Bacterial vaginosis

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Bacterial vaginosis
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt E-mail
elnashar53_at_hotmail.com
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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 pH,
sometimes associated with an homogenous
discharge, but in the absence of a demonstrable
inflammatory response (Eschenbach et al, 1988)
History
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BV is the most common cause of vaginal discharge
in young women of reproductive age. Prevalence
between 5 35 depends on method of screening
the locality.
Prevalence
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Polymicrobial G. vaginalis (coccobacilli,
surface pathogen), Anaerobic bacteria
(Bacteroids, Mobiluncus, Prevotella)
Mycoplasma hominis. There is synergistic
relationship between the acquired organisms.
They replace lactobacilli
Aetiology
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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 production of succinate blunt
the chemotactic response of polymorphnuclear
leukocytes reduce their killing ability. This
explains absence of cellular inflammatory
response.
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Gram stain b bacteroids, c mobilincus, g
gardenerlla, ppeptostreptococci
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Electron micrograph of Mobiluncus
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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 .
Predisposing factors
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• 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.
• Detection of BV in 12 of virgins after menarche.

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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 3.Bacterioph
age ( virus that infects bacteria)
Pathogenesis
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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) .Seldom associated with
mucosal inflammation or irritation of the vagina
or vulval itch.
Clinical picture
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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 sexual
intercourse, or infection with T. vaginalis





Diagnosis
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2.Whiff test (amine test). Addition of 10 KOH
to a sample of vaginal discharge produces fishy
odor. It has a positive predictive value of 90
specificity of 70

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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 mistaken for
clue cells lactobacilli may adhere to
epithelial cells in low numbers. .
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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 the cost need for microscopist. .
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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 (Affirm VP III) may
have clinical utility.
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. Pap. smear clue cells. Limited clinical
utility because of low sensitivity .Culture It
is not recommended as a diagnostic tools because
it is not specific.
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• Amsels criteria
• 3 of the following
• .Homogenous discharge.
• .pHgt 4.5.
• . Amine test.
• .Clue cells.
• Gram stain alone corresponds well to Amsels
  criteria to the presence of the associated
  bacteria.

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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 women with tubal
factor infertility had BV compared to 16 of male
factor infertility (Wilson et al, 2000).
Complications
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4. Post-hysterectomy vaginal cuff infection. 5.
Uretheral syndrome. 6. HIV susceptibility
infection. The presence of BV increases
susceptibility to HIV infection BV is not
associated with CIN
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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 (13-23
w) is higher in women with BV. 2. Postabortal
sepsis. The use of antibiotic prophylaxis before
surgical termination of pregnancy demonstrates a
protective effect.
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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. 7.Postpartum
endometritis, post cesarean wound infection
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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
recommendation). 2. Women undergoing some
surgical procedures(Grade A recommendation).
Treatment
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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 bed time for 7 days.
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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.
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• 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-vaginal
  lactobacilli or douching for treatment of BV.

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• 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 the bacteria
  associated with bacterial vaginosis

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.Follow up Follow-up visits are unnecessary if
symptoms resolve. Another recommended treatment
regimen may be used to treat recurrent
disease. Management of husband is not recommended
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• 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
  persistent infection later in pregnancy.

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Recommended regimen Metronidazole 250 mg orally
three times a day for 7 days, OR Clindamycin 300
mg orally twice a day for 7 days
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• 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 et al,1994 Joesoef
  et al,1995 Vermeulen et al,1999).

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• Multiple studies meta-analysis have not
  demonstrated a consistent association between
  metronidazole during pregnancy teratogenic or
  mutagenic effects in newborns (Caro-Paton et
  al,1997).

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Indications 1. All symptomatic pregnant women
should be tested treated. 2. Asymptomatic
pregnant women at high risk for PTL ( previous
history), should be screened early in pregnancy
treated (Cochrane library,2002)
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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 reduced the rate of late
miscarriage PTL in general obstetric population
(Ugwumadu et al, 2003).
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How to screen for BV ? (Gierdingen et al,
2000) Ask about symptoms pH of the vagina is
determined frequently during pregnancy. If pH gt
4.5 ( BV or TV in 84), do wet mount. Follow-up
of pregnant women One month after treatment to
evaluate whether therapy was effective is
recommended.
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• 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)

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Thank you
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt E-mail
elnashar53_at_hotmail.com