Jessica L. Thomason

Bacterial vaginosis: current review with indications for asymptomatic therapy.

Bacterial vaginosis is a definable clinical entity whose exact origin is unknown. A shift in normal vaginal flora from aerobic, predominantly but not exclusively lactobacilli, to a predominantly anaerobic flora characterizes the condition. More than one half of all women with bacterial vaginosis have no symptoms. The condition is not entirely benign. The potentially pathogenic bacteria present in the vagina in large numbers place these women at risk for postoperative morbidity and adverse obstetric outcome. Sexual transmission has not been proved, but therapeutic cures sometimes require that patient and partner be treated simultaneously. Recommended therapy is with metronidazole or clindamycin and must be given for 7 days for maximal effectiveness. Recurrence of disease can be a problem.

Bacterial vaginosis: Diagnostic and pathogenetic findings during topical clindamycin therapy

We examined subjective and objective correlates among 67 women with symptomatic bacterial vaginosis before and after treatment with intravaginal clindamycin or placebo. We found no preponderance of any sexual practices among these patients. Nine patients (13.4%) had had hysterectomy. Whereas odor and discharge were the most common symptoms, 30 patients (44.8%) also complained of vulvovaginal irritation. Symptoms correlated poorly with objective therapeutic outcome. On examination the diagnosis would have been missed in seven patients (10.4%) if the clinician relied on presence of an abnormal vaginal discharge to suggest bacterial vaginosis. Vaginal pH greater than 4.5 was found immediately after curative therapy in 59.6% of patients. Mobiluncus spp. morphotypes were 99.0% specific and 52.1% sensitive and proline aminopeptidase activity in vaginal fluid was 84.4% sensitive and 70.2% specific for diagnosis. Our Gram stain criteria yielded no false-negative results, 6.1% false-positive, and frequent indeterminate results after therapy. We found little evidence for sexual transmission of bacterial vaginosis. Recurrence after effective therapy was not predicted by vaginal pH elevation, positive or indeterminate Gram stain result, or positive proline aminopeptidase test.

Simplified Gram stain interpretive method for diagnosis of bacterial vaginosis

OBJECTIVEnTwo methods which only consider bacterial morphotypes and require counting various types of bacteria, for interpreting Gram stains of vaginal secretions for the purpose of diagnosing bacterial vaginosis were previously described. A new interpretative method, which combines clue cells with bacterial morphotypes as diagnostic markers, is offered.nnnSTUDY DESIGNnOne hundred twenty patients were tested with the new interpretative method and clinical criteria of bacterial vaginosis as the reference standard.nnnRESULTSnThe new method was found comparable to older methods when all were compared with clinical diagnostic methods. The sensitivity of the clue cell method was 86.1% and the specificity was 92.8%. The predictive value of a positive test was 83.7% for a population with a prevalence of bacterial vaginosis of 30%. The negative predictive value was 94.0%.nnnCONCLUSIONnIf clue cells are present and the nonlactobacilli morphotypes exceed lactobacilli morphotypes, bacterial vaginosis can be diagnosed without the need for exact bacterial counts.

Is trichomoniasis often associated with bacterial vaginosis in pregnant adolescents

The same criteria for identifying bacterial vaginosis are often present in women with trichomoniasis. These criteria include elevated vaginal pH, vaginal odor, homogeneous discharge, increased anaerobic bacteriologic vaginal flora, and elevated levels of bacterial enzymes. Clinically mixed vaginal infections occur, and because the treatment for these two conditions can be different, it is important to distinguish between them. Trichomoniasis can interfere with a Gram stain diagnosis or the proline aminopeptidase test for bacterial vaginosis. Clue cells are not generally found in women with Trichomonas vaginalis, but when present, they strongly indicate the concomitant presence of bacterial vaginosis.

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.

Is analysis of vaginal secretions for volatile organic acids to detect bacterial vaginosis of any diagnostic value

A study was undertaken to determine which fermentation products in vaginal secretions serve as the best markers for bacterial vaginosis. Three categories of markers had been previously identified, but due to cost considerations it was necessary to accurately determine if analysis for all three were necessary. With the use of vaginal secretions from well-defined patient populations, we applied gas-liquid chromatography to test for both volatile and nonvolatile acid fermentation products. It was found that only the detection of nonvolatile acids was necessary, because no additional patients with bacterial vaginosis were identified by subsequent analysis of volatile acids. Routine analysis of volatile acids to identify patients with bacterial vaginosis is labor intensive and costly and had no clinical diagnostic value.

Comparative Study of Intravaginal Metronidazole and Triple-Sulfa Therapy for Bacterial Vaginosis

OBJECTIVEnWe sought to compare the efficacy of metronidazole gel vs. triple-sulfa cream in the treatment of bacterial vaginosis (BV).nnnMETHODSnIn 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.nnnRESULTSnAt 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 < or = 0.02). The clinical diagnosis demonstrated a high correlation (88%) with the diagnosis made by an independent assessment by Grams stain. The side effects reported by the patients using metronidazole gel were infrequent and mild and were similar to those reported with triple-sulfa.nnnCONCLUSIONSnMetronidazole gel is a safe, effective, and well-tolerated treatment for BV.

Effectiveness of Gonozyme for detection of gonorrhea in low-risk pregnant and gynecologic populations

The Gonozyme Diagnostic Kit (Abbott Laboratories, North Chicago, IL) was evaluated in a population at low-risk for gonorrhea. Two hundred seventy-two female patients, consisting of 152 obstetrical patients and 120 gynecologic patients attending a family-planning clinic, were tested for Neisseria gonorrhoeae by use of culture and Gonozyme testing of specimens from the endocervical canal. The average ages were 16.1 years for the obstetric patients and 17.8 years for the gynecologic patients. The overall sensitivity of Gonozyme as compared with culture was 60.8% (57.1% for obstetric patients and 62.5% for gynecologic patients); the overall specificity was 98.4%. An association was observed between the number of colony-forming-units (cfu) per plate and a positive Gonozyme test; specimens with less than 60 cfu/plate usually yielded a negative Gonozyme result. We conclude that Gonozyme is a highly specific test but its low sensitivity as compared with that of culture does not allow it to replace standard culture media for screening of low-risk women for infection with N. gonorrhoeae.

Quality control standards for the proline aminopeptidase assay used to detect bacterial vaginosis

We describe the preparation and usage of positive and negative quality control standards for the proline aminopeptidase assay of vaginal secretions as an indicator of bacterial vaginosis.

Is pH test paper as accurate as the electronic measurement of thepH of vaginal secretions

A comparison was made of two brands of pH test paper and electronic instrumentation for measuring the pH of vaginal secretions. When the pH of vaginal secretions was greater than 4.5 (abnormal), there was no significant difference between the methods, showing that pH test paper is reliable for pH determination of vaginal secretions.