregnancy that BV is detected the greater the risk of PTL. Treatment of high risk, BV positive pregnant women has resulted in reduction of PTL by 40-50%. 4.Bactraemia after instrumental delivery 6.Chorioamnionitis.

A. Non pregnant Benefits of treatment: . relieve vaginal symptoms & signs of infection. . Reduce the risk for infectious complications after hysterectomy or abortion. . Reduction of other infectious complications e.g., HIV, STD Indications 1. Symptomatic women (Grade A

Recommended regimens (CDC,2002) Metronidazole 500 mg orally twice a day for 7 days, OR Metronidazole gel 0.75%, one full applicator (5g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5g) intravaginally at

Alternative regimens (CDC,2002) Metronidazole 2 g orally in a single dose, OR Clindamycin 300 mg orally twice a day for 7 days, OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days.

Notes: •The recommended metronidazole regimens are equally effective. Metronidazole gel is more expensive than tablets •The vaginal clindamycin is less effective than the metronidazole regimens. •The alternative regimens have lower efficacy for BV. •No data support the use of non-

•Clindamycin cream or oral is preferred in case of allergy or intolerance to metronidazole. •Theoretically, Metronidazole has an advantage because it is less active against lactobacilli than clindamycin. •Conversely, clindamycin is more active than metronidazole against most of

.Follow up Follow-up visits are unnecessary if symptoms resolve. Another recommended treatment regimen may be used to treat recurrent disease.

B. Pregnant Natural history: •BV is present in up to 20% of pregnant women depending on how often the population is screened. •The majority is asymptomatic. •It may spontaneously resolve without treatment, although the majority is likely to have

Recommended regimen Metronidazole 250 mg orally three times a day for 7 days, OR

Notes: •Existing data do not support the use of topical agents during pregnancy. Evidence from three trials suggests an increase in adverse events (e.g. prematurity & neonatal infection), particularly in newborns, after use of clindamycin cream (McGregor

•Multiple studies & meta-analysis have not demonstrated a consistent association between metronidazole during pregnancy &

Indications 1. All symptomatic pregnant women should be tested & treated. 2. Asymptomatic pregnant women at high risk for PTL ( previous history), should be

3. Asymptomatic pregnant females at low risk for PTL: Data are conflicting whether treatment reduces adverse outcomes of pregnancy. One trial, using oral clindamycin demonstrated a reduction in PTL & postpartum infectious complications (Hay et al, 2001). Oral clindamycin early in the second trimester significantly

How to screen for BV ? (Gierdingen et al, 2000) Ask about symptoms & pH of the vagina is determined frequently during pregnancy. If pH > 4.5 ( BV or TV in 84%), do wet mount. Follow-up of pregnant women One month after treatment to

C. lactation •Metronidazole enters breast milk & may affect its taste. The manufacturer recommend avoiding high doses if breast feeding. •Small amounts of clindamycin enter breast milk.

•It is prudent therefore to use an intravaginal treatment for lactating women (Grade C recommendation)

Benha University Hospital, Egypt E-mail: [email protected]