Bacterial vaginosis

1. ABOUBAKR ELNASHAR

2. 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)
ABOUBAKR ELNASHAR

3. 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.
ABOUBAKR ELNASHAR

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

5. 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.
ABOUBAKR ELNASHAR

6. Gram stain
b= bacteroids, c= mobilincus, g= gardenerlla, p=peptostreptococci
ABOUBAKR ELNASHAR

7. Electron micrograph of Mobiluncus
ABOUBAKR ELNASHAR

8. 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
ABOUBAKR ELNASHAR

9. 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.
ABOUBAKR ELNASHAR

10. The reason for the alteration in flora is unclear.
1.Hormonal changes:
mechanism is unclear
2.Enzymatic changes:
Mucinase & siallidase are elevated in vaginal
discharge of BV. Breaking down the mucosal
barrier
3.Bacteriophage (virus that infects bacteria)
ABOUBAKR ELNASHAR

11. 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.
ABOUBAKR ELNASHAR

12. 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
ABOUBAKR ELNASHAR

13. 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%
ABOUBAKR ELNASHAR

14. 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.
ABOUBAKR ELNASHAR

15. 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.
ABOUBAKR ELNASHAR

16. 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.
ABOUBAKR ELNASHAR

17. . 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.
ABOUBAKR ELNASHAR

18. 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.
ABOUBAKR ELNASHAR

19. 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).
ABOUBAKR ELNASHAR

20. 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
ABOUBAKR ELNASHAR

21. 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.
ABOUBAKR ELNASHAR

22. 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
ABOUBAKR ELNASHAR

23. 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).
ABOUBAKR ELNASHAR

24. 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.
ABOUBAKR ELNASHAR

25. 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.
ABOUBAKR ELNASHAR

26. 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.
ABOUBAKR ELNASHAR

27. •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
ABOUBAKR ELNASHAR

28. .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
ABOUBAKR ELNASHAR

29. 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.
ABOUBAKR ELNASHAR

30. Recommended regimen
Metronidazole 250 mg orally three times a day for 7
days, OR
Clindamycin 300 mg orally twice a day for 7 days
ABOUBAKR ELNASHAR

31. 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).
ABOUBAKR ELNASHAR

32. •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).
ABOUBAKR ELNASHAR

33. 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)
ABOUBAKR ELNASHAR

34. 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).
ABOUBAKR ELNASHAR

35. 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 evaluate whether
therapy was effective is recommended.
ABOUBAKR ELNASHAR

36. 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)
ABOUBAKR ELNASHAR

37. Recurrent BV:
European (IUSTI/WHO) Guideline, 2011
Most patients will have recurrences within 3 to 12
months, whatever treatment has been used.
Suppressive regimens
Metronidazole jell (Metrojell)
weekly during 16 weeks
Adjuvant regimen
lactobacilli
daily intravaginal for 6 months
Acidifying gel
ABOUBAKR ELNASHAR

38. Benha University Hospital, Egypt
ABOUBAKR ELNASHAR