Bacterial vaginosis: review of treatment options and potential clinical indications for therapy

Lactic acid gel versus metronidazole for recurrent bacterial vaginosis in women aged 16 years and over: the VITA RCT

Background

Bacterial vaginosis is a common and distressing condition associated with serious comorbidities. Antibiotic treatment is usually clinically effective in the short term, but recurrence is common and side effects can occur.

Objectives

The objective is to assess whether or not intravaginal lactic acid gel is clinically effective and cost-effective for treating recurrent bacterial vaginosis compared with oral metronidazole (Flagyl, Sanofi).

Design

This was an open-label, multicentre, parallel-arm, randomised (1 : 1) controlled trial.

Setting

This took place in one general practice and 19 sexual health centres in the UK.

Participants

Women aged ≥ 16 years with bacterial vaginosis symptoms and one or more episode(s) within the past 2 years took part.

Interventions

The interventions were 5 ml of intravaginal lactic acid gel taken once daily for 7 days (intervention) or 400-mg oral metronidazole tablets taken twice daily for 7 days (control).

Main outcome measures

The primary outcome was the resolution of bacterial vaginosis symptoms 14 days after randomisation. The secondary outcomes were time to first recurrence of symptoms; number of recurrences and treatment courses over 6 months; microbiological resolution on microscopy of vaginal smears at week 2; time to resolution of symptoms; tolerability, adherence and acceptability of the treatment; prevalence of concurrent sexually transmitted infections; quality of life; and cost-effectiveness.

Results

Recruitment stopped prior to reaching the target of 1900 participants on recommendation from the Data Monitoring Committee and Trial Steering Committee after a planned review of the results indicated that the research question had been answered. Overall, 518 participants were randomised and primary outcome data were available for 409 participants (79%; 204 in the metronidazole arm, 205 in the lactic acid gel arm). Participant-reported symptom resolution at week 2 was higher with metronidazole (143/204; 70%) than with lactic acid gel (97/205; 47%) (adjusted risk difference –23.2%, 95% confidence interval –32.3% to –14.0%). Recurrence in 6 months in a subset of participants who had initial resolution and were available for follow-up was similar across arms (metronidazole arm: 51/72, 71%; lactic acid gel arm: 32/46, 70%). A higher incidence of some side effects was reported with metronidazole than with lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). At week 2, the average cost per participant with resolved symptoms was £86.94 (metronidazole), compared with £147.00 (lactic acid gel). Some participants preferred using lactic acid gel even if they perceived it to be less effective than metronidazole.

Limitations

Loss to follow-up for collection of the primary outcome data was 21% and was similar in both arms. There is a risk of bias owing to missing outcome data at 3 and 6 months post treatment.

Conclusions

A higher initial response was seen with metronidazole than with lactic acid gel, but subsequent treatment failure was common with both. Lactic acid gel was less cost-effective than metronidazole. In general, women disliked taking repeated courses of metronidazole and preferred lactic acid gel, even when they were aware that it was less likely to provide symptom resolution. In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients. Further microbiological analysis of vaginal samples would be useful to identify additional factors affecting response to treatment.

Trial registration

Current Controlled Trials ISRCTN14161293.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 2. See the NIHR Journals Library website for further project information.

Bacterial vaginosis-A brief synopsis of the literature

Bacterial vaginosis (BV) affects women of reproductive age and can either be symptomatic or asymptomatic. Approximately 50 % of women are symptomatic and experience vaginal malodor, discharge, itching and increased vaginal pH. BV can increase the risk of contracting many sexually transmitted infections (STIs) such as human immunodeficiency virus (HIV), Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV) and herpes simplex virus-2 (HSV-2). Though effective treatment options do exist, metronidazole or clindamycin, these methods have proven not to be effective long term. The purpose of this review is to summarize current literature on the epidemiology of BV and highlight areas of deficiency in current clinical practice with respect to BV. BV recurrence rates are high, approximately 80 % three months after effective treatment. Furthermore, in some instances treatment is ineffective and BV persists. Literature also documents the relationship between BV and human papillomavirus (HPV). HPV is the most common sexually transmitted infection among young adult women while BV is the most common cause of vaginal symptoms among women of reproductive age. BV is associated with high levels of anaerobic organisms which can damage the vaginal epithelium and increase the risk of HPV infection. Recent research also highlights the role of the vaginal microbiome in BV. The results of this review warrant further exploration into the etiology of BV as well as exploration of more long-term effective treatment and the investigation of prognostic indicators. Additionally, the need for a standard definition of recurrent and persistent BV is recognized.

Metronidazole versus lactic acid for treating bacterial vaginosis (VITA): protocol for a randomised controlled trial to assess the clinical and cost effectiveness of topical lactic acid gel for treating second and subsequent episodes of bacterial vaginosis

Background

Bacterial vaginosis (BV) affects 30–50% of women at some time in their lives and is an embarrassing and distressing condition which can be associated with potentially serious comorbidities. Current antibiotic treatments such as metronidazole are effective but can result in side effects, and recurrence is common. This trial aims to investigate whether lactic acid gel is clinically effective and cost effective in the treatment of recurrent BV compared with metronidazole.

Methods

VITA is an open-label, multicentre, parallel group randomised controlled trial for women with a clinical diagnosis of BV and at least one previous BV episode in the past 2 years. Participants will be randomised 1:1 to intravaginal lactic acid gel 5 ml once daily for 7 days or oral metronidazole tablets 400 mg twice daily for 7 days. All participants will be followed up for 6 months to assess health status and healthcare costs. A subgroup will be interviewed to further explore adherence, tolerability and acceptability of treatment. The estimated sample size is 1900 participants to detect a 6% absolute increase in response rate to 86% in those receiving lactic acid gel. The primary outcome is participant-reported resolution of BV at Week 2.

Discussion

Results from this trial will help inform UK treatment guidelines for BV and may provide an alternative effective treatment for recurrent episodes of this condition which avoids repeated exposure to antibiotics.

Trial registration

ISRCTN, ISRCTN14161293. Registered on 8 September 2017.

Vaginal microbiome transplantation in women with intractable bacterial vaginosis

We report the results of a first exploratory study testing the use of vaginal microbiome transplantation (VMT) from healthy donors as a therapeutic alternative for patients suffering from symptomatic, intractable and recurrent bacterial vaginosis (ClinicalTrials.gov NCT02236429 ). In our case series, five patients were treated, and in four of them VMT was associated with full long-term remission until the end of follow-up at 5-21 months after VMT, defined as marked improvement of symptoms, Amsel criteria, microscopic vaginal fluid appearance and reconstitution of a Lactobacillus-dominated vaginal microbiome. One patient presented with incomplete remission in clinical and laboratory features. No adverse effects were observed in any of the five women. Notably, remission in three patients necessitated repeated VMT, including a donor change in one patient, to elicit a long-standing clinical response. The therapeutic efficacy of VMT in women with intractable and recurrent bacterial vaginosis should be further determined in randomized, placebo-controlled clinical trials.

2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge

Four common pathological conditions are associated with vaginal discharge: bacterial vaginosis, aerobic vaginitis, candidosis, and the sexually transmitted infection, trichomoniasis. Chlamydial or gonococcal cervical infection may result in vaginal discharge. Vaginal discharge may be caused by a range of other physiological and pathological conditions including atrophic vaginitis, desquamative inflammatory vaginitis, cervicitis, and mucoid ectopy. Psychosexual problems may present with recurrent episodes of vaginal discharge and vulval burning. These need to be considered if tests for specific infections are negative. Many of the symptoms and signs are non-specific and a number of women may have other conditions such as vulval dermatoses or allergic and irritant reactions.

Effects of metronidazole combined probiotics over metronidazole alone for the treatment of bacterial vaginosis: a meta-analysis of randomized clinical trials

OBJECT

To evaluate the curative effect of metronidazole combined probiotics over metronidazole alone in the treatment of BV.

METHODS

We are searching randomized controlled trials on major online databases including PubMed, Science Direct, and Cochrane Database between 1990 and 2015. The primary outcome measure was the cure rate of BV. Cochran's Chi-square test (Q test) was used to test for heterogeneity among trials, and the I ² index. We used mixed-effects modeling for parameters of the summary hazard ratios (HRs), odds ratios (ORs), and their 95% confidence intervals (CIs).

RESULTS

Analysis suggests the cure rate of BV [RR = 1.12, 95% CI (0.94-1.32), p = 0.20], and the I ² index was 83%. The value of I ² index decreased to 16% after removing the study of Anukam et al., and Amsel 1.04 (95% CI 0.96-1.13) (p = 0.35), Nugent 1.02 (95% CI 0.94-1.11), short-term 1.01 (95% CI 0.93-1.10) (p = 0.79), long-term 1.06 (95% CI 0.98-1.14) (p = 0.13), Europe 1.06 (95% CI 0.95-1.19) (p = 0.32), Non-Europe 0.99 (95% CI 0.94-1.05) (p = 0.83). When the two same groups data were combined, respectively, the RRs for all studies were the same as 1.03 (95% CI 0.96-1.09) (p = 0.42) showing that there is not statistically significant in relevant stratums.

CONCLUSION

The result has showed an overall little significance for the efficacy of metronidazole combined probiotics over metronidazole alone for the treatment of BV. We need more further studies to provide enough evidence to confirm the benefits of probiotics in the treatment of BV.

Mechanisms of action of systemic antibiotics used in periodontal treatment and mechanisms of bacterial resistance to these drugs

Antibiotics are important adjuncts in the treatment of infectious diseases, including periodontitis. The most severe criticisms to the indiscriminate use of these drugs are their side effects and, especially, the development of bacterial resistance. The knowledge of the biological mechanisms involved with the antibiotic usage would help the medical and dental communities to overcome these two problems. Therefore, the aim of this manuscript was to review the mechanisms of action of the antibiotics most commonly used in the periodontal treatment (i.e. penicillin, tetracycline, macrolide and metronidazole) and the main mechanisms of bacterial resistance to these drugs. Antimicrobial resistance can be classified into three groups: intrinsic, mutational and acquired. Penicillin, tetracycline and erythromycin are broad-spectrum drugs, effective against gram-positive and gram-negative microorganisms. Bacterial resistance to penicillin may occur due to diminished permeability of the bacterial cell to the antibiotic; alteration of the penicillin-binding proteins, or production of β-lactamases. However, a very small proportion of the subgingival microbiota is resistant to penicillins. Bacteria become resistant to tetracyclines or macrolides by limiting their access to the cell, by altering the ribosome in order to prevent effective binding of the drug, or by producing tetracycline/macrolide-inactivating enzymes. Periodontal pathogens may become resistant to these drugs. Finally, metronidazole can be considered a prodrug in the sense that it requires metabolic activation by strict anaerobe microorganisms. Acquired resistance to this drug has rarely been reported. Due to these low rates of resistance and to its high activity against the gram-negative anaerobic bacterial species, metronidazole is a promising drug for treating periodontal infections.

Tinidazole in the treatment of bacterial vaginosis

Bacterial vaginosis (BV) is the commonest cause of vaginal discharge in women of childbearing age. Oral metronidazole has long been established as an effective therapy in the treatment of BV. However, adverse effects due to metronidazole are frequent and this may lead to problems with adherence to a 7-day course of treatment and subsequently result in treatment failure. Oral tinidazole has been used to treat bacterial vaginosis for over 25 years but in a number of different dosage regimens. Placebo controlled trials have consistently shown increases in cure rate with tinidazole. Longer courses of treatment (eg, 1 g daily for 5 days) appear to be more effective than a 2 g oral single dose. Comparative studies suggest that oral tinidazole is equivalent to oral metronidazole, intravaginal clindamycin cream, and intravaginal metronidazole tablets, in efficacy in treating BV. However, tinidazole has a more favorable side effect profile than oral metronidazole notably with better gastrointestinal tolerability and less metallic taste. Bacterial vaginosis is associated with high rates of recurrence and appropriate management of such recurrences can prove difficult. Recurrent BV has been linked with persistence of Gardnerella vaginalis after treatment; however the clinical implications of the possible greater activity of tinidazole against G. vaginalis are not yet clear. Repeated courses of oral metronidazole may be poorly tolerated and an alternative but equally effective treatment that is better tolerated may be preferable. In comparison to oral metronidazole, cost is clearly an issue as oral metronidazole is considerably cheaper and available in generic form. However where avoidance of oral metronidazole is necessary because of side effects, oral tinidazole is a cost-effective alternative.

The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women

BACKGROUND

Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV-1 transmission. This has led to renewed research interest in its treatment.

OBJECTIVES

To assess the effects of antimicrobial agents on BV in non-pregnant women.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date).

SELECTION CRITERIA

Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram-stain criteria of BV.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data.

MAIN RESULTS

Twenty-four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re-analysed the remainder.Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four-week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole.

AUTHORS' CONCLUSIONS

Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better-designed trials with larger sample sizes to test the effectiveness of promising drugs.

Treatment options for bacterial vaginosis in patients at high risk of preterm labor and premature rupture of membranes

AIM

To estimate the efficacy of different therapeutic modalities on proven cases of bacterial vaginosis (BV) in patients at high risk of preterm labor and premature rupture of membranes.

METHODS

This was a longitudinal prospective comparative study set in the antenatal outpatient clinic of the department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt. Four hundred and sixty-eight patients with a clinical picture of threatened preterm labor or at high risk of premature rupture of membranes in the third trimester were screened for BV. Positive BV was diagnosed in 156 patients. They were randomly classified into four equal groups according to the line of medical treatment. The treatments were: (i) oral metronidazole, (ii) clindamycin vaginal cream, (iii) oral clindamycin, or (iv) metronidazole vaginal suppositories. The effects of medical treatment on Amsel's criteria as well as maternal and fetal outcomes were measured.

RESULTS

Based on Amsel's criteria, 156 patients (33.3%) were diagnosed with BV. There was a significant disappearance of vaginal discharge, with decreased percentages of pH > 4.5, positive amine test, and clue cells after treatment of BV in the four groups without any statistically significant difference between them. There were variable effects of the different treatments on increasing birthweight values, admission to neonatal intensive care units, and prolongation of the gestational age. Some maternal adverse effects have been recorded. There were significant improvements of the outcomes for oral metronidazole and clindamycin compared with outcomes for intravaginal metronidazole and clindamycin.

CONCLUSIONS

Metronidazole and clindamycin achieve nearly equivalent cure rates when administered orally or vaginally in patients at high risk of preterm labor and premature rupture of membranes. Oral metronidazole is considered the drug of choice in treating BV due its high cure rate, better outcomes, and low cost.

Successful treatment of bacterial vaginosis with a policarbophil-carbopol acidic vaginal gel: results from a randomised double-blind, placebo-controlled trial

OBJECTIVE

We evaluated the efficacy of a mucoadhesive vaginal gel (MVG, Miphil) with acidic-buffering properties in bacterial vaginosis (BV).

STUDY DESIGN

Double-blind, placebo-controlled, 12-week trial.

SUBJECTS

A total of 45 non-pregnant women with BV were enrolled in the trial. Patients were treated with MVG 2.5 g or the corresponding placebo (P) daily for the first week and then every 3 days for the following 5 weeks (treatment phase) in a 2:1 ratio. All patients were followed for an additional 6 weeks without treatments (follow-up phase). Clinical cure was defined as absence of vaginal discharge, vaginal pH <4.5, a negative fish odour test and a Nugent score <7.

RESULTS

At week 6, 28 out of 30 women (93%) in the MVG group were clinically cured in comparison with only 1 out of 15 (6%) in the P group (P=0.0001). At week 12, 86% of MVG treated women remained cured in comparison with 8% in P group (P=0.0001). At baseline, the vaginal pH was 6.1+/-0.7 in the MVG and 5.5+/-0.7 in the P group. Vaginal pH significantly (P=0.003) decreased to 4.3+/-0.3 in the MVG group. In P group non-significant modifications of vaginal pH were observed (5.1+/-0.5).

CONCLUSION

Our results demonstrated that this MVG is an effective treatment of BV.

Efficacy of the combination of 2 g oral tinidazole and acidic buffering vaginal gel in comparison with vaginal clindamycin alone in bacterial vaginosis: a randomized, investigator-blinded, controlled trial

OBJECTIVE

To evaluate the efficacy of tinidazole (T) (Trimonase, Mipharm, Italy) and an acidic vaginal gel (Miphil) (M) in comparison with vaginal clindamycin (CL) (Cleocin Pharmacia Upjohn) in BV.

DESIGN

A multicentre, randomised, investigator-blinded, controlled trial.

POPULATION AND METHODS

64 women with BV were enrolled. Thirty-two were allocated to receive oral T 2g, single dose, and 32 were assigned to CL 2% for 7 consecutive days. After week 1, T group were treated with an acidic vaginal gel, 2g every 3 days, for additional 3 weeks, whereas CL group did not received any additional treatment. Patients were evaluated at week 1 and 4. Vaginal pH, the BV-blue test (Gryphus Diagnostics, USA) and the whiff test were performed at baseline and at week 4.

MAIN OUTCOMES MEASURES

Clinical cure rate; normalisation of vaginal pH (pH<4.5); and laboratory cure rate (defined as a clinical cure rate and a negative results of BV-blue and whiff test).

RESULTS

At baseline, vaginal pH values were (mean+/-S.D.) 5.4+/-0.7 and 5.3+/-0.5 in T and CL groups, respectively. Six patients (2 in T group and 4 in CL group) withdrew from the study due to side effects. At week 1, the clinical cure rates were 84% in both T and CL treated group (P=N.S.). At week 4, clinical cure rates were 94% in T+M group and 77% in CL group (P=N.S.). The laboratory cure rates were 81% in T+M group and 59% in CL group (P<0.04). Vaginal pH normalisation (i.e. pH <4.5) was achieved in 78% and in 38% of T+M and CL groups, respectively (P<0.0007).

CONCLUSIONS

In the short term, 2g single oral dose tinidazole was at least as effective as 7-day of vaginal clindamycin. The sequential treatment of tinidazole and acidic vaginal gel was superior to vaginal clindamycin in lowering vaginal pH and achieving a higher laboratory tests normalization rate at 1-month follow-up.

Antibiotic resistance of subgingival species during and after antibiotic therapy

AIM

The purpose of the present investigation was to determine the percentage and identity of antibiotic-resistant species in subgingival plaque and saliva samples from chronic periodontitis patients treated by scaling and root planing followed by orally administered amoxicillin or metronidazole.

METHOD

In all, 20 chronic periodontitis patients were selected for study. After clinical and microbiological monitoring, subjects were randomly assigned to receive either orally administered amoxicillin at the dosage of 500 mg, 3 times daily for 14 days or orally administered metronidazole at the dosage of 250 mg, 3 times daily for 14 days. For the antibiotic resistance determinations, subgingival plaque samples were taken from six posterior teeth at baseline, and 90 days; and from two randomly selected teeth at 3, 7 and 14 days during and after antibiotic administration. Samples were plated on enriched blood agar plates with or without either 2 micro g/mL metronidazole or 2 micro g/mL amoxicillin. Colonies were counted at 7 days. Significant differences in percentage of resistant organisms over time were determined by the Quade test. Microbial growth was washed from antibiotic-containing media and the identity of species determined using checkerboard DNA-DNA hybridization. Data were compared with those obtained in a previous study from subjects receiving SRP only or SRP followed by 14 days of orally administered doxycycline. The level of doxycycline used to determine antibiotic resistance in that study was 4 micro g/mL.

RESULTS

The mean percentage of resistant isolates increased during antibiotic administration and returned to baseline levels by 90 days post therapy. The mean percentages (+/- SEM) of isolates resistant to 2 micro g/mL metronidazole were 53 +/- 9, 65 +/- 9, 79 +/- 4 and 69 +/- 7 at baseline, 3, 7 and 14 days during antibiotic administration, and 57 +/- 4, 64 +/- 5, 62 +/- 7 and 47 +/- 6 at 3, 7, 14 and 90 days after antibiotic administration. At the same time points, the percentage of resistant isolates to amoxicillin was 0.5 +/- 0.2, 22 +/- 12, 14 +/- 5 and 37 +/- 11 during, and 31 +/- 11, 8 +/- 3, 3 +/- 2 and 3 +/- 0.6 after, administration. Antibiotic-resistant isolates of resistant species detected during or after therapy were also detected prior to therapy. The most prevalent resistant species in the metronidazole-treated group were: A. naeslundii 1, S. constellatus, A. naeslundii 2, S. mitis, S. oralis, A. odontolyticus, S. sanguis, and in the amoxicillin-treated group: S. constellatus, P. nigrescens, E. saburreum, A. naeslundii 1, S. oralis, P. melaninogenica and P. intermedia.

CONCLUSIONS

Systemic antibiotic administration transiently increased the percentage of resistant subgingival species, but a major component of subgingival plaque remained sensitive to the agents during their administration. Antibiotic-resistant isolates of resistant species could be detected in samples both prior to and after therapy. However, % antibiotic-resistant isolates returned to baseline levels 90 days after antibiotic administration.

Clinical aromatherapy and AIDS

Clinical aromatherapy is the use of essential oils for expected outcomes that are measurable and is a therapy that is used as part of nursing care in Switzerland, Germany, Australia, Canada, the United Kingdom, and, more recently, the United States. Essential oils are steam distillates obtained from aromatic plants. These volatile extracts have been used for many years by French hospitals against airborne bacteria and fungi. As antimicrobial agents, essential oils may be appropriate in HIV/AIDS for specific opportunistic infections. Aromatherapy can also alter perceptions of chronic pain, help maintain skin integrity, and is useful in stress management. Methods of application vary depending on the site of infection and the psychological profile of the patient and can include inhalation, compresses, baths, massage, and the "m" technique. This article will explore the potential use of essential oils in HIV/AIDS focusing on four opportunistic infections: Cryptococcus neoformans, Candida albicans, methicillin-resistant Staphylococcus aureus, and herpes simplex types I and II.

Maternal periodontal disease and preterm low birthweight: case-control study

Periodontal disease has been suggested to be an important risk factor for preterm low birthweight (PLBW). Here we report a case-control study of 236 cases (infants < 37 wks and weighing < 2499 g) and a daily random sample of 507 controls (> or = 38 wks and weighing > or = 2500 g). Clinical periodontal indices were measured on the labor wards. Associated risk factors for periodontal disease and PLBW were ascertained by means of a structured questionnaire and maternity notes. The risk for PLBW decreased with increasing pocket depth (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.68 to 1.00). After adjustment for maternal age, ethnicity, maternal education, smoking, alcohol consumption, infections, and hypertension during pregnancy, this decreased further (OR 0.78, 95% CI 0.64 to 0.99). We found no evidence for an association between PLBW and periodontal disease. Our results do not support a specific drive to improve periodontal health of pregnant women as a means of improving pregnancy outcomes.

Effectiveness of current therapy of bacterial vaginosis

The study was conducted in order to evaluate effectiveness of the treatment of bacterial vaginosis (BV) with different therapeutic regimes according to recommendations of the World Health Organization (WHO). During a one-year period (February 2000-February 2001) the Sexually Transmitted Diseases (STD) Center was visited by 482 women aged 14-51. The diagnosis of BV was established by standard methods: Amsel's clinical criteria and Gram stain of vaginal discharge. The first-line treatment was oral Metronidazole 2 g single dose. Second line was Metronidazole 500 mg twice daily orally for 7 days or oral Clindamycin 300 mg twice daily for seven days. BV was confirmed in 74 women (15.4%). Most often it was observed in women aged 17-30 years of age. Thirty-three (44.6% of total) were young women 14-21 years of age. Thirty-one (42%) women received a follow-up examination and of those, 11 (38.7%) needed a repeat treatment for BV due to unsatisfactory results of this treatment. It is concluded that treatment of BV with standard methods was not always effective with no significant difference between women under 21 years and older women found in regards to response to treatment. Besides antibiotic treatment, the so-called Probiotics (Lactobacillus acidophilus) can be taken into consideration as an alternative treatment. Additional research about the therapeutic effect of this type of drugs is needed.

Microecology, bacterial vaginosis and probiotics: perspectives for bacteriotherapy

Probiotics enriched in lactobacilli have been proposed as an effective and alternative tool to antibiotics for the treatment of bacterial vaginosis. The protective role of H(2)O(2)-producing lactobacilli has been strongly emphasized, but no clear-cut correlation appears to link the metabolic characteristics of administered lactobacilli with the clinical impact of probiotic therapy. On account of our review of basic mechanisms involved in bacterial vaginosis, we suggest that lactobacilli with an elevated arginine deiminase activity could have a greater therapeutic potential than strains producing only H(2)O(2). Preliminary results from our laboratory have demonstrated that treatment with probiotics containing arginine deiminase-positive lactobacilli improves clinical symptoms and is paralleled by a significant decline of polyamine levels in vaginal microenvironment. This is of outstanding interest due to the central role of polyamines in the pathogenesis of bacterial vaginosis. We should critically rethink, against this perspective, the use of probiotics for the treatment of affected women.

Vaginitis: meeting the clinical challenge

Vaginitis is a common gynecologic disorder that is responsible for 10 million office visits to physicians each year. Infectious vaginitis is the most common cause of a vaginal discharge, but other important diagnostic considerations include infectious cervicitis, a physiologic discharge, atrophic vaginitis, and allergic or irritant vaginitis. Although the history and gynecologic examination may suggest the diagnosis, laboratory confirmation should be routinely sought by performance of the vaginal pool wet mount examination, the amine whiff test, determination of the vaginal pH, and the Q-tip test. Once a precise diagnosis is made, effective therapy can then be prescribed. For patients with Candida vaginitis, therapeutic options include either the vaginal administration of a number of available imidazole or triazole antifungal agents or the prescription of the oral triazole agent fluconazole. Oral metronidazole remains the only effective treatment for trichomoniasis in the United States. Bacterial vaginosis, which has been linked to a number of obstetric and gynecologic complications, is effectively treated with oral metronidazole, although vaginal metronidazole gel and oral and vaginal clindamycin formulations are available as well.

Bacterial vaginosis

Bacterial vaginosis represents a unique upheaval of the complex vaginal bacterial flora with disappearance of lactobacilli and overgrowth of Gardnerella vaginalis and resident anaerobic vaginal bacteria. Little progress has occurred in identifying causal factors, although the pathophysiology of this syndrome is better understood. Although symptoms are easily recognizable, obstetric and gynecologic complications continue to increase in number. Bacterial vaginosis is far more than a nuisance infection. Problems with diagnosis continue to dominate clinical practice, although new tests have been introduced. Therapeutic options have increased, although recurrent disease remains common, and management of this common complication constitutes a major challenge.

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.

Managing sexually transmitted diseases in adolescents

Control of sexually transmitted diseases (STDs) in adolescents is a primary responsibility of health care providers. Using the tools of history and physical examination, and drawing on the awareness of different stages of adolescent development, health care providers can define at-risk for STDs. This article discusses screening practices, disease control through reporting and preventive counseling, and treatment guidelines for common STD syndromes.

The pediatrician and the sexually active adolescent. A primer for sexually transmitted diseases

Sexual activity is a common practice among young adolescents, placing them at high risk for STDs, many of which have long-term consequences. Early diagnosis and treatment are essential to limit both the consequences and the spread of these infections. The clinician has a responsibility to the adolescent patient to recognize and treat these diseases. Using history and physical examination, the clinician should be able to determine an adolescent's risk for an STD, and, based on this risk, undertake the appropriate evaluations. Patient treatment, follow-up, and management of sex partners are then guided by the results of either presumptive or definitive diagnostic tests.

Metronidazole. A therapeutic review and update

The nitroimidazole antibiotic metronidazole has a limited spectrum of activity that encompasses various protozoans and most Gram-negative and Gram-positive anaerobic bacteria. Metronidazole has activity against protozoans like Entamoeba histolytica, Giardia lamblia and Trichomonas vaginalis, for which the drug was first approved as an effective treatment. Anaerobic bacteria which are typically sensitive are primarily Gram-negative anaerobes belonging to the Bacteroides and Fusobacterium spp. Gram-positive anaerobes such as peptostreptococci and Clostridia spp. are likely to test sensitive to metronidazole, but resistant isolates are probably encountered with greater frequency than with the Gram-negative anaerobes. Gardnerella vaginalis is a pleomorphic Gram-variable bacterial bacillus that is also susceptible to metronidazole. Helicobacter pylori has been strongly associated with gastritis and duodenal ulcers. Classic regimens for eradicating this pathogen have included metronidazole, usually with acid suppression medication plus bismuth and amoxicillin. The activity of metronidazole against anaerobic bowel flora has been used for prophylaxis and treatment of patients with Crohn's disease who might develop an infectious complication. Treatment of Clostridium difficile-induced pseudomembraneous colitis has usually been with oral metronidazole or vancomycin, but the lower cost and similar efficacy of metronidazole, coupled with the increased concern about imprudent use of vancomycin leading to increased resistance in enterococci, have made metronidazole the preferred agent here. Metronidazole has played an important role in anaerobic-related infections. Advantages to using metronidazole are the percentage of sensitive Gram-negative anaerobes, its availability as oral and intravenous dosage forms, its rapid bacterial killing, its good tissue penetration, its considerably lower chance of inducing C. difficile colitis, and expense. Metronidazole has notable effectiveness in treating anaerobic brain abscesses. Metronidazole is a cost-effective agent due to its low acquisition cost, its pharmacokinetics and pharmacodynamics, an acceptable adverse effect profile, and its undiminished antimicrobial activity. While its role as part of a therapeutic regimen for treating mixed aerobic/anaerobic infections has been reduced by newer, more expensive combination therapies, these new combinations have not been shown to have any therapeutic advantage over metronidazole. Although the use of metronidazole on a global scale has been curtailed by newer agents for various infections, metronidazole still has a role for these and other therapeutic uses. Many clinicians still consider metronidazole to be the 'gold standard' antibiotic against which all other antibiotics with anaerobic activity should be compared.

Treatment of vaginal infections: candidiasis, bacterial vaginosis, and trichomoniasis

OBJECTIVE

To describe the signs and symptoms of and recommend treatments for Candida vulvovaginitis, bacterial vaginosis, and Trichomonas vaginitis.

DATA SOURCES

Current clinical literature.

DATA SYNTHESIS

Patients with candidal vulvovaginitis often present with itching, burning, white discharge, vulvar or vaginal erythema, painful intercourse, and stinging on urination. It is treated with oral or topical antifungal agents. Bacterial vaginosis is characterized by a musty or fishy vaginal odor and a thin, white vaginal discharge. It is treated with oral or topical metronidazole or clindamycin. Patients with trichomoniasis usually complain of profuse, yellow-green discharge and vaginal or vulvar irritation. The standard treatment is a single 2 gram dose of oral metronidazole for both the patient and sexual partners.

CONCLUSION

Given the potential adverse effects of the drugs used to treat these conditions, pharmacists are in a unique position to recommend appropriate therapies and to refer patients to other health care providers as needed.