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Vaginiti e vaginosi


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Vaginiti e vaginosi

  1. 1. Vaginite aerobica: una nuova patologia ?<br />Inquadramento <br />e <br />scelta terapeutica<br />
  2. 2. Batteri<br /> Miceti<br />Le infezioni vulvo/vaginali<br />Protozoi<br />Virus<br />
  3. 3. Quantità<br />Assente/<br />moderata<br />moderata<br />profusa<br />moderata<br />Colore<br />chiaro<br />Bianco/grigio<br />bianco<br />giallo<br />Consistenza<br />Flocculare<br />omogenea<br />variabile<br />omogenea<br />pH<br /><4.5<br />>4.5<br /><4.5<br />>5<br />Fishy <br />odor<br />negativo<br />positivo<br />negativo<br />variabile<br />Microscopia<br />Cellule<br />Clue <br />cells,<br />Blastospore<br />Leucociti<br />epiteliali<br />coccobacilli<br />ife<br />Trichomonas<br />presenza di<br />assenza di<br />lattobacilli<br />leucociti<br />Correlazione tra tipo di secrezione, microscopia e patologia<br />TIPO DI<br />NORMALE<br />VAGINOSI<br />VAGINITE<br />VAGINITE<br />da<br />da<br />SECREZIONE<br />BATTERICA<br />Candida<br />Trichomonas<br />
  4. 4. La comunità scientifica ha stabilito che le vaginiti infettive sono:<br />VAGINITI SPECIFICHE DA:<br />Candida spp.<br />Trichomonas vaginalis <br />2. VAGINOSI BATTERICA<br />
  5. 5.
  6. 6. 34,5%<br />32,6%<br />Candidosi vaginale<br />Altri<br />6,9%<br />26,0%<br />Trichomoniasi<br />Vaginosi batterica<br />Epidemiologia<br />Vaginiti sintomatiche (N=3661)<br />Università di Pavia, Ambulatorio di Ginecologia 1988-95Spinillo, Am J Obstet Gynecol 97; 176:138-41<br />
  7. 7. Studio epidemiologico sulle candidosi a Catania (1990 )<br />Diagnosi clinica Conferma microbiologica<br />Vaginite micotica Candidosi Negativi<br /> 248 134 36 78<br />54 % 14.5 % 31.45 %<br />Lattobacilli Batteri enterici<br />presenti 68.4 %<br />scarsi 70.4 %<br />assenti 100 %<br />Tempera G., 1990<br />
  8. 8. Studio epidemiologico sulle candidosi a Catania(1990 )<br />Isolamentibatterici in 78 casidialterazioneecosistemavaginale<br />Lattobacilli Batteri enterici<br />presenti 68.4 %<br />scarsi 70.4 %<br />assenti 100 %<br />Tempera G., 1990<br />
  9. 9. Sindrome da alterazione dell’ecosistema vaginale (VED) - 1990 -<br />Segni e sintomi di infezione vulvo/vaginale<br />Assenza di Candida/Trichomonas<br />Non rispondenza ai criteri di Amsel<br />Alterazione ecosistema vaginale, senza aumento di germi anaerobi<br />Costante presenza di batteri provenienti dal serbatoio intestinale<br />Tempera G., 1990<br />
  10. 10. Sindrome da alterazione dell’ecosistema vaginale (VED) - 1990 -<br />SEGNI E SINTOMI:<br />Lieve infiammazione<br />Leucorrea giallastra<br />Presenza di sgradevole odore di marcio, ma negatività al KOH test<br />Valori di pH variabili<br />Moderato bruciore e/o arrossamento anche cervicale<br />Tempera G., 1990<br />
  11. 11. VED : striscio vaginale con colorazione di Gram<br />presenza di leucociti<br />Tempera G., 1990<br />
  12. 12. Sindrome da alterazione dell’ecosistema vaginale (VED)<br />Caratteristiche microbiologiche:<br />Aumento ( 3 – 5 ) volte di isolamento di:<br /> E. coli<br /> Enterococchi<br />Tempera G., 1990<br />
  14. 14. ETA’ ESTROGENI EPITELIO GLICOGENO pH MICROBIOTA<br />+<br />neonatale<br />¨¨¨<br />4-5<br />Lattobacilli<br />_<br />prepubere<br />¨<br />7<br />Coliformi<br />++<br />fertile<br />¨¨¨¨<br />3.5-4<br />Lattobacilli<br />_<br />menopausale<br />¨<br />7<br />Coliforme<br />I rapporti qualitativi e quantitativi dei microrganismi residenti variano in funzione dell’età e soprattutto dell’attività ormonale della donna<br />Legenda: quantità di estrogeni stratificazione dell’epitelio vaginale<br />
  16. 16. Quandoil pH vaginale sale oltreivalorifisiologici, igermiacidofili<br /> ( LATTOBACILLI)<br /> non traggonopiùalcunvantaggioda tale ambiente e lascianoil campo aigermipotenzialmentepatogeni<br />
  17. 17. E. coli<br />Lactobacillus<br />acidophylus<br />S. agalactiae<br />V.E.D.<br />Altri <br />Enterobatteri<br />Enterococchi<br />Tempera G., 1990<br />
  18. 18. Donders G. et al., BJOG, Jannuary 2002<br />Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis:<br />aerobic vaginitis<br />631 women presenting at the O/G clinic of Leuven Belgium with symptoms of vaginitis<br />Clinical parameters ( discharge, pain, itching, redness…)<br />Laboratory procedures ( pH, KOH test, <br />
  19. 19. Donders G. et al., BJOG, Jannuary 2002<br />Una nuova realtà <br />patologica <br />E. coli<br />Altri<br />enterobatteri<br />Enterococcchi<br />Vaginite aerobica<br />S. agalactiae<br />Lattobacilli<br />
  20. 20. Vaginite aerobica<br />pH >5<br />Fishy odor test negativo<br />diminuita presenza di Lattobacilli<br />alta presenza di leucociti<br />secrezione giallastra, odore sgradevole<br />manifestazioni infiammatorie, dispareunia<br />Donders G. et al. 2002. International Journal of Obstetrics and Gynaecology<br />
  21. 21. LBG: criterio di valutazione secondo Donders et al. 2002<br />Grado 1: flora normale<br /> predominanza di lattobacilli<br /> scarsissima presenza di cocchi<br />Grade 2: flora intermedia<br /> diminuizione della flora lattobacillare<br /> presenza di altri batteri<br />Grade 3: flora anormale<br /> assenza di lattobacilli <br /> presenza di numerosi altri batteri<br />
  22. 22. VAGINITI AEROBICHE<br /><ul><li> Escherichia coli ( GERME MARKER ??)
  23. 23. Streptococcus agalactiae
  24. 24. Staphylococcus aureus
  25. 25. Enterococcus faecalis</li></ul>Donders 2002 International Juornal of Obstetrics and Gynecology<br />
  26. 26.
  27. 27. Microbiology (2002), 148, 2745–2752 <br />Vaginal Escherichia coli share common<br />virulence factor profiles, serotypes and<br />phylogeny with other extraintestinal E. coli<br />Mana Obata-Yasuoka,et al<br />Extraintestinal pathogenic strain: VEC<br />This study provides additional evidence for a link among<br />extraintestinal E. coli, supporting the concept that the VEC are a reservoir along the ‘faecal–vaginal–urinary/neonatal’ course of transmission in the extraintestinal E. coli infections.<br />
  28. 28. Normal flora<br />Intestinal<br />infection<br />Urinary tract<br /> infection<br />Meningitis<br />Pneumonia<br />Aerobic <br />Vaginitis<br />Septicaemia<br />Abdominal<br />Infections<br />
  29. 29. Vaginiti<br />Origine e frequenza<br />vaginosi batterica<br />40 - 50 %<br />VAGINITI <br />INFETTIVE<br />COMUNI<br />vulvovaginite micotica<br />25 - 50 %<br />vaginite da Trichomonas<br />15 - 20 %<br />Vaginite aerobica<br />? ? ? ?<br />vaginiti streptococciche<br />VAGINITI<br />INFETTIVE<br />NON COMUNI<br />vaginiti stafilococciche<br />vaginiti batteriche secondarie<br />
  30. 30. Vaginite aerobica: una nuova patologia ?<br />IPOTESI TERAPEUTICHE<br />SCOPO<br /><ul><li>RIPRISTINO OMEOSTASI
  33. 33. ANTIBIOTICO MIRATO</li></ul>Tempera G., 1990<br />
  34. 34. La natura polimicrobica delle vaginiti aerobiche<br />rende estremamente variabile la risposta<br />alle terapie antibiotiche<br />
  35. 35. VAGINITE AEROBICAANTIBIOTICO IDEALE ???<br />Formulazione topica ??<br />Attività sulla maggior parte dei patogeni<br />Effetto battericida<br />Idoneo mantenimento delle concentrazioni ottimali in situ <br />Assenza di interferenza con l’ecosistema vaginale<br />Safety / Compliance / Costo<br />