ppt-Bacterial Vaginodsis

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					Benha University Hospital, Egypt
E-mail: elnashar53@hotmail.com
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
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.
Polymicrobial:
G. vaginalis (coccobacilli, surface
pathogen),
Anaerobic bacteria (Bacteroids,
Mobiluncus, Prevotella) &
Mycoplasma hominis.
There is synergistic relationship between
the acquired organisms.
They replace lactobacilli
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.
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.
Detection of BV in 12% of virgins after
menarche.
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.Bacteriophage ( virus that infects
bacteria)
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.
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
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%
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.
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.
.
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.
. 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.
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 women with tubal
factor infertility had BV compared to 16% of
male factor infertility (Wilson et al, 2000).
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
                  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.
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
                 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).
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.
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-vaginal
lactobacilli or douching for treatment of BV.
•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
.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
                    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.
Recommended regimen
Metronidazole 250 mg orally
three times a day for 7 days,
OR
Clindamycin 300 mg orally
twice a day for 7 days
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).
•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).
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)
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).
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.
                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: elnashar53@hotmail.com

				
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