Current Infectious Disease Reports

, Volume 15, Issue 2, pp 104–108 | Cite as

Mixed Vaginitis—More Than Coinfection and With Therapeutic Implications

  • Jack D. Sobel
  • Chitra Subramanian
  • Betsy Foxman
  • Marilyn Fairfax
  • Scott E. Gygax
Hot Topic
First Online:

Abstract

Mixed vaginitis is due to the simultaneous presence of at least two vaginal pathogens, both contributing to an abnormal vaginal milieu and, hence, symptoms and signs of vaginitis. In mixed vaginitis, both pathogens require specific therapy for complete eradication of concurrent manifestations. In coinfection, although two pathogens are identified, a potential pathogen may be present but may not be a cause of existing vaginal symptoms. Although data remain sparse, mixed vaginitis occurs rarely (<5 %). By contrast, pathogen coinfection occurs frequently in women with vaginitis. Approximately 20 %–30 % of women with bacterial vaginosis (BV) are coinfected with Candida species. Coexistence of BV pathogens and T. vaginalis is even more common, with coinfection rates of 60 %–80 %. Both coinfection and mixed vaginitis have significant clinical and therapeutic implications and are worthy of further investigation.

Keywords

Vaginitis Candida Bacterial vaginosis Trichomoniasis Coinfection Mixed infection 
This is a preview of subscription content, log in to check access.

Notes

Disclosure

No potential conflicts of interest relevant to this article were reported.

References

Papers of particular interest, published recently, have been highlighted as • Of importance

  1. 1.
    Kent HL. Epidemiology of vaginitis. Am J Obstet Gynecol. 1991;165:1168–76.PubMedGoogle Scholar
  2. 2.
    Blackwell A. Infectious causes abnormal vaginal discharge – part two. Matern Child Health. 1987;12:368–75.Google Scholar
  3. 3.
    Landers DV, Wiesenfeld HC, Heine RP, Krohn MA, Hillier SL. Predictive value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol. 2004;190:1004–10.PubMedCrossRefGoogle Scholar
  4. 4.
    Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000;62:1095–104.PubMedGoogle Scholar
  5. 5.
    El Sayed Zaki M, Raafat D, El Emshaty W, Azab MS, Goda H. Correlation of Trichomonas vaginalis to bacterial vaginosis: a laboratory-based study. J Infect Dev Ctries. 2010;4:156–63.PubMedCrossRefGoogle Scholar
  6. 6.
    Ferris DG, Hendrich J, Payne PM, Getts A, Rassekh R, Mathis D, et al. Office laboratory diagnosis of vaginitis. Clinician-performed tests compared with a rapid nucleic acid hybridization test. J Fam Pract. 1995;41:575–81.PubMedGoogle Scholar
  7. 7.
    Wiesenfeld HC, Macio I. The infrequent use of office-based diagnostic tests for vaginitis. Am J Obstet Gynecol. 1999;181:39–41.PubMedCrossRefGoogle Scholar
  8. 8.
    Mårdh PA, Tchoudomirova K, Elshibly S, Hellberg D. Symptoms and signs in single and mixed genital infections. Int J Gynaecol Obstet. 1998;63:145–52.PubMedCrossRefGoogle Scholar
  9. 9.
    Brotman RM, Klebanoff MA, Nansel TR, Yu KF, Andrews WW, Zhang J, et al. Bacterial vaginosis assessed by gram stain and diminished colonization resistance to incident gonococcal, chlamydial, and trichomonal genital infection. J Infect Dis. 2010;202:1907–15.PubMedCrossRefGoogle Scholar
  10. 10.
    Ness RB, Kip KE, Soper DE, Hillier S, Stamm CA, Sweet RL, et al. Bacterial vaginosis (BV) and the risk of incident gonococcal or chlamydial genital infection in a predominantly black population. Sex Transm Dis. 2005;32:413–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Goel V, Bhalla P, Sharma A, Mala YM. Lower genital tract infections in HIV-seropositive women in India. Indian J Sex Transm Dis. 2011;32:103–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Karaer A, Boylu M, Avsar AF. Vaginitis in Turkish women: symptoms, epidemiologic - microbiologic association. Eur J Obstet Gynecol Reprod Biol. 2005;121:211–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Patel Y, Gopalan S, Bagga R, Sharma M, Chopra S, Sethi S. A randomized trial comparing a polyherbal pessary (a complementary and alternative medicine) with Ginlac-V pessary (containing clotrimazole, tinidazole and lactobacilli) for treatment of women with symptomatic vaginal discharge. Arch Gynecol Obstet. 2008;278:341–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Dai Q, Hu L, Jiang Y, Shi H, Liu J, Zhou W, et al. An epidemiological survey of bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis in the Tibetan area of Sichuan Province, China. Eur J Obstet Gynecol Reprod Biol. 2010;150:207–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Wiesenfeld HC, Hillier SL, Krohn MA, Landers DV, Sweet RL. Bacterial vaginosis is a strong predictor of Neisseria gonorrhoeae and Chlamydia trachomatis infection. Clin Infect Dis. 2003;36:663–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Nyirjesy P, Sobel JD. Advances in diagnosing vaginitis: development of a new algorithm. Curr Infect Dis Rep. 2005;7:458–62.PubMedCrossRefGoogle Scholar
  17. 17.
    Bornstein J, Zarfati D. A universal combination treatment for vaginitis. Gynecol Obstet Invest. 2008;65:195–200.PubMedCrossRefGoogle Scholar
  18. 18.
    Govender L, Hoosen AA, Moodley J, Moodley P, Sturm AW. Bacterial vaginosis and associated infections in pregnancy. Int J Gynaecol Obstet. 1996;55:23–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Cepický P, Malina J, Líbalová Z, Kuzelová M. “Mixed" and "miscellaneous" vulvovaginitis: diagnostics and therapy of vaginal administration of nystatin and nifuratel. Ceska Gynekol. 2005;70:232–7. Czech.PubMedGoogle Scholar
  20. 20.
    Donders G, Bellen G, Ausma J, Verguts L, Vaneldere J, Hinoul P, et al. The effect of antifungal treatment on the vaginal flora of women with vulvo-vaginal yeast infection with or without bacterial vaginosis. Eur J Clin Microbiol Infect Dis. 2011;30:59–63.PubMedCrossRefGoogle Scholar
  21. 21.
    • Rivers CA, Adaramola OO, Schwebke JR. Prevalence of bacterial vaginosis and vulvovaginal candidiasis mixed infection in a southeastern american STD clinic. Sex Transm Dis. 2011;38:672–4. This study is one of extremely few that determined the frequency of coinfection and mixed infections in symptomatic women seen in a STD clinic and emphasized how frequently BV is present in women with trichomoniasis.PubMedCrossRefGoogle Scholar
  22. 22.
    Gatski M, Martin DH, Clark RA, Harville E, Schmidt N, Kissinger P. Co-occurrence of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women. Sex Transm Dis. 2011;38:163–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Levi AW, Harigopal M, Hui P, Schofield K, Chhieng DC. Comparison of Affirm VPIII and Papanicolaou tests in the detection of infectious vaginitis. Am J Clin Pathol. 2011;135:442–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Lowe NK, Neal JL, Ryan-Wenger NA. Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard. Obstet Gynecol. 2009;113:89–95.PubMedGoogle Scholar
  25. 25.
    Gatski M, Martin DH, Levison J, Mena L, Clark RA, Murphy M, et al. The influence of bacterial vaginosis on the response to Trichomonas vaginalis treatment among HIV-infected women. Sex Transm Infect. 2011;87:205–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Moodley P, Connolly C, Sturm AW. Interrelationships among human immunodeficiency virus type 1 infection, bacterial vaginosis, trichomoniasis, and the presence of yeasts. J Infect Dis. 2002;185:69–73.PubMedCrossRefGoogle Scholar
  27. 27.
    McGrory T, Meysick K, Lemchuk-Favel LT, Garber GE. The interaction of Lactobacillus acidophilus and Trichomonas vaginalis in vitro. J Parasitol. 1994;80:50–4.PubMedCrossRefGoogle Scholar
  28. 28.
    Gallo MF, Macaluso M, Warner L, Fleenor ME, Hook 3rd EW, Brill I, et al. Bacterial vaginosis, gonorrhea, and chlamydial infection among women attending a sexually transmitted disease clinic: a longitudinal analysis of possible causal links. Ann Epidemiol. 2012;22:213–20.PubMedCrossRefGoogle Scholar
  29. 29.
    Redondo-Lopez V, Meriwether C, Schmitt C, Opitz M, Cook R, Sobel JD. Vulvovaginal candidiasis complicating recurrent bacterial vaginosis. Sex Transm Dis. 1990;17:51–3.PubMedGoogle Scholar
  30. 30.
    Balkus JE, Richardson BA, Mandaliya K, Kiarie J, Jaoko W, Ndinya-Achola JO, et al. Establishing and sustaining a healthy vaginal environment: analysis of data from a randomized trial of periodic presumptive treatment for vaginal infections. J Infect Dis. 2011;204:323–6.PubMedCrossRefGoogle Scholar
  31. 31.
    McClelland RS, Richardson BA, Hassan WM, Graham SM, Kiarie J, Baeten JM, et al. Prospective study of vaginal bacterial flora and other risk factors for vulvovaginal candidiasis. J Infect Dis. 2009;199:1883–90.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Jack D. Sobel
    • 1
    • 5
  • Chitra Subramanian
    • 1
  • Betsy Foxman
    • 2
  • Marilyn Fairfax
    • 3
  • Scott E. Gygax
    • 4
  1. 1.Division of Infectious DiseasesWayne State University School of MedicineDetroitUSA
  2. 2.School of Public HealthUniversity of MichiganAnn ArborUSA
  3. 3.Department of PathologyWayne State University School of MedicineDetroitUSA
  4. 4.Femeris Women’s Health Research Center, Medical Diagnostic LaboratoriesA Member of Genesis Biotechnology GroupHamiltonUSA
  5. 5.Division of Infectious DiseasesHarper University HospitalDetroitUSA

Personalised recommendations