Vaginal leucocyte counts in women with bacterial vaginosis: relation to vaginal and cervical infections

OBJECTIVES: To evaluate whether an elevated vaginal leucocyte count in women with bacterial vaginosis (BV) predicts the presence of vaginal or cervical infections, and to assess the relation of vaginal WBC counts to clinical manifestations. METHODS: We retrospectively analysed the relation of vaginal leucocyte counts to vaginal and cervical infections and to clinical manifestations in non-pregnant women diagnosed with BV at an STD clinic visit. RESULTS: Of 296 women with BV studied, the median age was 24 years and 81% were African-American. Elevated vaginal leucocyte counts were associated with objective signs of vaginitis and cervicitis and also predicted candidiasis (OR 7.9, 95% CI 2.2 to 28.9), chlamydia (OR 3.1, 95% CI 1.4 to 6.7), gonorrhoea (OR 2.7, 95% CI 1.3 to 5.4), or trichomoniasis (OR 3.4, 95% CI 1.6 to 7.3). In general, as a screening test for vaginal or cervical infections, vaginal leucocyte count had moderate sensitivities and specificities, low positive predictive values, and high negative predictive values. CONCLUSIONS: An elevated vaginal leucocyte count in women with BV was a strong predictor of vaginal or cervical infections. Vaginal leucocyte quantification may provide an alternative approach to assessing need for empirical therapy for chlamydia and gonorrhoea, particularly in resource-limited high STD risk settings that provide syndromic management.     

阴道冲洗行为对阴道内菌群分布的影响分析

目的:探讨阴道冲洗行为与细菌性阴道炎和性传播疾病的关系。方法:选取100名生育年龄的妇女,其中有0~2个性伴侣的女性75名,有3个或3个以上性伴侣女性25名,让她们使用冲洗产品进行阴道冲洗,并分三个阶段进行观察。第一阶段定为时间是4周的冲洗阶段,第二阶段定为时间是10周的停止冲洗阶段,第三个阶段定为时间是4周的自主选择阶段,让观察者自主选择继续冲洗还是停止冲洗。在最初的14周中,每个观察者每周去医院进行2次阴道样本采集,从第15周开始每个观察者每周来医院进行1次阴道样本采集,分别观察三个阶段低性伴侣女性细菌性阴道炎的患病情况和多性伴侣女性的性传播疾病的患病情况。结果:在第一阶段和第二阶段期间,细菌性阴道炎的平均评分为(2.11±0.52)分和(1.89±0.23)分,无统计学差异(P0.05)。第三个阶段共有156个样本选择继续冲洗,244个样本选择停止冲洗。继续冲洗者的细菌性阴道炎评分显著高于停止冲洗者(P0.05)。继续冲洗样本的阴道炎菌群检出数显著多于停止冲洗样本(P0.05)。结论:过度的阴道冲洗并不能有效地阻止感染的发生,当停止阴道冲洗时,乳酸内环境恢复,感染明显下降。故合理进行阴道冲洗,积极控制感染,帮助建立乳酸内环境,才是治疗和预防疾病的关键。     

Vaginal swabs versus lavage for detection of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women

OBJECTIVES: Cervicovaginal lavage (CVL) is often used for research and may be easier and more accurate than vaginal swabs as a specimen collection method. GOAL: The goal of this study was to compare (CVL) with vaginal swabs for the detection of bacterial vaginosis (BV) and Trichomonas vaginalis (TV). STUDY: CVL and vaginal swabs were collected from 216 HIV-infected women. Clinical assessments were made using wet mount for TV and Amsel's criteria for BV through CVL and swab collection methods. Laboratory gold standards used were Nugent's criteria for BV and InPouch (Biomed Diagnostics, San Jose, CA) culture for TV collected by swab. RESULTS: The prevalence by gold standards for BV was 49.3% and for TV was 25.2%. Sensitivities for direct microscopy versus culture for TV were 72.2 for CVL and 52.8 for vaginal swab (P <0.05). Sensitivities for Amsel's versus Nugent's criteria for BV were 36.2 for CVL and 34.0 for vaginal swab (P <0.80). Kappa scores of agreement between CVL and vaginal swabs for BV and TV were excellent for both. CONCLUSION: CVL was comparable to vaginal swabs as a specimen collection method for these 2 lower genital tract infections and may be superior for the diagnosis of TV.     

A double-blind treatment study of bacterial vaginosis with normal vaginal lactobacilli after an open treatment with vaginal clindamycin ovules

The expected 4-week cure rate after conventional treatment of bacterial vaginosis are only 65-70%. In an attempt to improve the cure rate by adding probiotic lactobacilli we performed a double-blind placebo-controlled study of adjuvant lactobacilli treatment after an open treatment with vaginal clindamycin ovules. Women with bacterial vaginosis as defined by Amsel's criteria were treated with clindamycin ovules. Vaginal smears were collected and analysed according to Nugent's criteria. During the following menstruation period the women used, as an adjuvant treatment, either lactobacilli-prepared tampons or placebo tampons. The lactobacilli tampons were loaded with a mixture of freeze-dried L. fermentum, L. casei var. rhamnosus and L. gasseri. The cure rate was recorded after the second menstruation period. There was no improvement in the cure rate after treatment with lactobacilli-containing tampons compared to placebo tampons; the cure rates as defined by Amsel's criteria were 56% and 62%, respectively, and 55% and 63%, as defined by Nugent's criteria. This is the first study to report cure rates for women with 'intermediate' wet smear ratings according to Nugent's classification and this group had an overall cure rate of 44%. The cure rate of treatment of bacterial vaginosis was not improved by using lactobacilli-prepared tampons for one menstruation.     

Vaginal douche practices among black women at risk: exploring douching prevalence, reasons for douching, and sexually transmitted disease infection

OBJECTIVE: The objective of this study was to identify douching patterns and their relation to sexually transmitted disease (STD) among black women seeking an STD evaluation. STUDY DESIGN: This study was a cross-sectional survey with biologic testing for chlamydia and gonorrhea infection. RESULTS: Of 891 participants, 46.1% were current douchers. Commonly identified reasons for douching were to cleanse after menses (65.4%) and to feel fresh (42.2%). Frequent douching was associated with douching after sex (P<0.001), to alleviate an itch (P<0.001), and to feel fresh (P<0.001). Women who douched during menses (adjusted odds ratio [AOR]=4.78; 95% confidence interval [CI]=1.13-20.13) and to alleviate an itch (AOR=3.66; 95% CI=1.00-13.41) were more likely to have a current chlamydial infection. CONCLUSIONS: Douching was common among this high-risk population of black women. Prospective studies are needed to determine the consequences of douching and any mediating effects of women's motivation for the behavior on reproductive health.     

Frequent douching and clinical outcomes among HIV-infected women

OBJECTIVE: To determine the prevalence of douching among a cohort of HIV-infected women and to examine clinical outcomes associated with frequent douching-namely bacterial vaginosis, presence of a sexually-transmitted infections, and genital tract HIV-1 RNA shedding. STUDY DESIGN: Participants included a concurrent cohort of 187 women attending an HIV outpatient clinic in New Orleans, LA. Subjects underwent clinical examinations and answered questions in a computer-assisted survey at each visit. RESULTS: At baseline, 1-, and 3-month follow-ups, 64.2%, 56.5%, and 54.7% of women, respectively, indicated that they douched. In multivariable analyses, douching >1 time a month was independently associated with the outcomes of bacterial vaginosis and presence of a selected sexually transmitted infection (Trichomonas vaginalis, Neisseria gonorrhea, or Chlamydia trachomatis). Although not significant, women who douched >1 time a month were also twice as likely to have genital tract HIV-1 RNA shedding as nondouchers. CONCLUSIONS: This is the first study performed in women infected with HIV to link a significant dose-response relationship between douching and the clinical outcomes of bacterial vaginosis and presence of a sexually transmitted infection, and to examine the association between douching and genital tract HIV-1 RNA shedding.     

Vaginal douching: association with lower genital tract infections in African pregnant women

BACKGROUND AND OBJECTIVES: Douching, a common practice, could further increase the risk of genital infections. GOAL OF THIS STUDY: To describe douching practices in pregnant women and to evaluate associations with lower genital tract infections. STUDY DESIGN: Cross-sectional study in Abidjan, C?te d'Ivoire. RESULTS: Among 552 women included, douching before consultation was reported by 97% and was common practice for 98%. Intravaginal drying agents were used by 10%. Genital warts were less frequent for women who usually douched (p = 0.015). U. urealyticum infection was associated with douching and with the use of intravaginal agents. Diagnosis of genital infections was independent of douching with water or soap, but chlamydial infection was associated with douching with antiseptics, used by 14% of the women (p = 0.036). HIV infection was two times more frequent in women using antiseptics (p = 0.17). CONCLUSION: The study confirms the widespread practice of douching in African pregnant women. The harmful effects of antiseptics need to be substantiated.     

Prevalence of Mobiluncus spp among women with and without bacterial vaginosis as detected by polymerase chain reaction

BACKGROUND: Mobiluncus spp are highly associated with bacterial vaginosis, but their role in its pathogenesis is unknown. The authors used polymerase chain reaction (PCR) to compare the prevalence of Mobiluncus in women with and without bacterial vaginosis. GOAL: To compare the prevalence of Mobiluncus spp among women with and without bacterial vaginosis and to compare the sensitivities of PCR and Gram stain for detection. STUDY DESIGN: Vaginal specimens from 74 women were analyzed by PCR and Gram stain for the presence of Mobiluncus spp. Comparisons were made between the prevalence of this organism between the two cohorts and between the Gram stain and PCR detection methods. RESULTS: Mobiluncus was detected by PCR in 84.5% of women with bacterial vaginosis and in 38% of women without infection. M curtisii was rarely detected in the latter group, though it was found in 65.3% of women with bacterial vaginosis. The sensitivity and specificity of Gram stain compared with PCR were 46.9% and 100%, respectively. CONCLUSIONS: Mobiluncus is more common in healthy women than previously suspected, with M mulieris as the predominant species. The significant difference in the prevalence of M curtisii between women with bacterial vaginosis and uninfected women suggests that this species could be involved in the pathogenesis of bacterial vaginosis.     

An intervention to reduce vaginal douching among adolescent and young adult women: a randomized, controlled trial

OBJECTIVE: The objective of this study was to evaluate an intervention to reduce vaginal douching among adolescent and young women who report douching. STUDY: This study consisted of a randomized, controlled trial of 275 primarily black adolescent and young adults aged 14 to 23 years. All women participated in 3 15-minute individualized counseling sessions. The experimental group received interventions based on their stage of readiness for ceasing vaginal douching. The comparison condition emphasized healthy eating and nutrition. The primary outcome measure was douching cessation (i.e., no douching in the preceding 3 months) at the 6-and 12-month assessment; a secondary outcome was progression through the stages of change toward douching cessation. RESULTS: Based on an intention-to-treat model, participants assigned to the douching intervention group were significantly more likely to report having stopped douching at 6 months (relative risk [RR], 1.34; 95% confidence interval [CI], 1.03-1.73) and at 12 months (RR, 1.60; 95% CI, 1.28-2.00). At baseline, 89.9% of all women reported no intention to stop douching. Also based on an intention-to-treat model, there were no differences in stage across the 2 groups at 6 months (P = 0.29); however, at 12 months, the difference between the intervention and comparison group was statistically significant (P = 0.008). CONCLUSION: Stage-matched interventions can reduce douching among adolescent and young adult women.     

Efficacy of povidone-iodine vaginal suppositories in the treatment of bacterial vaginosis

A prospective, randomized clinical trial was performed to study the efficacy of povidone iodine (Betadine) suppositories for the treatment of bacterial vaginosis (BV) in comparison to capsules containing lactobacilli (D?derlein Med). Seventy patients with BV included in the study were randomly assigned to be either treated with povidone iodine suppositories or lactobacilli. Patients were treated once a day for 5 days. Initial examinations took place on the first day of the study with follow-up examinations on days 8 and 15. The examinations included clinical parameters, patient evaluation, secretion screens, and quantitative and qualitative microbiological tests of vaginal flora. Both treatment groups showed improvement of clinical parameters, condition of secretions and subjective state of health. At day 15 there was a trend towards a better efficacy of the treatment with povidone iodine but this was not significant. However, patients with acute BV treated with povidone iodine had significantly better scores after 15 days. Both treatments were well tolerated. The microbiological examinations showed an increase of the mean number of lactobacilli in the vagina on day 8 after initiation of treatment with lactobacilli, but a decrease on day 15. Contrary to that the lactobacilli counts from patients treated with povidone iodine suppositories decreased after the first week but increased in the second one. Potentially pathogenic germs, e.g. Gardnerella, Bacteroides and Enterobacteria were reduced in a higher extent and with a longer lasting effect after treatment with povidone iodine suppositories than with capsules containing lactobacilli. The results of this study show that native lactobacilli rapidly re-colonize after the antiseptic treatment with povidone iodine. Therefore, there is no need to use lactobacilli in addition.     

When is bacterial vaginosis not bacterial vaginosis?--a case of cervical carcinoma presenting as recurrent vaginal anaerobic infection.

Vaginal anaerobic infection is the most common cause of vaginal discharge in women. We present a case of recurrent vaginal anaerobic infection and cervical carcinoma and discuss the association of the two conditions. More frequent cytology/colposcopy may be indicated in women who give a history of recurrent or persistent vaginal anaerobic infection.     

Should male consorts of women with bacterial vaginosis be treated?

Nitroimidazoles have been shown to be the drugs of choice to treat women with bacterial vaginosis, but the recurrence rate is high. Some workers have suggested that the recurrence of symptoms may in fact be reinfection by male consorts, but no controlled studies have been undertaken to confirm this. In an international, multicentre, randomised, double blind trial, the recurrence rate was studied in 241 women with a clinical diagnosis of bacterial vaginosis. All women were treated with 2 g metronidazole twice at an interval of two days. The patients were randomly allocated to two groups, one contained 123 women, whose consorts were given the same dose of metronidazole, the other consisted of 118 women whose consorts were given inert but identical placebo tablets. The women were evaluated at weeks 1, 4, and 12 after treatment. At week 1, the cure rate was 97% (115/119) in women whose consorts had been treated and 98% (111/113) in the others. At week 4 bacterial vaginosis had recurred in 17% (19/112) of women whose consorts had been treated and in 13% (14/106) of those whose consorts had received placebo. At week 12 the recurrence rates were 21% (20/95) in women with treated consorts, and 16% (15/95) in the others. The differences in recurrence rates between the two groups of women were not significant. In conclusion, treating the sexual partners of women with bacterial vaginosis does not seem to increase the cure rate.     

Comparison of clindamycin phosphate vaginal cream with triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.

BACKGROUND: Triple sulfonamide vaginal cream has been used to treat bacterial vaginosis for many years. There are few studies in which triple sulfonamide cream has been compared with newer regimens. GOAL: To compare the efficacy and safety of clindamycin phosphate vaginal cream with that of triple sulfonamide vaginal cream in the treatment of bacterial vaginosis. STUDY DESIGN: In this double-blind, randomized multicenter study, nonpregnant women 16 years of age or older with symptomatic bacterial vaginosis were assigned to receive either 2% clindamycin phosphate vaginal cream or triple sulfonamide vaginal cream for 7 days. Follow-up visits were conducted 5 to 10 days and 25 to 39 days after completion of treatment. RESULTS: Clinical cure or improvement at 25 to 39 days was noted in 55 (69.6%) of 79 assessable participants who received clindamycin vaginal cream and in 33 (41.8%) of 79 women who received triple sulfonamide vaginal cream (P < 0.0001). Most of the difference between the treatment groups was noted in women with a history of bacterial vaginosis. Among women without a history of bacterial vaginosis, clindamycin and triple sulfonamide creams had similar efficacy. Evaluation of Gram-stained vaginal smears correlated with clinical outcome. Most patients in both treatment groups reported an improvement in symptoms. No significant difference was observed between the treatment groups in the incidence of adverse events. CONCLUSION: Clindamycin 2% vaginal cream is more effective than triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.     

Predictors of bacterial vaginosis in adolescent women who douche

OBJECTIVE: Risk factors for bacterial vaginosis (BV) include douching and sexual activity, although the exact cause of BV is unknown. GOAL: The goal of this study was to determine the relative significance of douching as a risk factor for BV. STUDY DESIGN: Two hundred fifty adolescent women who regularly douched were enrolled into a randomized douching intervention trial. Behavioral questionnaires and testing for sexually transmitted diseases and BV were performed. Associations between baseline characteristics and behaviors were compared for teens who were BV-positive and BV-negative at baseline. RESULTS: Positive correlates of BV included multiple partners, recent sexual intercourse, douching after menses, recent douching, and gonorrhea. Of these, douching after menses showed the strongest association (odds ratio, 5.11; 95% confidence interval, 1.99-13.15) in a multivariate analysis. CONCLUSIONS: Douching after menses was strongly correlated with BV; however, difficulty remains in trying to evaluate douching and sexual behavior independently.     

Vaginal douching, condom use, and sexually transmitted infections among Chinese female sex workers

BACKGROUND AND OBJECTIVE: Vaginal douching has been hypothesized to increase a woman's risk for human immunodeficiency virus (HIV) infection. However, data on the prevalence of this practice and its association with condom use and sexually transmitted infections (STIs) are limited. STUDY: A cross-sectional survey among 454 female sex workers (FSWs) in a Chinese county. RESULTS: Vaginal douching was reported by 64.7% of the women. The prevalence of self-reported history of STI and that of current STI was 19.4% and 41.5%, respectively. Fifteen percent of the women reported consistent use of condoms with their clients and 8.4% with their regular partners. Vaginal douching was significantly associated with decreased use of condoms (with clients: OR = 0.31; with regular partner(s): OR = 0.22) and increased rate of self-reported STI history (OR = 1.95). However, there was no direct relation between douching and current STI. Over one third of the women believed that douching can prevent STI/HIV. CONCLUSION: Vaginal douching exposes FSWs to a high risk of STI/HIV. Medical professional and public health workers should correct women's misconception about the effectiveness of douching and discourage women from douching through educational activities.     

Glycosidase and proteinase activity of anaerobic gram-negative bacteria isolated from women with bacterial vaginosis

BACKGROUND: It is known that glycosidases and proteases are produced by the anaerobic gram-negative bacteria associated with bacterial vaginosis (BV). We hypothesized that these enzymes enzymatically degrade mucins, thereby destroying the mucus gel that otherwise helps protect against sexually transmitted pathogens, including HIV. GOAL: The goal was to determine glycosidase and protease production by vaginal bacteria associated with BV and to compare these with symptoms and signs of abnormal discharge and to test vaginal fluid viscosity. STUDY DESIGN: The anaerobic gram-negative rods recovered from the vaginas of 153 women with normal flora, intermediate flora, or BV were tested for production of sialidase, fucosidase, galactosidase, glucosaminidase, and glycine and arginine aminopeptidases. RESULTS: Women with BV had higher frequencies and concentrations of bacteria producing mucin-degrading enzymes than did women with intermediate and normal flora (P < 0.001). Women with higher concentrations of bacteria producing mucin-degrading enzymes were more likely to have a thin discharge associated with BV (P < 0.001). The viscosity of diluted vaginal fluid samples from women with BV was significantly lower than those from women with normal flora (P = 0.001). CONCLUSION: These data support the hypothesis that BV organisms degrade the protective mucus gel.     

The effects of intravaginal clindamycin and metronidazole therapy on vaginal mobiluncus morphotypes in patients with bacterial vaginosis

OBJECTIVE: The objective of this study was to compare the effects of treatments for bacterial vaginosis (BV) on vaginal Mobiluncus morphotypes. STUDY DESIGN: Analyses were performed on Mobiluncus scores from similarly conducted studies evaluating clindamycin vaginal single-dose cream (CVSDC) or metronidazole vaginal gel (MVG) in 55 patients with BV and with Mobiluncus morphotypes at baseline. RESULTS: Both treatment groups demonstrated significant reductions in Mobiluncus score. However, the Mobiluncus score at test-of-cure was lower in the CVSDC than in the MVG group (P=0.0471). More patients in the CVSDC group than in the MVG group achieved microbiologic (57.5% vs. 26.7%; P=0.04), clinical (57.5% vs. 26.7%; P=0.04), and therapeutic cures of BV (45.0% vs. 20.0%; P=0.09). CONCLUSION: Clindamycin reduces vaginal Mobiluncus morphotypes to a greater extent than metronidazole in patients with BV; this correlates with a higher BV cure rate.