Chapter 7 : Bacterial Vaginosis as a Mixed Infection

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Our understanding of bacterial vaginosis (BV) is improving through observational studies and study of the interactions between bacteria in the laboratory. The vaginal ecosystem is subjected to a variety of hormonal changes that affect the balance between lactobacilli and anaerobes. It is likely that the normal lactobacillus flora may be overwhelmed by factors such as a prolonged alteration in the pH of the vagina following vaginal douching or frequent sexual intercourse. Instillation of large numbers of organisms from a male or female sex partner might trigger BV. Alternative hypotheses include the introduction of a lytic bacteriophage infection, reducing the lactobacillus population. Once the BV organisms are allowed to flourish, they utilize each other’s metabolites in a symbiotic manner and continue to maintain a pH of >4.5. Possibly, the lack of HO-producing lactobacilli in the vagina makes it easier for sexually transmitted pathogens, including human immunodeficiency virus (HIV), to gain a foothold, although it may be that the same risk factors for acquiring sexually transmitted diseases (STDs) are in fact precipitating BV. There is an urgent need to determine how to effectively prevent the adverse outcomes of pregnancy associated with BV. If we could control BV, we might additionally be able to reduce the risk of HIV infection, for which BV is an important risk factor. A promising approach is to recolonize the vagina with lactobacilli that are high-level HO producers and may be better able to inhibit the growth of anaerobes than the native lactobacillus flora.

Citation: Hay P. 2002. Bacterial Vaginosis as a Mixed Infection, p 125-136. In Brogden K, Guthmiller J (ed), Polymicrobial Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555817947.ch7
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Changes in the vaginal flora over a period of 3 months in a woman with recurrent BV (17). The day of the menstrual cycle, treatment with metronidazole (Met) or clotrimazole pessaries (Canesten), menstruation (Period), and unprotected sexual intercourse (USI) (indicated by diary and the presence of sperm on the smear) are shown. Days on which no slide was collected are shown as interruptions in the graph. The subject presents with BV, which resolves with metronidazole treatment. During her next period, develops. This resolves with treatment, to be followed by BV. The BV spontaneously resolves in midcycle, but candidiasis and BV recur shortly afterwards, and BV recurs again in the final month.

Citation: Hay P. 2002. Bacterial Vaginosis as a Mixed Infection, p 125-136. In Brogden K, Guthmiller J (ed), Polymicrobial Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555817947.ch7
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The composite (Amsel) criteria used for the diagnosis of BV in clinical practice

Citation: Hay P. 2002. Bacterial Vaginosis as a Mixed Infection, p 125-136. In Brogden K, Guthmiller J (ed), Polymicrobial Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555817947.ch7
Generic image for table

Standard treatments for BV

Citation: Hay P. 2002. Bacterial Vaginosis as a Mixed Infection, p 125-136. In Brogden K, Guthmiller J (ed), Polymicrobial Diseases. ASM Press, Washington, DC. doi: 10.1128/9781555817947.ch7

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