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Abbe C, Mitchell CM. Bacterial vaginosis: a review of approaches to treatment and prevention. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1100029. [PMID: 37325243 PMCID: PMC10264601 DOI: 10.3389/frph.2023.1100029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Bacterial vaginosis (BV) is a common cause of vaginitis worldwide and is associated with serious reproductive health outcomes, including increased risk of preterm birth, sexually transmitted infections, and pelvic inflammatory disease. The current and only FDA-approved treatment regimens for BV are antibiotics, such as metronidazole and clindamycin. Antibiotics provide a short-term cure for bacterial vaginosis; however, fail to provide a consistent long-term cure for many women. Fifty to eighty percent of women experience a BV recurrence within a year of completing antibiotic treatment. This may be because after antibiotic treatment, beneficial strains of Lactobacillus, such as L. crispatus, do not recolonize the vagina. In the absence of an effective long-term cure, patients, providers, and researchers are exploring different approaches to treatment and prevention, resulting in a rapid evolution of perspectives on BV pathogenesis and approaches to management. Current areas of investigation for BV management include probiotics, vaginal microbiome transplantation, pH modulation, and biofilm disruption. Behavioral modifications that may help include smoking cessation, condom use and hormonal contraception. Additional strategies considered by many people include dietary modification, non-medical vaginally applied products, choice of lubricant, and treatments from medical practices outside of allopathic medicine. This review aims to provide a comprehensive and up to date outline of the landscape of ongoing and potential treatment and prevention strategies for BV.
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Affiliation(s)
- Carmen Abbe
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, United States
| | - Caroline M. Mitchell
- Vincent Center for Reproductive Biology, Massachusetts General Hospital, Boston, MA, United States
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Ross JDC, Brittain C, Anstey Watkins J, Kai J, David M, Ozolins M, Jackson L, Abdali Z, Hepburn TM, Griffiths F, Montgomery A, Daniels J, Manley A, Dean G, Armstrong-Buisseret LK. Intravaginal lactic acid gel versus oral metronidazole for treating women with recurrent bacterial vaginosis: the VITA randomised controlled trial. BMC Womens Health 2023; 23:241. [PMID: 37161454 PMCID: PMC10169495 DOI: 10.1186/s12905-023-02303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 03/21/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Bacterial vaginosis is a common and distressing condition for women. Short-term antibiotic treatment is usually clinically effective, but recurrence is common. We assessed the effectiveness of intravaginal lactic acid gel versus oral metronidazole for treating recurrent bacterial vaginosis. METHODS We undertook an open-label, multicentre, parallel group, randomised controlled trial in nineteen UK sexual health clinics and a university health centre. Women aged ≥ 16 years, with current bacterial vaginosis symptoms and a preceding history of bacterial vaginosis, were randomised in a 1:1 ratio using a web-based minimisation algorithm, to 400 mg twice daily oral metronidazole tablets or 5 ml once daily intravaginal lactic acid gel, for 7 days. Masking of participants was not possible. The primary outcome was participant-reported resolution of symptoms within 2 weeks. Secondary outcomes included time to first recurrence of symptoms, number of recurrences and repeat treatments over 6 months and side effects. RESULTS Five hundred and eighteen participants were randomised before the trial was advised to stop recruiting by the Data Monitoring Committee. Primary outcome data were available for 79% (204/259) allocated to metronidazole and 79% (205/259) allocated to lactic acid gel. Resolution of bacterial vaginosis symptoms within 2 weeks was reported in 70% (143/204) receiving metronidazole versus 47% (97/205) receiving lactic acid gel (adjusted risk difference -23·2%; 95% confidence interval -32.3 to -14·0%). In those participants who had initial resolution and for whom 6 month data were available, 51 of 72 (71%) women in the metronidazole group and 32 of 46 women (70%) in the lactic acid gel group had recurrence of symptoms, with median times to first recurrence of 92 and 126 days, respectively. Reported side effects were more common following metronidazole than lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). CONCLUSIONS Metronidazole was more effective than lactic acid gel for short-term resolution of bacterial vaginosis symptoms, but recurrence is common following both treatments. Lactic acid gel was associated with fewer reported side effects. TRIAL REGISTRATION ISRCTN14161293 , prospectively registered on 18th September 2017.
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Affiliation(s)
- Jonathan D C Ross
- Department of GU Medicine, University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Whittall Street, Birmingham, B4 6DH, UK
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joe Kai
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, University Park, NG7 2RD, UK
| | - Miruna David
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Zainab Abdali
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Trish M Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK.
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alice Manley
- Department of GU Medicine, University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Whittall Street, Birmingham, B4 6DH, UK
| | - Gillian Dean
- Elton John Research Centre, Sussex House, 1 Abbey Road, Brighton, BN2 1ES, UK
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Armstrong-Buisseret L, Brittain C, Kai J, David M, Anstey Watkins J, Ozolins M, Jackson L, Abdali Z, Hepburn T, Griffiths F, Montgomery A, Daniels J, Manley A, Dean G, Ross JDC. Lactic acid gel versus metronidazole for recurrent bacterial vaginosis in women aged 16 years and over: the VITA RCT. Health Technol Assess 2022; 26:1-170. [DOI: 10.3310/zzkh4176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joe Kai
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Miruna David
- Clinical Microbiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zainab Abdali
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alice Manley
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jonathan DC Ross
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Diebold R, Schopf B, Stammer H, Mendling W. Vaginal treatment with lactic acid gel delays relapses in recurrent urinary tract infections: results from an open, multicentre observational study. Arch Gynecol Obstet 2021; 304:409-417. [PMID: 33772330 PMCID: PMC8277613 DOI: 10.1007/s00404-021-06040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE The main objective of this open, prospective, multicentre, observational study is to investigate the relapse rate and tolerability of lactic acid gels in adult female patients with recurrent urinary tract infections during routine practice. METHODS Data were collected from patients undergoing intermittent short courses of intravaginal treatment with lactic acid gel for prevention of recurrent urinary tract infections. The observation period for individual patients was 4 months, aimed at covering four short courses of intravaginal treatment. Data on UTI relapses, tolerability, handling and satisfaction with the treatment were collected via patient diaries and physician assessments and comprised any adverse events (AEs). RESULTS In total, 72 patients were treated. During the last 12 months prior to the study, patients had on average 4.0 UTIs. In the 4 months after commencing treatment, 63.5% of patients had no recurrence of UTI symptoms. Overall efficacy was rated by physicians as 'excellent/good' for 96.7% of patients. The patients' overall acceptance of local treatment was high with 94.1% being '(very) satisfied'. Similarly, handling was rated as '(very) easy' by 94.2% of patients. The tolerability was assessed as 'highly tolerable/tolerable' by over 98% of patients and physicians alike. Safety analyses reported six AEs of mild intensity, all of which had resolved by the end of the study. CONCLUSION Treatment with lactic acid gel may increase resilience against uropathogens, possibly preventing the need for antibiotic prevention of recurrent urinary tract infections. Treatment was positively assessed by the patients. The physician assessments corroborate these findings. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION DRKS00016760, 18.02.2019.
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Affiliation(s)
- Ruth Diebold
- Dr. Kade Pharmazeutische Fabrik GmbH, Berlin, Germany.
| | - Bettina Schopf
- Pharmalog Institut für klinische Forschung GmbH, Ismaning, Germany
| | - Holger Stammer
- Pharmalog Institut für klinische Forschung GmbH, Ismaning, Germany
| | - Werner Mendling
- German Centre for Infections in Obstetrics and Gynecology, Wuppertal, Germany
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Lactic acid-containing products for bacterial vaginosis and their impact on the vaginal microbiota: A systematic review. PLoS One 2021; 16:e0246953. [PMID: 33571286 PMCID: PMC7877752 DOI: 10.1371/journal.pone.0246953] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/28/2021] [Indexed: 01/14/2023] Open
Abstract
Objective The vaginal microbiota in bacterial vaginosis (BV) typically has low abundance of lactic acid producing lactobacilli. Lactic acid has properties that may make it effective for treating BV and/or restoring an optimal lactobacillus-dominated vaginal microbiota. We conducted a systematic review to describe the effect of intravaginal lactic acid-containing products on BV cure, and their impact on vaginal microbiota composition (PROSPERO registration: CRD42018115982). Methods PubMed, Embase and OVID were searched from inception to November 2019 to identify eligible studies. Included studies evaluated an intravaginal lactic acid-containing product and reported BV cure using established diagnostic methods, and/or vaginal microbiota composition using molecular methods. Studies were independently screened and assessed, and the proportion of women cured post-treatment was calculated. Study results were described in a qualitative manner. Results We identified 1,883 articles and assessed 57 full-texts for eligibility. Seven different lactic acid-containing products were evaluated and differed with respect to excipients, lactic acid concentration and pH. Most studies had medium or high risk of bias. Three trials compared the efficacy of a lactic acid-containing product to metronidazole for BV cure. One study found lactic acid to be equivalent to metronidazole and two studies found lactic acid to be significantly inferior to metronidazole. Two studies included a control group receiving a placebo or no treatment. One reported lactic acid to be superior than no treatment and the other reported lactic acid to be equivalent to placebo. Lactic acid-containing products did not significantly impact the vaginal microbiota composition. Conclusion There is a lack of high-quality evidence to support the use of lactic acid-containing products for BV cure or vaginal microbiota modulation. However, adequately powered and rigorous randomised trials with accompanying vaginal microbiota data are needed to evaluate the efficacy of lactic acid as a BV treatment strategy.
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Khalilzadeh S, Eftkhar T, Shirbeigi L, Tabarrai M, Toliyat T, Fayazmanesh S, Ghasemi Z, Shamohammadi S. Efficacy of a vaginal tablet as a Persian medicine product on vulvovaginal candidiasis: a double-blind, randomised, placebo-controlled trial. PHARMACEUTICAL BIOLOGY 2020; 58:574-580. [PMID: 32615837 PMCID: PMC8641665 DOI: 10.1080/13880209.2020.1784236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/11/2020] [Accepted: 06/14/2020] [Indexed: 06/11/2023]
Abstract
Context: In Persian medicine, topical ingredients such as Rosa damascena Mill. (Rosaceae), are usually recommended for the treatment of uterine diseases. Scientific evaluation of these historical documents can be valuable for finding new potential use in conventional medicine.Objective: This clinical trial was performed to determine whether the use of the 'ward' vaginal tablet, which contains Rosa damascena, Punica granatum L. (Punicaceae), Querqus infectoria Oliv. (Fagaceae), Myrtus communis L. (Myrtaceae) and Nardostachys jatamansi (D.Don) DC. (Caprifoliaceae) could alleviate the symptoms of vulvovaginal candidiasis.Materials and methods: A parallel double-blinded placebo-controlled study was done. Eighteen to fifty-year-old women with vulvovaginal candidiasis were divided into the 'ward' and placebo groups, 46 individuals in each group. The 'ward' group received the 'ward' vaginal tablet containing 200 mg of dried extract. Placebo group received a placebo (composed of corn starch and lactose). One tablet was applied through the vagina for 7 consecutive nights.Results: Two weeks after medication administration, the vaginal discharge sample of patients was re-cultured; 29 patients (63.045%) in the 'ward' group and 6 (13.04%) patients in the placebo group had negative culture (p < 0.001). All clinical symptoms including itching, irritation, and vaginal discharge were significantly reduced in the 'ward' group compared with the placebo group following the intervention and the follow up (p < 0.05).Discussion and conclusions: The findings suggest the 'ward' vaginal tablet could ameliorate vulvovaginal candidiasis. Future larger studies are recommended due to compare the therapeutic effect of the 'ward' vaginal tablet with common treatments.
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Affiliation(s)
- Somayyeh Khalilzadeh
- Department of Persian Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Eftkhar
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Laila Shirbeigi
- Department of Persian Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Malihe Tabarrai
- Department of Persian Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Tayebeh Toliyat
- Department of Pharmaceutics, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shamim Fayazmanesh
- Department of Pharmaceutics, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacognosy, Faculty of Pharmacy and Persian Medicine and Pharmacy Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeinab Ghasemi
- Medical Mycology of Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Safar Shamohammadi
- Razi Hospital Laboratory, Faculty member in medicine, Tehran University of Medical Sciences, Tehran, Iran
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Tidbury FD, Langhart A, Weidlinger S, Stute P. Non-antibiotic treatment of bacterial vaginosis-a systematic review. Arch Gynecol Obstet 2020; 303:37-45. [PMID: 33025086 DOI: 10.1007/s00404-020-05821-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/25/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Bacterial vaginosis (BV) is one of the most common vaginal complaints of women of reproductive age, characterized by a shift from a Lactobacillus-dominated vaginal microbiome towards a more diverse flora of facultative and obligately anaerobic bacteria. BV can increase the risk of preterm births, contracting sexually transmitted infections and developing other chronic health issues. Standard treatment for BV are antibiotics, however despite initial efficacy, they do not provide effective long-term treatment and recurrence or persistence prevention. This systematic review focuses on describing the current study situation and summarizing the newest data on the efficacy of alternative non-antibiotic options, namely probiotic products containing lactobacilli, lactic acid, sucrose gel, combination products with estriol, and supplementation of antibiotics. METHODS We conducted a systematic literature search using the MEDLINE database and evaluated the 33 trials which met our inclusion criteria. CONCLUSION The diverse study designs produced extremely varied outcomes, but so far the results are promising. Furthermore, these alternatives have shown little to no adverse effects and are consequently generally considered safe to use. In general, the results of this review warrant more thorough trials with larger cohort sizes to provide sufficient evidence for these alternatives to be a part of official treatment recommendations.
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Affiliation(s)
- Fiona Damaris Tidbury
- Gynecologic Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, University Clinic Inselspital Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland
| | - Anita Langhart
- Department of Anaesthesiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Susanna Weidlinger
- Gynecologic Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, University Clinic Inselspital Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland
| | - Petra Stute
- Gynecologic Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, University Clinic Inselspital Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
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Armstrong-Buisseret L, Brittain C, David M, Dean G, Griffiths F, Hepburn T, Jackson L, Kai J, Montgomery A, Roberts T, Thandi S, Ross JDC. 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. Trials 2019; 20:648. [PMID: 31775859 PMCID: PMC6880606 DOI: 10.1186/s13063-019-3731-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Lindsay Armstrong-Buisseret
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Clare Brittain
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Miruna David
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Gillian Dean
- Elton John Research Centre, Sussex House, 1 Abbey Road, Brighton, BN2 1ES, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Joe Kai
- School of Medicine, Tower Building, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alan Montgomery
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Tracy Roberts
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Jonathan D C Ross
- Department of GU Medicine, University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Whittall Street, Birmingham, B4 6DH, UK.
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van der Veer C, Bruisten SM, van Houdt R, Matser AA, Tachedjian G, van de Wijgert JHHM, de Vries HJC, van der Helm JJ. Effects of an over-the-counter lactic-acid containing intra-vaginal douching product on the vaginal microbiota. BMC Microbiol 2019; 19:168. [PMID: 31345159 PMCID: PMC6659218 DOI: 10.1186/s12866-019-1545-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/18/2019] [Indexed: 12/26/2022] Open
Abstract
Background Over-the-counter intra-vaginal lactic-acid containing douches are marketed as vaginal hygiene products that support optimal vaginal pH balance. We report the effect of a commercially available douche (Etos®) on the vaginal microbiota (VM) in a prospective study. Results Twenty-five healthy women were recruited through advertisements in 2015–2017 (ethical approval: METC-2014_413) and followed over three menstrual cycles. The participants had a median age of 24 years [IQR: 22–29], were mostly Dutch-Caucasian (88%), and 60% used combined oral contraceptives. All participants douched three times a week during the second cycle, starting on the first day of that cycle. Participants completed a questionnaire at baseline, kept a daily diary to report douching, menses, and sexual activity, self-collected vaginal swabs every other day during the first and third cycle and daily during the second cycle, and measured vaginal pH mid-cycle. A median of 44 vaginal swabs [inter-quartile range (IQR): 41–50] were assessed per participant by 16S rRNA gene (V3-V4 region) sequencing and a Candida albicans PCR was done at four time-points. At baseline, 21 participants (84%) had Lactobacillus-dominated VM (Lactobacillus crispatus (n = 14), L. iners (n = 6), or diverse Lactobacillus species (n = 1) and 4 participants (16%) had VM consisting of diverse anaerobes. In multinomial logistic regression models, a trend towards increased odds were observed for having diverse anaerobic VM in the second and third cycle, compared to the first cycle, after adjusting for menses [odds ratio (OR) = 1.4 (95% CI: 0.9–2.1) and OR = 1.7 (95% CI: 0.9–3.1), respectively] (p = 0.376). Douching did not affect vaginal pH. Menses increased the odds for having VM consisting of diverse anaerobes almost two-fold (OR = 1.7; 95% CI: 1.0–2.8), while douching during menses increased the odds 2.6 fold (OR = 2.6; 95% CI: 1.0–6.5), compared to not menstruating (p = 0.099). Participants were more likely to test positive for C. albicans after cycle 2, compared to cycle 1 [OR = 3.0 (95% CI: 1.2–7.2); p = 0.017]. Conclusion The Etos® douche did not significantly affect the vaginal pH or VM composition, although increased odds for having diverse anaerobic VM was observed, especially when douching during menses. Furthermore, douching may promote C. albicans infections. Electronic supplementary material The online version of this article (10.1186/s12866-019-1545-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- C van der Veer
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands.
| | - S M Bruisten
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands.,Amsterdam Infection & Immunity Institute Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - R van Houdt
- Department of Medical Microbiology and Infection prevention, VU University Medical Center, Amsterdam, the Netherlands
| | - A A Matser
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands
| | - G Tachedjian
- Disease Elimination Program Life Sciences Discipline, Burnet Institute, Melbourne, Victoria, Australia.,Department of Microbiology, Monash University, Clayton, Victoria, Australia.,Department of Microbiology and Immunology at the Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - J H H M van de Wijgert
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - H J C de Vries
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands.,Amsterdam Infection & Immunity Institute Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.,Academic Medical Centers, Department of Dermatology, Amsterdam, the Netherlands
| | - J J van der Helm
- Department of Infectious Diseases, Public Health Service, GGD, Amsterdam, the Netherlands
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10
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Khalilzadeh S, Eftekhar T, Rahimi R, Mehriardestani M, Tabarrai M. An Evidence-Based Review of Medicinal Plants Used for the Treatment of Vaginitis by Avicenna in " the Canon of Medicine". Galen Med J 2019; 8:e1270. [PMID: 34466482 PMCID: PMC8344152 DOI: 10.31661/gmj.v8i0.1270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/07/2018] [Accepted: 12/07/2018] [Indexed: 12/21/2022] Open
Abstract
Vaginitis is one of the most common gynecological problems in reproductive age. Because of the limitations of the conventional drugs, identification of new pharmacological interventions for this disease seems to be necessary. The purpose of this article is to review the medicinal herbs mentioned for the treatment of vaginitis by the great Iranian scientist, Avicenna, in his book "the Canon of Medicine " to scientifically demonstrate their effects and their potential to be used as complementary therapies. The medicinal plants listed for vaginitis treatment in "the Canon of Medicine " were extracted. The scientific name and English common name of the given medicinal plants were searched in databases including PubMed, Scopus, and Cochrane Library until December 2017 to obtain any in vitro, animal, and clinical evidence related to vaginitis. Various pharmacological activities, including anti-inflammatory, wound healing, antimicrobial, antifungal, analgesic, and anti-prostaglandin E2, have been demonstrated for medicinal plants emphasized by Avicenna for vaginitis. Randomized controlled trials (RCTs) on Myrtus reported an improvement in the treatment of bacterial vaginosis. Four RCTs on pomegranate indicated a reduction in inflammatory factors in the patients. Medicinal herbs offered in Herbal Medicine are valuable sources for the treatment of various diseases. Effects and pharmacodynamics having been proved by conventional medicine confirm the effectiveness of these herbs. Therefore, these plants can be used in the treatment of vaginitis thanks to further clinical studies.
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Affiliation(s)
- Somayyeh Khalilzadeh
- Department of Persian medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Eftekhar
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Roja Rahimi
- Department of Traditional Pharmacy, School of Traditional Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mozhgan Mehriardestani
- Department of Traditional Pharmacy, School of Traditional Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Malihe Tabarrai
- Department of Persian medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Correspondence to: Malihe Tabarrai, School of Persian medicine, Tehran university of Medical Sciences, Gity alley, Vafamanesh St., Heravi Sq., Tehran, Iran Telephone Number: 00989127909906 Email Address:
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11
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Verstraelen H, Vervaet C, Remon JP. Rationale and Safety Assessment of a Novel Intravaginal Drug-Delivery System with Sustained DL-Lactic Acid Release, Intended for Long-Term Protection of the Vaginal Microbiome. PLoS One 2016; 11:e0153441. [PMID: 27093291 PMCID: PMC4836750 DOI: 10.1371/journal.pone.0153441] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 03/29/2016] [Indexed: 12/29/2022] Open
Abstract
Bacterial vaginosis is a prevalent state of dysbiosis of the vaginal microbiota with wide-ranging impact on human reproductive health. Based on recent insights in community ecology of the vaginal microbiome, we hypothesize that sustained vaginal DL-lactic acid enrichment will enhance the recruitment of lactobacilli, while counteracting bacterial vaginosis-associated bacteria. We therefore aimed to develop an intravaginal device that would be easy to insert and remove, while providing sustained DL-lactic acid release into the vaginal lumen. The final prototype selected is a vaginal ring matrix system consisting of a mixture of ethylene vinyl acetate and methacrylic acid-methyl methacrylate copolymer loaded with 150 mg DL-lactic acid with an L/D-lactic acid ratio of 1:1. Preclinical safety assessment was performed by use of the Slug Mucosal Irritation test, a non-vertebrate assay to evaluate vaginal mucosal irritation, which revealed no irritation. Clinical safety was evaluated in a phase I trial with six healthy nulliparous premenopausal volunteering women, with the investigational drug left in place for 7 days. Colposcopic monitoring according to the WHO/CONRAD guidelines for the evaluation of vaginal products, revealed no visible cervicovaginal mucosal changes. No adverse events related to the investigational product occurred. Total release from the intravaginal ring over 7 days was estimated through high performance liquid chromatography at 37.1 (standard deviation 0.9) mg DL-lactic acid. Semisolid lactic acid formulations have been studied to a limited extent in the past and typically consist of a large volume of excipients and very high doses of lactic acid, which is of major concern to mucosal safety. We have documented the feasability of enriching the vaginal environment with pure DL-lactic acid with a prototype intravaginal ring. Though the efficacy of this platform remains to be established possibly requiring further development, this approach may offer a novel avenue to modulate and protect the vaginal microbiota.
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Affiliation(s)
- Hans Verstraelen
- Department of Obstetrics & Gynaecology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Chris Vervaet
- Department of Pharmaceutics, Laboratory of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Jean-Paul Remon
- Department of Pharmaceutics, Laboratory of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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12
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Petrova MI, Lievens E, Malik S, Imholz N, Lebeer S. Lactobacillus species as biomarkers and agents that can promote various aspects of vaginal health. Front Physiol 2015; 6:81. [PMID: 25859220 PMCID: PMC4373506 DOI: 10.3389/fphys.2015.00081] [Citation(s) in RCA: 270] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/02/2015] [Indexed: 12/21/2022] Open
Abstract
The human body is colonized by a vast number of microorganisms collectively referred to as the human microbiota. One of the main microbiota body sites is the female genital tract, commonly dominated by Lactobacillus spp., in approximately 70% of women. Each individual species can constitute approximately 99% of the ribotypes observed in any individual woman. The most frequently isolated species are Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus jensenii and Lactobacillus iners. Residing at the port of entry of bacterial and viral pathogens, the vaginal Lactobacillus species can create a barrier against pathogen invasion since mainly products of their metabolism secreted in the cervicovaginal fluid can play an important role in the inhibition of bacterial and viral infections. Therefore, a Lactobacillus-dominated microbiota appears to be a good biomarker for a healthy vaginal ecosystem. This balance can be rapidly altered during processes such as menstruation, sexual activity, pregnancy and various infections. An abnormal vaginal microbiota is characterized by an increased diversity of microbial species, leading to a condition known as bacterial vaginosis. Information on the vaginal microbiota can be gathered from the analysis of cervicovaginal fluid, by using the Nugent scoring or the Amsel's criteria, or at the molecular level by investigating the number and type of Lactobacillus species. However, when translating this to the clinical setting, it should be noted that the absence of a Lactobacillus-dominated microbiota does not appear to directly imply a diseased condition or dysbiosis. Nevertheless, the widely documented beneficial role of vaginal Lactobacillus species demonstrates the potential of data on the composition and activity of lactobacilli as biomarkers for vaginal health. The substantiation and further validation of such biomarkers will allow the design of better targeted probiotic strategies.
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Affiliation(s)
- Mariya I Petrova
- Department of Bioscience Engineering, University of Antwerp Antwerp, Belgium ; Centre of Microbial and Plant Genetics, KU Leuven Leuven, Belgium
| | - Elke Lievens
- Department of Bioscience Engineering, University of Antwerp Antwerp, Belgium ; Centre of Microbial and Plant Genetics, KU Leuven Leuven, Belgium
| | - Shweta Malik
- Department of Bioscience Engineering, University of Antwerp Antwerp, Belgium ; Centre of Microbial and Plant Genetics, KU Leuven Leuven, Belgium
| | - Nicole Imholz
- Department of Bioscience Engineering, University of Antwerp Antwerp, Belgium ; Centre of Microbial and Plant Genetics, KU Leuven Leuven, Belgium
| | - Sarah Lebeer
- Department of Bioscience Engineering, University of Antwerp Antwerp, Belgium ; Centre of Microbial and Plant Genetics, KU Leuven Leuven, Belgium
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13
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Dover SE, Aroutcheva AA, Faro S, Chikindas ML. NATURAL ANTIMICROBIALS AND THEIR ROLE IN VAGINAL HEALTH: A SHORT REVIEW. INTERNATIONAL JOURNAL OF PROBIOTICS & PREBIOTICS 2008; 3:219-230. [PMID: 20657710 PMCID: PMC2908489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Lactobacillus species maintain the vaginal ecosystem in a healthy condition by production of antimicrobial substances. Depletion of lactobacilli in the vagina results in bacterial vaginosis (BV), where the normal flora is replaced by several bacterial pathogens, usually Gardnerella vaginalis and obligate anaerobes. BV may cause complications such as premature labor, low birth weight and increased risk of HIV acquisition. The currently recommended antibiotic treatments for BV are not always effective and often lead to reoccurrence of the infection. In many cases, this is due to the antibiotic-resistant forms of the pathogens. Therefore, there is an interest in the development of treatments using antimicrobials derived primarily from Lactobacillus spp., such as ribosomally produced antimicrobial peptides (bacteriocins) and lactic acid. These substances effectively inhibit pathogenic bacteria, are safe and do not pose any threat to healthy vaginal Lactobacillus spp. It may be possible to find an effective treatment against BV while reducing the infection's reoccurrence and the treatment-related complications through hurdle technology. This would be achieved by combining antimicrobials produced by Lactobacillus spp. with different natural antimicrobials obtained from plants or other non-pathogenic organisms.
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Affiliation(s)
- S E Dover
- The Royal Institute of Technology, School of Biotechnology, Valhallavägen 79, 100 44, Stockholm, Sweden
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14
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Simoes JA, Bahamondes LG, Camargo RPS, Alves VMN, Zaneveld LJD, Waller DP, Schwartz J, Callahan MM, Mauck CK. A pilot clinical trial comparing an acid-buffering formulation (ACIDFORM gel) with metronidazole gel for the treatment of symptomatic bacterial vaginosis. Br J Clin Pharmacol 2006; 61:211-7. [PMID: 16433875 PMCID: PMC1884999 DOI: 10.1111/j.1365-2125.2005.02550.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIM To compare the effectiveness of an acid-buffering formulation gel (ACIDFORM) with metronidazole gel in the treatment of symptomatic bacterial vaginosis (BV). METHODS After a confirmed diagnosis of BV according to the criteria established by Nugent and Amsel, 30 nonpregnant women were enrolled in a randomized, double-blind clinical study. The women were randomly assigned to receive either 5 g ACIDFORM gel (n = 13) or 10% metronidazole gel (n = 17) intravaginally once daily for five consecutive days. Participants were evaluated in two follow-up visits (7-12 days and 28-35 days after treatment). Therapeutic success was defined as the presence of less than three of Amsel's criteria. If three or more criteria were present at first or second follow-up visit, the woman was excluded from the study and treated orally with metronidazole. Nugent scores were recorded at each visit but these were not used to define cure. RESULTS At the first follow-up visit, 15 (88%) of the women in the metronidazole group were cured compared with only three (23%) in the ACIDFORM group (P < 0.001). The remaining 12 women (10 of the ACIDFORM group and two of the metronidazole group) were considered as failure and were treated orally with metronidazole. At the second follow-up visit, two of the ACIDFORM-treated women and six of the metronidazole-treated women presented recurrent BV. Four women in the ACIDFORM group and one in the metronidazole group reported occasional burning and itching during product use. CONCLUSION ACIDFORM gel was significantly less effective than high-dose metronidazole gel for the treatment of symptomatic BV.
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Affiliation(s)
- Jose A Simoes
- Department of Obstetrics and Gynaecology, School of Medicine, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
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15
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Liversedge NH, Turner A, Horner PJ, Keay SD, Jenkins JM, Hull MG. The influence of bacterial vaginosis on in-vitro fertilization and embryo implantation during assisted reproduction treatment. Hum Reprod 1999; 14:2411-5. [PMID: 10469722 DOI: 10.1093/humrep/14.9.2411] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There is growing evidence that the pathogenic effects of bacterial vaginosis may not be confined to the lower genital tract. Possible associations with infertility and effects on fertilization and implantation were studied in patients undergoing in-vitro fertilization (IVF) treatment. High vaginal swabs taken at the time of oocyte collection were assessed by Gram staining. The prevalence of bacterial vaginosis and of intermediate and normal flora in 301 patients was 25.6, 14.0 and 60.4% respectively. Bacterial vaginosis was more prevalent in patients with tubal (31.5%, n = 149) compared with non-tubal (19.7%, n = 152) infertility (odds ratio (OR) 1.87, CI 1.11-3.18, P = 0.02). Bacterial vaginosis did not have an adverse effect on fertilization rate. Further, no significant difference in implantation rates was seen when comparing bacterial vaginosis (15. 8%, OR 1.03, CI 0.66-1.61) and intermediate flora (13.1%, OR 0.82, CI 0.45-1.52) with normal flora (15.5%). Though confidence intervals around the observations were relatively wide, the findings suggest that routine screening for bacterial vaginosis in the hope of improving the success of IVF treatment is not justified. The prevention of complications in pregnancy associated with bacterial vaginosis might be a more relevant indication for screening at the time of IVF treatment, in particular patients with tubal disease, if treatment were shown to be effective for that particular purpose. However, antibiotic treatment before IVF has been shown to be positively disadvantageous for IVF by encouraging other organisms.
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Affiliation(s)
- N H Liversedge
- Department of Obstetrics and Gynaecology, St Michael's Hospital, Southwell Street, Bristol BS2 8EG, Public Health Laboratory, Bristol , UK
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16
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Abstract
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.
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Affiliation(s)
- C D Freeman
- Department of Medicine, University of Missouri-Kansas City School of Medicine, USA.
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17
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Comparative study of intravaginal metronidazole and triple-sulfa therapy for bacterial vaginosis. Infect Dis Obstet Gynecol 1996; 4:66-70. [PMID: 18476069 PMCID: PMC2364475 DOI: 10.1155/s1064744996000154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/1995] [Accepted: 05/29/1996] [Indexed: 11/26/2022] Open
Abstract
Objective: We sought to compare the efficacy of metronidazole gel vs. triple-sulfa cream in the treatment
of bacterial vaginosis (BV). Methods: In a double-blinded study, 247 women with symptomatic BV were randomly assigned to receive
either 5 g of 0.75% metronidazole gel twice daily for 5 days or triple-sulfa cream twice daily for 5 days.
There were 205 (96 treated with metronidazole and 109 treated with triple-sulfa) evaluable patients to
compare efficacy at the final visit. Approximately 60% of these patients had been previously treated for
BV, reflecting the recurrent nature of the disease in this patient population. Results: At the first (12–16 days) return visit, 81/103 (79%) patients in the metronidazole group were
cured compared with 80/113 (71%) patients in the triple-sulfa cream group (P = 0.333). At the final (28–35
days) return visit, 63/96 (66%) in the 96 metronidazole group remained cured compared with only 51/109
(47%) in the triple-sulfa group (P = 0.02). An intent-to-treat analysis similarly showed that the cure rate
with metronidazole was superior to triple-sulfa (P ≤ 0.02). The clinical diagnosis demonstrated a high
correlation (88%) with the diagnosis made by an independent assessment by Gram's stain. The side effects
reported by the patients using metronidazole gel were infrequent and mild and were similar to those
reported with triple-sulfa. Conclusions: Metronidazole gel is a safe, effective, and well-tolerated treatment for BV.
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