bacteria VAGINOSIS

Bacterial Vaginosis 

Bacterial  vaginosis   is the most  common urogenital disease   affecting about 19-24%  of the women   during the reproductive age, and   occurs as a result of    imbalance  in   the vaginal    microbiota, Disruption of the normal   lactobacillus and   subsequently  increase  in predominantly  anaerobic  bacteria    including   Gardnerella vaginalis, Mycoplasma  hominis,  Prevotella,  and Peptostreptococcus   have led to its occurrence.

Lactobacillus is associated with supporting full term birth and healthy pregnancy,   and is the dominant microbe in the vagina of women. Hence, its  disruption  increases   the risk of potentially severe   gynecological   and obstetric complications. Bacterial vaginosis is associated with  an elevation   of cervico- vaginal  pro inflammatory  cytokines including   interleukin-   1 beta  and lL -8, which   initiates   the cascade   of inflammatory events   involved  in labour, Bacterial  vaginosis is associated with increased risk of pelvic    inflammatory    disease, tubal factor   infertility , late   miscarriage, chorioamnionitis, premature rupture  of membranes, preterm birth and    postpartum  endometritis.

Antibiotic  therapy is the current  treatment for   bacterial vaginosis   , but its  uncertainty in preventing  preterm birth   in women   has been   reported. Also,    antibiotics are unable   to fully eradicate   bacterial  vaginosis  vaginal   biofilms    associated bacteria , which    can   explain  its high    recurrence   rates. Therefore , probiotics  have been  suggested as an add an to antibiotic therapy  in restoring vaginal  lactobacilli  and reversing  bacterial vaginosis.

NORMAL  VAGINAL  FLORA

 Over  50  microbial  species have been  recovered from the vaginal   tract   and lactobacillus  is the predominant   species .

BACTERIAL VAGINOSIS – DYSBIOSIS

 It is  abnormal vaginal discharge  characterized by an  overgrowth   of predominantly anaerobic organisms  in the vagina  leading   to a replacement   of lactobacilli and an increase   in vaginal  pH.

It   often   remits spontaneously , but  may present   as chronic or recurrent disease.

Often seen in women   of childbearing  age and  sometimes even menopausal  women .

Depletion of lactobacilli  population  and the presence   of  Gram – negative anaerobes, or an some cases Gram- positive  cocci, and aerobic  pathogens.

BACTERIAL  VAGINOSIS

 Depletion   of lactobacilli population

Presence  of Gram – negative   anaerobes, Gram – positive  cocci, and aerobic pathogens

SYMPTOMS

Offensive   fishy  smelling vaginal   discharge

Not  associated   with soreness, itching or irritation

Approximately 50% women   are asymptomatic.

SIGNS

Thin white   , homogenous discharge   coating  the walls   of the vagina

No evidence   of inflammation

Unpleasant  fishy  odour  of discharge

BACTERIAL  VAGINOSIS  DIAGNOSIS

CLINICAL DIAGNOSIS

AMSEL’S Criteria : At   least  three of the four  criteria   are present   for the diagnosis  to be confirmed.

Fishy   smell

Clue  cells   on wet mount   microscopy

Full blown > 20 %

Partial > 0and < 20 %

Vaginal pH > 4.5

LABORATORY   DIAGNOSIS

  Gram stained  vaginal  smear

Hay/ Ison criteria :

Grade 1  : Lactobacillus  morphotypes  are predominate 

Grade 2 :   Mixed flora  with some Lactobacilli is present. Gardnerella or Mobiluncus morphotypes  are also present

Grade 3 : Predominantly  Gardnerella and / or Mobiluncus morpho   types and few or absent Lactobacilli,

Grade 4 : Predominantly Gram – positive  cocci

The  Nugent score :

Normal  <4

Intermediate 4-6

Bacterial vaginosis >6

WHOM TO SCREEN ?

AMSEL’S   Criteria : At least three of the four criteria  are present   for the diagnosis   to be confirmed.

All symptomatic patients

Asymptomatic  with high risk

SCREENING TEST

Amsel’s criteria

COMPLICATION

 Bacterial vaginosis is not a  sexually transmitted but it may  be associated with sexually transmitted  infections  and other    genital infections.

Increased risk of acquiring human immunodeficiency virus in pregnant women.

Decrease incidence of chlamydia  have been reported  in women  treated for  asymptomatic  bacterial vaginosis

Its    prevalence  is high  in women   with pelvic  inflammatory disease.

It is   common in women   undergoing   elective   termination of pregnancy  and is associated with post – TOP endometritis  and PID.

In  pregnancy  bacterial   vaginosis is associated with late miscarriage   , preterm   birth , preterm    premature rupture of  membranes  , and postpartum endometritis

It is   associated with an increased   incidence  of vaginal cuff cellulitis and  abscess  formation   following   transvaginal   hysterectomy

It is  associated with non gonococcal  urethritis in male partners.

MANAGEMENT

 General  advice :

To avoid   vaginal   douching

Avoid   use of  shower  gel

Avoid use of antiseptic  agent  or shampoo

Treatment of    recurrence   : Co – treatment with antibiotics  and probiotics  but probiotics  is preferred.

Treatment for SCREEN POSITIVE –Symptomatic  pregnant /  non pregnant ,  Asymptomatic with high risk pregnancy   ,  women undergoing  some   surgical procedure

Co- treatment   with antibiotic  and probiotic

Metronidazole  400 mg  twice  daily for 5-7 days .

Or  Metronidazole 2 g single   dose

Or Intravaginal   metronidazole gel once daily for 5 days

Or Intravaginal  clindamycin  cream   once daily  for 7 days

Probiotics : Lactobacilli species like  acidophilus, rhamnosus, reuterii , fermentum etc  for 15 days,

DIAGNOSTIC  AND DIFFERENTIAL DIAGNOSIS ALGORITHM

 Vaginal  discharge – Gray  thin,  watery or yellowish – green

White  cottage- cheese appearing , homogenously thick – check pH -1)  >pH 4.5 2) < pH 4.5

>pH 4.5 –Saline microscopy -1) Trichomonads- Trichomonads vaginalis  2) Clue  cells with positive   whiff test- Bacterial  vaginosis  3) No Trichomonads  No clue cells -  Cervicitis obtains GC/ Chlamydia DNA probe, NAAT  on probe  or urine – Positive –PID. Negative – No  diagnosis

<pH 4.5 – Hyphae seen –Candida Vulvovaglnitis

No Hyphae seen – Obtain a yeast culture . Negative – Normal physiological