Vaginitis in Adult Women

Association of opportunistic bacterial pathogens with female infertility: A case-control study

AIM

Infertility affects a significant proportion of women worldwide, and the colonization of certain vaginal pathogens has been suggested as a possible contributing factor. To explore the relationship between bacterial pathogens and female infertility, a case-control study was conducted involving 55 infertile women as cases and 5 fertile women as controls.

METHOD

Conventional culture-based techniques and biochemical assays followed by 16S rDNA sequence analysis were employed for the identification of vaginal isolates from the two groups. The strength of association between the isolated bacterium and infecundity was derived by odds ratio calculation.

RESULTS

The investigation revealed the presence of bacteria including Enterococcus faecalis, Escherichia coli, Bacillus spp., Acinetobacter baumannii, Pseudomonas spp., Micrococcus luteus, Staphylococcus aureus, Staphylococcus haemolyticus, Staphylococcus hominis, Staphylococcus capitis, Staphylococcus epidermidis, and Staphylococcus saprophyticus in the vaginal swabs of infertile women. Of these, the odds ratios for Staphylococcus aureus, Klebsiella pneumoniae, E. faecalis, and E. coli were 5.43 (95% CI = 0.28, 103.49), 4.59 (95% CI = 0.24, 87.93), 2.25 (95% CI = 0.11, 44.16), and 1.70 (95% CI = 0.09, 34.01), respectively, displaying an association with infertility. Moreover, vaginal colonization of these four bacterial species was also dominant in cases that were diagnosed with pelvic inflammatory disease and idiopathic infertility by laparoscopic examination.

CONCLUSION

Overall, the findings of this study indicate a probable association between specific pathogenic microorganisms and women's barrenness, emphasizing the significant role of these disease-causing agents in hindering conception. This highlights the significance of a complete understanding of the vaginal microbiome and emphasizes further research in this area.

Prevalence, Associated Factors, and Appropriateness of Empirical Treatment of Trichomoniasis, Bacterial Vaginosis, and Vulvovaginal Candidiasis among Women with Vaginitis

Trichomoniasis (TV), bacterial vaginosis (BV), and vulvovaginal candidiasis (VVC) are the most common causes of vaginitis. This study investigated the prevalence of these diagnoses, their associated factors, and the appropriateness of the empirical treatment. From March 25, 2019, to June 17, 2022, 429 women with symptoms or signs of vaginitis were enrolled in a hospital in northern Taiwan with 438 episodes of vaginitis. Vaginal swabs were collected for Gram's staining, in vitro cultures for Trichomonas vaginalis, bacteria, and yeasts, and multiplex PCR assay for TV, BV, and VVC. Their empirical treatments were recorded. Factors associated with different etiologies of vaginitis were sought in multivariable logistic regression models. The prevalence of TV, BV, and VVC were 2.1%, 22.8%, and 21.7%, respectively, while coinfections of BV and VVC, TV and BV, TV and VVC, and triple infection occurred in 5.0%, 0.2%, 0.2%, and 0.7%, respectively. Multivariable analyses revealed that having multiple sexual partners was associated with TV and BV (adjusted odds ratio [aOR] 9.756 and 3.246, respectively), while menopausal women were less likely to have VVC (aOR 0.184). Moreover, dysuria was associated with TV (aOR 4.981), vaginal itch and pelvic pain with VVC (aOR 3.223 and 0.425, respectively), and discharge pH > 4.5 with BV (aOR 1.767). Other clinical symptoms and pelvic examination features had limited value for differential diagnosis. Among the 78 empirical antifungal and metronidazole prescriptions, 55.2% were ineffective or unnecessary. Our study highlights the importance to integrate appropriate diagnostic tools into the clinical care of women with vaginitis. IMPORTANCE Vaginal complaints are widespread among women and are associated with emotional, physical, and economic burdens with challenges in their diagnosis and management. In this survey, we identified that 40% of vaginitis in Taiwan was caused by either trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis, or a combination of these infections. Our data suggested that typical physical findings appeared infrequently among women with these infections and their empirical treatments were frequently inappropriate. Our findings highlighted the importance of integrating proper diagnostic tools into clinical practice to improve the diagnosis and management of vaginitis, as recommended by national and international guidelines.

Pharmacokinetics of metronidazole in pregnant patients with bacterial vaginosis

OBJECTIVE

The present study was undertaken to investigate the pharmacokinetics of metronidazole in pregnant patients with bacterial vaginosis.

METHODS

Twenty patients received metronidazole (Flagyl ®, Pfizer, 235 East 42nd Street, NY, NY 10017) oral dose 500 mg twice a day for 3 consecutive days. Pharmacokinetic analyses of metronidazole were performed after a single oral dose on the morning of day 4.

RESULTS

Although absolute estimates of metronidazole total body exposure were highest in women during early term pregnancy, weight-corrected estimates of exposure maximum plasma drug concentration (C(max)) and the area under the plasma concentration-versus-time curve (AUC(0-12)), along with apparent oral clearance and distribution volume, were not significantly different between women at early, middle, and late stages of pregnancy and were in the range of reported values for nonpregnant patients receiving a similar dose.

CONCLUSIONS

The pharmacokinetic profile of metronidazole did not change at the different time points assessed during pregnancy.

Rapid testing for vaginal yeast detection: a prospective study

OBJECTIVE

The purpose of this study was to determine the accuracy of rapid vaginal yeast detection assay compared with yeast cultures for the diagnosis of vulvovaginal candidiasis.

STUDY DESIGN

This was a prospective study that involved 104 subjects, 34 asymptomatic women and 70 symptomatic women with vaginitis. Vaginal swabs were obtained from all subjects for wet mount, yeast culture, and the rapid yeast detection test. Overall, the prevalence rate was 39.4%, based on positive yeast cultures. The rapid yeast test performed by the physician was positive in 30 of 41 subjects with positive cultures and 13 of 63 subjects with negative cultures.

RESULTS

The rapid yeast test had 73.1% sensitivity and 82.0% negative predictive value compared with the wet mount, which had 43.9% sensitivity and 70.9% negative predictive value. In symptomatic patients, the test had 77.4% sensitivity and 81% negative predictive value compared with wet mount, which had 51.6% sensitivity. Patient-performed test results were identical to the tests that were performed by the physicians. The cost of the rapid yeast test kit is estimated to be <$10, compared with a mean of $65 for the yeast culture.

CONCLUSION

Rapid yeast detection assay is accurate and affordable compared with the gold standard yeast culture in the diagnosis of vulvovaginal candidiasis. Relative to the wet mount, it is more sensitive, cheaper, and accurate for the rapid diagnosis of vaginal yeast infection.

Association of asymptomatic bacterial vaginosis with endometrial microbial colonization and plasma cell endometritis in nonpregnant women

OBJECTIVE

This study was undertaken to determine whether asymptomatic bacterial vaginosis (BV) is associated with an increased risk of endometrial microbial colonization or plasma cell endometritis in nonpregnant women.

STUDY DESIGN

In this observational cohort study conducted between August 1995 and August 2001, microbial cultures (n = 769) and histopathology (n = 482) were performed on endometrial specimens obtained from women with a recent preterm or term delivery (83 +/- 16 days). Endometritis was defined as the presence of plasma cells. BV was defined using Amsel and Nugent criteria.

RESULTS

The study population was 71% black, 29% white, 69% single, and 31% had 12 years or more of education. Endometrial cultures were positive for at least 1 microorganism in 83% (n = 637/769) of the women and plasma cell endometritis was present in 39% (n = 190/482). BV was present in 26% (n = 191/722) by Amsel and 38% (n = 289/769) by Nugent criteria. Women with Nugent-BV (RR [relative risk] = 1.12, 95% CI 1.05-1.19) but not Amsel-BV (RR = 1.06, 95% CI 1.00-1.13) were significantly more likely to have a positive endometrial culture. A consistent and significant association was observed between BV (by Amsel or Nugent criteria) and an increased frequency of endometrial colonization with BV-associated microorganisms grouped and defined in various ways (RR ranged from 1.96-4.22). No association between BV and plasma cell endometritis was observed.

CONCLUSION

Asymptomatic BV is associated with a modest increased likelihood of endometrial microbial colonization and colonization by BV-associated bacteria but is not associated with plasma cell endometritis in nonpregnant women.

"Shotgun" versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis

BACKGROUND

Although vaginitis is a common outpatient problem, only 60% of patients can be diagnosed at the initial office visit of a primary care provider using the office procedures of pH testing, whiff tests, normal saline, and potassium hydroxide preps.

OBJECTIVE

To determine the most cost-effective diagnostic and treatment approach for the medical management of vaginitis.

DESIGN

Decision and cost-effectiveness analyses.

PARTICIPANTS

Healthy women with symptoms of vaginitis undiagnosed after an initial pelvic exam, wet mount preparations, pH, and the four criteria to diagnose bacterial vaginosis.

SETTING

General office practice.

METHODS

We evaluated 28 diagnostic strategies comprised of combinations of pH testing, vaginal cultures for yeast and Trichomonas vaginalis, Gram's stain for bacterial vaginosis, and DNA probes for Neisseria gonorrhoeae and Chlamydia. Data sources for the study were confined to English language literature.

MEASUREMENT

The outcome measures were symptom-days and costs.

RESULTS

The least expensive strategy was to perform yeast culture, gonorrhoeae and Chlamydia probes at the initial visit, and Gram's stain and Trichomonas culture only when the vaginal pH exceeded 4.9 (330 dollars, 7.30 symptom days). Other strategies cost 8 dollars to 76 dollars more and increased duration of symptoms by up to 1.3 days. In probabilistic sensitivity analysis, this strategy was always the most effective strategy and was also least expensive 58% of the time.

CONCLUSIONS

For patients with vaginitis symptoms undiagnosed by pelvic examination, wet mount preparations and related office tests, a comprehensive, pH-guided testing strategy at the initial office visit is less expensive and more effective than ordering tests sequentially.

Antimicrobial resistance associated with the treatment of bacterial vaginosis

OBJECTIVE

This study was undertaken to evaluate antimicrobial susceptibility of vaginal anaerobic bacteria before and after treatment of bacterial vaginosis.

STUDY DESIGN

A randomized clinical trial of 119 nonpregnant women with bacterial vaginosis receiving either intravaginal metronidazole for 5 days or clindamycin for 3 days was performed. Women had 1 baseline and 3 follow-up visits at which quantitative vaginal cultures were performed. Anaerobic isolates underwent antimicrobial susceptibility testing.

RESULTS

Complete susceptibility data was available on 95 women (47 metronidazole and 48 clindamycin). Of 1059 anaerobic bacterial isolates, less than 1% demonstrated resistance to metronidazole. In contrast, 17% demonstrated baseline clindamycin resistance, and 53% demonstrated resistance to clindamycin after therapy. Women exposed to clindamycin (but not metronidazole) had high frequencies (80%) of clindamycin-resistant anaerobic bacteria that persisted for 90 days after treatment.

CONCLUSION

Treatment of bacterial vaginosis with clindamycin is associated with marked evidence of antimicrobial resistance among vaginal anaerobic bacteria. This may increase the vaginal reservoir of macrolide-resistant bacteria.

Comparison of once-daily and twice-daily dosing of 0.75% metronidazole gel in the treatment of bacterial vaginosis

BACKGROUND AND OBJECTIVES

Bacterial vaginosis is the most common cause of vaginal symptoms in women and has potential complications. Efforts to improve treatment of this disease process are warranted.

GOAL OF THIS STUDY

The goal of this study was to compare the safety and efficacy of once-daily intravaginal administration of 0.75% metronidazole gel for 5 days to the established twice-daily regimen in the treatment of bacterial vaginosis.

STUDY DESIGN

Nonpregnant women with bacterial vaginosis diagnosed by accepted clinical criteria at 14 geographically diverse general gynecology clinics were enrolled in this prospective, randomized, investigator-blind, parallel study. They were treated with either once-daily or twice-daily 0.75% metronidazole gel 5 g intravaginally for 5 days and were reevaluated at 7 to 12 days and 28 to 35 days after completing treatment. Efficacy was determined by clinical criteria. Adverse drug reactions were monitored.

RESULTS

Of the 514 evaluable women enrolled, bacterial vaginosis was cured at the first return visit among evaluable patients in 153 of 199 (77%) of those who received the once-daily and in 157 of 196 (80%) of those who received the twice-daily administration. Bacterial vaginosis was cured among evaluable patients at the final visit in 104 of 180 (58%) of those who received once-daily and 109 of 178 (61%) of those who received the twice-daily regimen. Intent-to-treat analysis showed cure at 1 month in 118 of 207 (57%) of those treated once daily and 129 of 209 (62%) of those treated twice daily. Side effects were mild, and none caused treatment discontinuation.

CONCLUSIONS

Once-daily dosing of 0.75% metronidazole gel 5 g for 5 days yields efficacy, safety, and tolerance equivalent to the currently used twice-daily dosing in the treatment of bacterial vaginosis, adding another competitive choice to the available therapeutic options for this condition.

Bacterial vaginosis: association with adverse pregnancy outcome

Bacterial vaginosis is the most common lower genital tract infection encountered among women of reproductive age. This condition can best be considered as a vaginal syndrome associated with an alteration of the normal vaginal flora rather than an infection specific to any one microorganism. Bacterial vaginosis is a clinical condition with a complex microbiology that is characterized by a reduced concentration of a normally abundant Lactobacillus species along with high concentrations of gram-negative and anaerobic bacteria, particularly, Gardnerella vaginalis and Mobiluncus, Bacteroides, Prevotella, and Mycoplasma species. The exact make up of the microorganisms and their relative concentration vary among women who have this condition. Although it was previously regarded as a harmless condition, recent work has linked bacterial vaginosis to numerous upper genital tract complications such as preterm labor and preterm delivery, preterm premature rupture of the membranes, chorioamnionitis, and postpartum endometritis. The findings from recent prospective randomized trials suggest that treatment of bacterial vaginosis in certain women who are at high risk for preterm delivery decreases the rate of preterm birth.

Common genitourinary infections

Vulvovaginal pain, itching, and burning are a triad of symptoms for which women frequently seek health care. Often accompanied by vaginal discharge and dysuria, these symptoms account for as many as 5 million office visits a year. Proper assessment and management of these symptoms by nurses, nurse practitioners, and nurse midwives can help to substantially improve a woman's quality of life and help prevent long-term problems. Several differing syndromes or infections can be the cause of these symptoms. The most common causes are discussed, and a plan for management and prevention is presented.

Incidence, species distribution and antifungal sensitivity pattern of vaginal yeasts in Sri Lankan women

A total of 432 high vaginal swabs from patients with vulvovaginitis were processed for the presence of yeasts. Candida species were isolated from 40 (32.4%). In comparison, vaginal swabs from 107 normal asymptomatic women yielded only eight (7.3%) isolates (P < 0.001). Candida albicans was the commonest species isolated (76%). Other species included C. tropicalis, C. krusei, C. kefyr, C. glabrata and C. guilliermondii. Of the C. albicans isolates, 42.8% showed in vitro resistance to miconazole and 6.6% to econazole. Ninety-two percent of the isolates were sensitive to the polyenes (nystatin and amphotericin B) and 87% and 74% to clotrimazole and ketaconazole respectively.