Selecting Anti-Microbial Treatment of Aerobic Vaginitis

  • Gilbert G. G. Donders
  • Katerina Ruban
  • Gert Bellen
Genitourinary Infections (J Sobel, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Genitourinary Infections

Abstract

Aerobic vaginitis (AV) is a vaginal infectious condition which is often confused with bacterial vaginosis (BV) or with the intermediate microflora as diagnosed by Nugent’s method to detect BV on Gram-stained specimens. However, although both conditions reflect a state of lactobacillary disruption in the vagina, leading to an increase in pH, BV and AV differ profoundly. While BV is a noninflammatory condition composed of a multiplex array of different anaerobic bacteria in high quantities, AV is rather sparely populated by one or two enteric commensal flora bacteria, like Streptococcus agalactiae, Staphylocuccus aureus, or Escherichia coli. AV is typically marked by either an increased inflammatory response or by prominent signs of epithelial atrophy or both. The latter condition, if severe, is also called desquamative inflammatory vaginitis. As AV is per exclusionem diagnosed by wet mount microscopy, it is a mistake to treat just vaginal culture results. Vaginal cultures only serve as follow-up data in clinical research projects and are at most used in clinical practice to confirm the diagnosis or exclude Candida infection. AV requires treatment based on microscopy findings and a combined local treatment with any of the following which may yield the best results: antibiotic (infectious component), steroids (inflammatory component), and/or estrogen (atrophy component). In cases with Candida present on microscopy or culture, antifungals must be tried first in order to see if other treatment is still needed. Vaginal rinsing with povidone iodine can provide rapid relief of symptoms but does not provide long-term reduction of bacterial loads. Local antibiotics most suitable are preferably non-absorbed and broad spectrum, especially those covering enteric gram-positive and gram-negative aerobes, like kanamycin. To achieve rapid and short-term improvement of severe symptoms, oral therapy with amoxyclav or moxifloxacin can be used, especially in deep dermal vulvitis and colpitis infections with group B streptococci or (methicillin resistant) Staphylococcus aureus. Since the latter colonizations are frequent, but seldom inflammatory infections, we in general discourage the use of oral antibiotics in women with AV. In cases with a severe atrophy component (more than 10 % of epithelial cells are of the parabasal type), local estrogens can be used; and in postmenopausal or breast cancer patients with a contraindication for estrogens, even a combination of probiotics with an ultra-low dose of local estriol may be considered.

Keywords

Aerobic vaginitis Desquamative inflammatory vaginitis Bacterial vaginosis Wet mount Microscopy Corticosteroids Vaginal treatment Metronidazole Clindamycin Gynoflor Probiotic Local estrogen Vaginal atrophy Vaginal immunity Group B streptococ Kanamycin Pregnancy complications Vaginal inflammation Leucorrhea Dyspareunia 

References

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

  1. 1.
    Donders GG. Definition and classification of abnormal vaginal flora. Best Pract Res Clin Obstet Gynaecol. 2007;21(3):355–73.CrossRefPubMedGoogle Scholar
  2. 2.
    Donders G. We, specialists in vulvovaginitis. Am J Obstet Gynecol. 2001;184(2):248–9.CrossRefPubMedGoogle Scholar
  3. 3.•
    Donders GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG. 2002;109(1):34–43. This paper describes the original definition of aerobic vaginitis (AV) and provides evidence of inflammation and cytologic abberations that differentiate the condition from the well-known bacterial vaginosis.CrossRefPubMedGoogle Scholar
  4. 4.
    Gardner HL. Desquamative inflammatory vaginitis: a newly defined entity. Am J Obstet Gynecol. 1968;102(8):1102–5.PubMedGoogle Scholar
  5. 5.
    Murphy R. Desquamative inflammatory vaginitis. Dermatol Ther. 2004;17(1):47–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Nyirjesy P. Management of persistent vaginitis. Obstet Gynecol. 2014;124(6):1135–46.CrossRefPubMedGoogle Scholar
  7. 7.
    Oates JK, Rowen D. Desquamative inflammatory vaginitis. A review. Genitourin Med. 1990;66(4):275–9.PubMedCentralPubMedGoogle Scholar
  8. 8.
    Reichman O, Sobel J. Desquamative inflammatory vaginitis. Best Pract Res Clin Obstet Gynaecol. 2014;28(7):1042–50.CrossRefPubMedGoogle Scholar
  9. 9.
    Mirmonsef P, Gilbert D, Zariffard MR, Hamaker BR, Kaur A, Landay AL, et al. The effects of commensal bacteria on innate immune responses in the female genital tract. Am J Reprod Immunol. 2011;65(3):190–5.CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Cauci S, Driussi S, Guaschino S, Isola M, Quadrifoglio F. Correlation of local interleukin-1beta levels with specific IgA response against Gardnerella vaginalis cytolysin in women with bacterial vaginosis. Am J Reprod Immunol. 2002;47(5):257–64.CrossRefPubMedGoogle Scholar
  11. 11.
    Mitchell CM, Balkus J, Agnew KJ, Cohn S, Luque A, Lawler R, et al. Bacterial vaginosis, not HIV, is primarily responsible for increased vaginal concentrations of proinflammatory cytokines. AIDS Res Hum Retrovir. 2008;24(5):667–71.CrossRefPubMedGoogle Scholar
  12. 12.
    Nikolaitchouk N, Andersch B, Falsen E, Strombeck L, Mattsby-Baltzer I. The lower genital tract microbiota in relation to cytokine-, SLPI- and endotoxin levels: application of checkerboard DNA-DNA hybridization (CDH). APMIS. 2008;116(4):263–77.CrossRefPubMedGoogle Scholar
  13. 13.
    Donders GG, Bosmans E, Dekeersmaecker A, Vereecken A, Van BB, Spitz B. Pathogenesis of abnormal vaginal bacterial flora. Am J Obstet Gynecol. 2000;182(4):872–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Marconi C, Santos-Greatti MM, Parada CM, Pontes A, Pontes AG, Giraldo PC, et al. Cervicovaginal levels of proinflammatory cytokines are increased during chlamydial infection in bacterial vaginosis but not in lactobacilli-dominated flora. J Low Genit Tract Dis. 2014;18(3):261–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Briselden AM, Moncla BJ, Stevens CE, Hillier SL. Sialidases (neuraminidases) in bacterial vaginosis and bacterial vaginosis-associated microflora. J Clin Microbiol. 1992;30(3):663–6.PubMedCentralPubMedGoogle Scholar
  16. 16.
    Cauci S, Driussi S, Monte R, Lanzafame P, Pitzus E, Quadrifoglio F. Immunoglobulin A response against Gardnerella vaginalis hemolysin and sialidase activity in bacterial vaginosis. Am J Obstet Gynecol. 1998;178(3):511–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Cauci S, Monte R, Driussi S, Lanzafame P, Quadrifoglio F. Impairment of the mucosal immune system: IgA and IgM cleavage detected in vaginal washings of a subgroup of patients with bacterial vaginosis. J Infect Dis. 1998;178(6):1698–706.CrossRefPubMedGoogle Scholar
  18. 18.
    Cauci S, Thorsen P, Schendel DE, Bremmelgaard A, Quadrifoglio F, Guaschino S. Determination of immunoglobulin A against Gardnerella vaginalis hemolysin, sialidase, and prolidase activities in vaginal fluid: implications for adverse pregnancy outcomes. J Clin Microbiol. 2003;41(1):435–8.CrossRefPubMedCentralPubMedGoogle Scholar
  19. 19.
    Marconi C, Donders GG, Bellen G, Brown DR, Parada CM, Silva MG. Sialidase activity in aerobic vaginitis is equal to levels during bacterial vaginosis. Eur J Obstet Gynecol Reprod Biol. 2013;167(2):205–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Marconi C, Donders GG, Martin LF, Ramos BR, Duarte MT, Parada CM, et al. Chlamydial infection in a high risk population: association with vaginal flora patterns. Arch Gynecol Obstet. 2012;285(4):1013–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Donders GG, Van BB, Van de Walle P, Kaiser RR, Pohlig G, Gonser S, et al. Effect of lyophilized lactobacilli and 0.03 mg estriol (Gynoflor(R)) on vaginitis and vaginosis with disrupted vaginal microflora: a multicenter, randomized, single-blind, active-controlled pilot study. Gynecol Obstet Investig. 2010;70(4):264–72.CrossRefGoogle Scholar
  22. 22.
    Donders G, Neven P, Moegele M, Lintermans A, Bellen G, Prasauskas V, et al. Ultra-low-dose estriol and Lactobacillus acidophilus vaginal tablets (Gynoflor((R))) for vaginal atrophy in postmenopausal breast cancer patients on aromatase inhibitors: pharmacokinetic, safety, and efficacy phase I clinical study. Breast Cancer Res Treat. 2014;145(2):371–9.CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.•
    Han C, Wu W, Fan A, Wang Y, Zhang H, Chu Z, et al. Diagnostic and therapeutic advancements for aerobic vaginitis. Arch Gynecol Obstet 2015;291(2):251–7. Perfect state of the art of the current AV treatment possibilities. Google Scholar
  24. 24.
    Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2013;1, CD007892.PubMedGoogle Scholar
  25. 25.
    Achilles SL, Reeves MF. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception. 2011;83(4):295–309.CrossRefPubMedGoogle Scholar
  26. 26.
    Tsai YC, Lin MY, Chen SH, Chung MT, Loo TC, Huang KF, et al. Vaginal disinfection with povidone iodine immediately before oocyte retrieval is effective in preventing pelvic abscess formation without compromising the outcome of IVF-ET. J Assist Reprod Genet. 2005;22(4):173–5.CrossRefPubMedCentralPubMedGoogle Scholar
  27. 27.
    Wewalka G, Stary A, Bosse B, Duerr HE, Reimer K. Efficacy of povidone-iodine vaginal suppositories in the treatment of bacterial vaginosis. Dermatology. 2002;204 Suppl 1:79–85.CrossRefPubMedGoogle Scholar
  28. 28.
    Mumtaz S, Ahmad M, Aftab I, Akhtar N, Ul HM, Hamid A. Aerobic vaginal pathogens and their sensitivity pattern. J Ayub Med Coll Abbottabad. 2008;20(1):113–7.PubMedGoogle Scholar
  29. 29.
    Fan A, Yue Y, Geng N, Zhang H, Wang Y, Xue F. Aerobic vaginitis and mixed infections: comparison of clinical and laboratory findings. Arch Gynecol Obstet. 2013;287(2):329–35.CrossRefPubMedGoogle Scholar
  30. 30.
    Monif GR. Semiquantitative bacterial observations with group B streptococcal vulvovaginitis. Infect Dis Obstet Gynecol. 1999;7(5):227–9.CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Cool-Foley AA, Nathan C, O’Donovan III C, Simon D. Eradication of methicillin-resistant Staphylococcus aureus vaginitis with mupirocin. DICP. 1991;25(12):1331–3.PubMedGoogle Scholar
  32. 32.
    Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women. Arch Gynecol Obstet. 2011;284(1):95–8.CrossRefPubMedGoogle Scholar
  33. 33.
    van der Meijden WI, Ewing PC. Papular colpitis: a distinct clinical entity? Symptoms, signs, histopathological diagnosis, and treatment in a series of patients seen at the Rotterdam vulvar clinic. J Low Genit Tract Dis. 2011;15(1):60–5.CrossRefPubMedGoogle Scholar
  34. 34.
    Kasten MJ. Clindamycin, metronidazole, and chloramphenicol. Mayo Clin Proc. 1999;74(8):825–33.CrossRefPubMedGoogle Scholar
  35. 35.
    Sobel JD. Desquamative inflammatory vaginitis: a new subgroup of purulent vaginitis responsive to topical 2% clindamycin therapy. Am J Obstet Gynecol. 1994;171(5):1215–20.CrossRefPubMedGoogle Scholar
  36. 36.
    Sobel JD, Reichman O, Misra D, Yoo W. Prognosis and treatment of desquamative inflammatory vaginitis. Obstet Gynecol. 2011;117(4):850–5.CrossRefPubMedGoogle Scholar
  37. 37.
    Woods CR. Macrolide-inducible resistance to clindamycin and the D-test. Pediatr Infect Dis J. 2009;28(12):1115–8.CrossRefPubMedGoogle Scholar
  38. 38.
    Sabol KE, Echevarria KL, Lewis JS. Community-associated methicillin-resistant Staphylococcus aureus: new bug, old drugs. Ann Pharmacother. 2006;40(6):1125–33.CrossRefPubMedGoogle Scholar
  39. 39.
    Lin K, Tierno Jr PM, Komisar A. Increasing antibiotic resistance of streptococcus species in New York City. Laryngoscope. 2004;114(7):1147–50.CrossRefPubMedGoogle Scholar
  40. 40.
    Tempera G, Furneri PM. Management of aerobic vaginitis. Gynecol Obstet Investig. 2010;70(4):244–9.CrossRefGoogle Scholar
  41. 41.••
    Tempera G, Abbadessa G, Bonfiglio G, Cammarata E, Cianci A, Corsello S, et al. Topical kanamycin: an effective therapeutic option in aerobic vaginitis. J Chemother. 2006;18(4):409–14. Well designed study testing 2 local treatment options for AV.CrossRefPubMedGoogle Scholar
  42. 42.
    Tempera G, Bonfiglio G, Cammarata E, Corsello S, Cianci A. Microbiological/clinical characteristics and validation of topical therapy with kanamycin in aerobic vaginitis: a pilot study. Int J Antimicrob Agents. 2004;24(1):85–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Jaisamrarn U, Triratanachat S, Chaikittisilpa S, Grob P, Prasauskas V, Taechakraichana N. Ultra-low-dose estriol and lactobacilli in the local treatment of postmenopausal vaginal atrophy. Climacteric. 2013;16(3):347–55.CrossRefPubMedCentralPubMedGoogle Scholar
  44. 44.
    Buchholz S, Mogele M, Lintermans A, Bellen G, Prasauskas V, Ortmann O, et al. Vaginal estriol-lactobacilli combination (Gynoflor) therapy and sexual quality of life in aromatase inhibitor-treated breast cancer patients with atrophic vaginitis. Climacteric 2014;1–23. doi:10.3109/13697137.2014.991301.
  45. 45.
    Donders GG, Vereecken A, Bosmans E, Spitz B. Vaginal cytokines in normal pregnancy. Am J Obstet Gynecol. 2003;189(5):1433–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Donders GG, Van CK, Bellen G, Reybrouck R, Van den Bosch T, Riphagen I, et al. Predictive value for preterm birth of abnormal vaginal flora, bacterial vaginosis and aerobic vaginitis during the first trimester of pregnancy. BJOG. 2009;116(10):1315–24.CrossRefPubMedGoogle Scholar
  47. 47.
    Curzik D, Drazancic A, Hrgovic Z. Nonspecific aerobic vaginitis and pregnancy. Fetal Diagn Ther. 2001;16(3):187–92.CrossRefPubMedGoogle Scholar
  48. 48.
    Rezeberga D, Lazdane G, Kroica J, Sokolova L, Donders GG. Placental histological inflammation and reproductive tract infections in a low risk pregnant population in Latvia. Acta Obstet Gynecol Scand. 2008;87(3):360–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Donders G, Bellen G, Rezeberga D. Aerobic vaginitis in pregnancy. BJOG. 2011;118(10):1163–70.CrossRefPubMedGoogle Scholar
  50. 50.
    Lamont RF, Nhan-Chang CL, Sobel JD, Workowski K, Conde-Agudelo A, Romero R. Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2011;205(3):177–90.CrossRefPubMedCentralPubMedGoogle Scholar
  51. 51.
    Kiss H, Petricevic L, Husslein P. Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery. BMJ. 2004;329(7462):371.CrossRefPubMedCentralPubMedGoogle Scholar
  52. 52.
    Larsson PG, Fahraeus L, Carlsson B, Jakobsson T, Forsum U. Late miscarriage and preterm birth after treatment with clindamycin: a randomised consent design study according to Zelen. BJOG. 2006;113(6):629–37.CrossRefPubMedGoogle Scholar
  53. 53.
    Lamont RF, Duncan SL, Mandal D, Bassett P. Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora. Obstet Gynecol. 2003;101(3):516–22.CrossRefPubMedGoogle Scholar
  54. 54.
    Ugwumadu A, Manyonda I, Reid F, Hay P. Effect of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic women with abnormal vaginal flora and bacterial vaginosis: a randomised controlled trial. Lancet. 2003;361(9362):983–8.CrossRefPubMedGoogle Scholar
  55. 55.
    Kekki M, Kurki T, Pelkonen J, Kurkinen-Raty M, Cacciatore B, Paavonen J. Vaginal clindamycin in preventing preterm birth and peripartal infections in asymptomatic women with bacterial vaginosis: a randomized, controlled trial. Obstet Gynecol. 2001;97(5 Pt 1):643–8.CrossRefPubMedGoogle Scholar
  56. 56.
    McGregor JA, French JI, Jones W, Milligan K, McKinney PJ, Patterson E, et al. Bacterial vaginosis is associated with prematurity and vaginal fluid mucinase and sialidase: results of a controlled trial of topical clindamycin cream. Am J Obstet Gynecol. 1994;170(4):1048–59.CrossRefPubMedGoogle Scholar
  57. 57.
    Lamont RF, Taylor-Robinson D, Bassett P. Rescreening for abnormal vaginal flora in pregnancy and re-treating with clindamycin vaginal cream significantly increases cure and improvement rates. Int J STD AIDS. 2012;23(8):565–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Nenadic DB, Pavlovic MD. Cervical fluid cytokines in pregnant women: relation to vaginal wet mount findings and polymorphonuclear leukocyte counts. Eur J Obstet Gynecol Reprod Biol. 2008;140(2):165–70.CrossRefPubMedGoogle Scholar
  59. 59.
    Krauss-Silva L, Almada-Horta A, Alves MB, Camacho KG, Moreira ME, Braga A. Basic vaginal pH, bacterial vaginosis and aerobic vaginitis: prevalence in early pregnancy and risk of spontaneous preterm delivery, a prospective study in a low socioeconomic and multiethnic South American population. BMC Pregnancy Childbirth. 2014;14:107.CrossRefPubMedCentralPubMedGoogle Scholar
  60. 60.
    Derbent AU, Ulukanligil M, Keskin EA, Soylu G, Kafali H. Does vaginal irrigation with saline solution in women with infectious vaginitis contribute to the clinical and microbiological results of antibiotic therapy? Gynecol Obstet Investig. 2012;73(3):195–200.CrossRefGoogle Scholar
  61. 61.
    Frey TB. Antimicrobial topical agents used in the vagina. Curr Probl Dermatol. 2011;40:36–47.CrossRefGoogle Scholar
  62. 62.
    Donders GG, Berger J, Heuninckx H, Bellen G, Cornelis A. Vaginal flora changes on Pap smears after insertion of levonorgestrel-releasing intrauterine device. Contraception. 2011;83(4):352–6.CrossRefPubMedGoogle Scholar
  63. 63.
    Fan AP, Xue FX. Clinical characteristics of aerobic vaginitis and its mixed infections. Zhonghua Fu Chan Ke Za Zhi. 2010;45(12):904–8.PubMedGoogle Scholar
  64. 64.
    Cepicky P, Malina J, Libalova Z, Kuzelova M. “Mixed” and “miscellaneous” vulvovaginitis: diagnostics and therapy of vaginal administration of nystatin and nifuratel. Ceska Gynekol. 2005;70(3):232–7.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Gilbert G. G. Donders
    • 1
    • 2
    • 3
    • 4
  • Katerina Ruban
    • 1
  • Gert Bellen
    • 1
  1. 1.Femicare Clinical Research for WomenTienenBelgium
  2. 2.University Hospital AntwerpAntwerpBelgium
  3. 3.Regional Hospital H HartTienenBelgium
  4. 4.Femicare vzwTienenBelgium

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