Relay Tutorials : Relevant Easy Learning Accessible to You brings an update on Bacterial Vaginosis and the role of pre and probiotics in the management.

1. Bacterial vaginosis : How to deal with it ?
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3. What we know so far….
• Bacterial vaginosis (BV) is a highly prevalent vaginal
polymicrobial disorder, affecting 5%–58% women of
childbearing age in different parts of the world.
• Walker J, Hocking JS, Fairley CK, et al The prevalence and incidence of bacterial vaginosis in a cohort of young Australian women. In:Conference
proceedings of the International Society for Sexually Transmitted Diseases Research. Quebec, Canada, 2011.
• Whether symptomatic or asymptomatic, it increases risks pelvic
inflammatory disease, subsequent infertility and preterm
delivery, sexually transmitted infections (STIs) & HIV
transmission
• Dingens AS, Fairfortune TS, Reed S, et al Bacterial vaginosis and adverse outcomes among full-term infants: a cohort study. BMC Pregnancy
Childbirth 2016;16:278–86.doi:10.1186/s12884-016-1073-y

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• BV is the most common cause of vaginal
discharge in young women of
reproductive age.
• Prevalence of BV among women in India
varies from 20-40% depending upon
population studied.
4
Prevalence

5. It’s ATTACK vs DEFENCE

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Synthesis of
protective
mucus
Acidic pH
(3.5 – 4.5)
Tough stratified
squamous
epithelium
Inflammatory
reaction
Normal
vaginal
microflora
Defences of the female genital tract against
infection

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• Lactobacilli are the dominant microflora of the
vaginal system.
Vaginal Microflora

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• BV develops when normal Lactobacillus bacteria in the vagina
are disrupted and replaced by predominantly anaerobic
bacteria Gardnerella vaginalis, mycoplasma hominis,
Prevotella, Peptostreptococcus (Ya et al., 2010).
Other bacteria such as Escherichia coli from the rectum have
also been shown to cause this disease.

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• Infection is associated with a group of
pathogenic anaerobic bacteria rather than a
specific pathogen.
• Polymicrobial- Gardenerella vaginalis
(coccobacilli, surface pathogen),Anaerobic
bacteria (Bacteroids, Mobiluncus, Prevotella) &
Mycoplasma hominis.
• High concentrations of Gardnerella are found in
up to 95% of women with BV
Etiology

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11. BV is defined as abnormal microflora
of the vagina characterized by an
overgrowth of anaerobic bacteria and
G.vaginalis with a marked decrease
in the presence of Lactobacillus.
Bacterial Vaginosis

12. Risk factors
Douching
regularly
Smoking
Multiple sex
partners
IUCDs
Poor hygiene
Previous STDs
Predisposing factors

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• Approximately 50% of women with BV are
asymptomatic.
• Vaginal discharge: thin, homogenous, whitish-grey,
fishy smell
• Absence of discharge does not imply the absence of
BV.
• Other symptoms are pruritis (itching), lower
abdominal pain, local irritation etc.
Clinical Features

14. Clinical examination
Vaginal discharge: Malodorous; homogenous;
clear, white, or gray; fishy odour
+/- pruritus: not a primary symptom
No signs of vaginal inflammation
Amsel’s criteria
At least three criteria have to be met
before a woman can be declared as a
patient of BV.
1. Homogenous vaginal discharge
2. Vaginal pH > 4.5
3. Positive whiff (amine) test
4. Presence of clue cells
Clinical diagnosis

15. • Now rarely used by physicians due to the time it takes
• Requires the use of a trained microscopist.
• A score of 0-10 is generated from combining three other
scores.
• 0–3 is considered negative for BV
• 4–6 is considered intermediate
• 7+ is considered indicative of BV
NUGENT score/ Gram stain

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• Recurrent infection leading to pelvic inflammatory
disease (PID)
• Vaginal cuff cellulitis following hysterectomy
• Risk of HIV acquisition and transmission
• Risk of acquisition of herpes simplex virus type 2 (HSV-
2), gonorrhea, chlamydia, and trichomonas infection
• Pregnancy complications: second trimester
miscarriage, premature rupture of membranes
(PROM), preterm birth, endometritis
• Tubal infertility
Complications

17. • Culture isn’t recommended.
• Cervical pap has no utility in the diagnosis
• Other useful tests are DNA hybridization probe test, Affirm VPIII,
OSOM BV Blue test .
• Follow up visits unnecessary if symptoms resolve.
CDC recommends

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• Treatment is recommended for women with symptoms
• Antibiotics are the mainstay of therapy for BV.
• Local application or oral administration metronidazole,tinidazole or clindamycin
are recommended for the treatment of BV.
• Data from clinical trials indicate- woman’s response to therapy and the likelihood
of relapse or recurrence ain’t affected by treatment of her sex partner, routine
treatment of sex partners isn’t recommended.
Management (CDC Guidelines)

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• Metronidazole 500 mg orally twice a day for 7 days
OR
• Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
OR
• Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
• Tinidazole 2 g orally once daily for 2 days
OR
• Tinidazole 1 g orally once daily for 5 days
OR
• Clindamycin 300 mg orally twice daily for 7 days
CDC recommended regimen for BV

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• Pregnancy – asymptomatic but high risk for preterm
labour – treat .
• Symptomatic - Test & treat . the recommended regimen
in pregnant women is metronidazole 2 g orally in a
single dose. Avoid tinidazole.
• No screening recommended
• HIV positive – treat same as recommended for other
patients.
• Metronidazole 500mg twice daily for 7 days.
• Retest after 3 months.
Special condition (CDC)

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• Limited data available for optimal management strategies for women
with persistent or recurrent BV. Using different recommended
treatment regimen can be considered however, retreatment with the
same recommended regimen is an acceptable approach .
• Multiple recurrences after completion of recommended regimen, 0.75%
metronidazole gel twice weekly for 4–6 months has been shown to
reduce recurrences, although this benefit might not persist when
suppressive therapy is discontinued
CDC Guidelines for relapse/recurrence

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• The recommended antibiotics, including metronidazole or
clindamycin, results in low cure rates (10%–15%) high
recurrence rates (up to 80%).
• Possibly due to an inability of the host to restore the
lactobacilli-dominated vaginal flora, so use of Lactobacillus
probiotics a promising treatment and prevention strategy.
Repeated antibiotic exposure increases risk of the
emergence of resistant strains.
Bradshaw CS, Morton AN, Hocking J, et al. High recurrence rates of bacterial vaginosis over the course of 12
months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis 2006;193:1478–86.
13. Tomusiak A, Strus M, Heczko PB. Antibiotic resistance of Gardnerella vaginalis isolated from cases of bacterial
vaginosis. Ginekol Pol 2011;82:900–4

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•Probiotics are live microorganisms which confer a health benefit
to the host, when administered in suitable amounts
•Ex. Lactobacilli, Bifidobacterium
Prebiotics: a non-digestible food ingredient that beneficially
affects the host by selectively stimulating the growth and/or
activity of probiotic bacteria.
Ex. Fructose Oligo Saccharide
What are pre & probiotics?

24. Mechanism
Maintenance of
a low pH
Production of
antimicrobial
substances
Degradation of
polyamines
Occupation of
specific adhesion
sites at the
epithelial surface of
the urinary tract
Production of
surfactants with
antiadhesive
properties
Homayouni A, Bastani P, Ziyadi S, et al. Effects of probiotics on the recurrence of bacterial vaginosis: a review. J Low Genit Tract Dis. 2014 Jan;18(1):79-86.
Probiotics: Mechanism of Action

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Probiotics maintains the vaginal pH<4.5 thereby not allowing a conducive
environment for the growth of the pathogenic microbes
Produces lactic acid, acetic acid and hydrogen peroxide also have antimicrobial
activity
Lactobacilli competitively block adhesion of pathogens to the vaginal
epithelium thus preventing the spread of infection
Production of bacteriocins that can inhibit the growth of pathogens, including
some associated with BV, such as G. vaginalis.
In vitro studies have shown that Lactobacillus strains can significantly disrupt
Gardnerella vaginalis biofilms and inhibit the growth of pathogens.

26. • Found tentative but insufficient evidence for probiotics as a treatment
for BV.
• A 2014 review reached the same conclusion.
• A 2013 review found some evidence supporting the use of probiotics
during pregnancy.
• The preferred probiotics for BV are those containing high doses of
lactobacilli (around 109CFUs) given in the vagina.
• Intravaginal administration is preferred to taking them by mouth.
• Prolonged repetitive courses of treatment appear to be more promising
than short course.
2009 Cochrane review

27. • More and more studies uncovering the diversity of
microbiota of vagina, it seems apparent that the
balance between a healthy and diseased state
involves some sort of equilibrium or see-saw effect,
which can swing in either direction depending on a
number of factors, such as hormone levels, douching,
sexual practices, as well bacterial interactions and
host defenses !