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Bacterial Vaginosis: Diagnosis, Prevalence, and Treatment
Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Bacterial Vaginosis (BV) is a disorder of unknown etiology, characterized by a foul smelling vaginal discharge, loss or reduction of the normal vaginal Lactobacilli, and overgrowth of other anaerobic bacteria. Thus, it presents a formidable problem for clinicians as well as microbiologists researching its etiology, clinical course, treatment, and epidemiology. The present work focuses on the unresolved issues of the epidemiology and treatment of BV in order to provide valid methods for treatment studies of this condition and to describe the prevalence of BV in defined populations.

The first study validates the use of PAP-stained smears in the diagnosis of BV. The study assesses the methods of Amsel’s clinical criteria and Nugent criteria on Gram-stain smears, against Pap-stained smears and also validates different observers. The result shows that the PAP-staining of vaginal smears is a good method in BV diagnosis; the kappa value is 0.86 (interobserver weighted kappa index) compared to 0.81 for Gram-stained smears, and 0.70 for rehydrated air-dried smears using the mean Nugent score as the criterion standard. This enables population based studies on archived PAP-stained smears from the screening of cervical cancer.

In the second study, we use the knowledge gained from study one to investigate the prevalence of BV in a cohort from the population of Åland. The prevalences of BV on the Åland Islands were: 15.6 %, 11.9 %, 8.7 %, and 8.6% in 1993, 1998, 2003, and 2008, respectively. This means that the prevalence of BV decreased between1993-2008 from 15.6% to 8.6%. The confidence intervals are not overlapping, thus indicating a significant decrease in prevalence from 1993 to 2008.

The third study is a prospective, double-blind placebo controlled treatment study of BV. After conventional treatment with clindamycin, the patients were treated with adjuvant treatment of Lactobacilli-loaded tampons or placebo. The study showed no differences between the treatment and the placebo group, indicating that the tampon does not work at all. There are a variety of possible explanations for the result, which are analyzed in this thesis.

The fourth study aimed to evaluate whether clindamycin is retained for a long time in the vaginal mucosa, thus disturbing the Lactobacilli in an attempt to reimplant Lactobacilli in the probiotic treatment studies. In conventional treatment, it is also useful to know whether clindamycin is retained, especially when considering the pressure from antibiotics on the antimicrobial sensitivity pattern. In the study, we found that the clindamycin disappears rapidly.

Conclusion: BV research requires effort from many different scientific disciplines and the riddle of this condition and its treatment can only be resolved by concerted actions in research and treatment. The vision for the future includes, among other factors, better molecular biology based diagnostic tools, and knowledge of population based bacterial floras.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2011. , 47 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1246
Keyword [en]
Bacterial vaginosis, prevalence, diagnosis, PAP-smear, probiotic treatment, clindamycin
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-68812ISBN: 978-91-7393-178-6OAI: oai:DiVA.org:liu-68812DiVA: diva2:421197
Public defence
2011-05-31, Berzeliussalen, Ingång 65, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-06-08 Created: 2011-06-08 Last updated: 2011-08-18Bibliographically approved
List of papers
1. Validation of the use of Pap-stained vaginal smears for diagnosis of bacterial vaginosis
Open this publication in new window or tab >>Validation of the use of Pap-stained vaginal smears for diagnosis of bacterial vaginosis
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2007 (English)In: Acta Pathologica, Microbiologica et Immunologica Scandinavica (APMIS), ISSN 0903-4641, E-ISSN 1600-0463, Vol. 115, no 7, 809-813 p.Article in journal (Refereed) Published
Abstract [en]

Papanicolaou-stained cervicovaginal smears (Pap smears) are used to screen for cervical cancer. Since there is a lack of consensus in published reports respecting the efficacy of Pap-stained smears in BV diagnostics, there is a need to validate their use for diagnosis of BV. Slides from the international BV00 workshop were Pap stained and independently analyzed by four investigators under a phase-contrast microscope. All workshop slides - whether Pap-stained, Gram-stained or rehydrated air-dried smears - were scored according to the same Nugent classification. The diagnostic accuracy of Pap smears for diagnosis of BV had a sensitivity of 0.85 and a specificity of 0.92, with a positive and negative predictive value of 0.84 and 0.93, respectively. The interobserver weighted kappa index was 0.86 for Pap-stained smears compared to 0.81 for Gram-stained smears, and 0.70 for rehydrated air-dried smears using the mean Nugent score as the criterion standard. Provided that the samples are taken from equivalent locations (the vaginal fornix) and analyzed according to the same scoring criteria, there is no discernable difference in the diagnostic accuracy of the three smear-staining methods. The Pap-stained vaginal smears can be used as a wholly adequate alternative to Gram-stained smears for BV diagnosis. © Apmis 2007.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-38583 (URN)10.1111/j.1600-0463.2007.apm_607.x (DOI)44808 (Local ID)44808 (Archive number)44808 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2011-06-08Bibliographically approved
2. The prevalence of BV in the population on the Åland Islands during a 15-year period
Open this publication in new window or tab >>The prevalence of BV in the population on the Åland Islands during a 15-year period
2010 (English)In: APMIS, ISSN 0903-4641, Vol. 118, no 11, 903-908 p.Article in journal (Refereed) Published
Abstract [en]

The aim of the study was to describe the prevalence and age distribution of bacterial vaginosis (BV) during an observation period of 15 years in a population study with cross-sectional samples of adult women living on the Aland Islands. The Aland Islands form an archipelago in the Baltic Sea and are a province of Finland. Every fifth year, specific age groups in the adult female population are invited to participate in a screening program for early diagnosis of cervical cancer using a papanicolaou (PAP)-stained vaginal smear. Women in the age groups of 20, 25, 30, 35, 40, 45, 50, 55, and 60 years are called each year. BV diagnosis of the PAP-stained smears uses the classification according to Nugent. The PAP-stained smears from the screening program of cervical cancer 1993, 1998, 2003, and 2008 were used in this study. A total of 3456 slides were investigated and 271 women could be followed for the 15-year observation period. The prevalence of BV declined from 15.6% in 1993 to 8.6% in 2008. The highest prevalence occurred among the age groups of 35 and 50 years. Among the 271 women who could be followed for the 15-year observation period, two-third showed normal/intermediate flora and one-third were infected with BV at least once. As this is a cross-sectional population study spanning 15 years, the prevalence of BV in the female adult population of the Aland Islands can be estimated. The prevalence has declined between 1993 and 2008 from 15.6% to 8.6%.

Place, publisher, year, edition, pages
Blackwell Publishing Ltd, 2010
Keyword
BV, prevalence, population study, diagnostics, PAP smear
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-61210 (URN)10.1111/j.1600-0463.2010.02678.x (DOI)000283161100012 ()
Available from: 2010-11-05 Created: 2010-11-05 Last updated: 2011-06-08Bibliographically approved
3. A double-blind treatment study of bacterial vaginosis with normal vaginal lactobacilli after an open treatment with vaginal clindamycin ovules
Open this publication in new window or tab >>A double-blind treatment study of bacterial vaginosis with normal vaginal lactobacilli after an open treatment with vaginal clindamycin ovules
2005 (English)In: Acta Dermato-Venereologica, ISSN 0001-5555, E-ISSN 1651-2057, Vol. 85, no 1, 42-46 p.Article in journal (Refereed) Published
Abstract [en]

The expected 4-week cure rate after conventional treatment of bacterial vaginosis are only 65-70%. In an attempt to improve the cure rate by adding probiotic lactobacilli we performed a double-blind placebo-controlled study of adjuvant lactobacilli treatment after an open treatment with vaginal clindamycin ovules. Women with bacterial vaginosis as defined by Amsel's criteria were treated with clindamycin ovules. Vaginal smears were collected and analysed according to Nugent's criteria. During the following menstruation period the women used, as an adjuvant treatment, either lactobacilli-prepared tampons or placebo tampons. The lactobacilli tampons were loaded with a mixture of freeze-dried L. fermentum, L. casei var. rhamnosus and L. gasseri. The cure rate was recorded after the second menstruation period. There was no improvement in the cure rate after treatment with lactobacilli-containing tampons compared to placebo tampons, the cure rates as defined by Amsel's criteria were 56% and 62%, respectively, and 55% and 63%, as defined by Nugent's criteria. This is the first study to report cure rates for women with 'intermediate' wet smear ratings according to Nugent's classification and this group had an overall cure rate of 44%. The cure rate of treatment of bacterial vaginosis was not improved by using lactobacilli-prepared tampons for one menstruation.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24622 (URN)10.1080/00015550410022249 (DOI)6803 (Local ID)6803 (Archive number)6803 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2011-06-08Bibliographically approved
4. Vaginal retention of locally administered clindamycin
Open this publication in new window or tab >>Vaginal retention of locally administered clindamycin
2011 (English)In: APMIS, ISSN 0903-4641, Vol. 119, no 6, 373-376 p.Article in journal (Refereed) Published
Abstract [en]

Since bacterial vaginosis (BV) is characterized by a lack of, or very few, lactobacilli and high numbers of small, mostly anaerobic bacteria, an obvious treatment modality would be eradication of the BV-associated bacterial flora followed by reintroduction of lactobacilli vaginally. As probiotic treatment with lactobacilli is one tool for improving the cure rate when treating BV, it is necessary to know the length of time after treatment that clindamycin can be found in the vagina and if this could interfere with the growth of the probiotic lactobacilli. We evaluated the vaginal concentration of clindamycin in 12 women for 8 days to obtain data on the concentration of clindamycin in the vagina after intravaginal treatment with the drug. The participants were examined five times between two menstrual periods: before treatment, the day after treatment was finished, and 3, 5 and 8 days post-treatment. The first day post-treatment clindamycin 0.46 x 10-3 to 8.4 x 10-3 g/g vaginal fluid (median 2.87 x 10-3) was found. Thereafter, the concentration of clindamycin decreased rapidly. In 10 patients clindamycin was found after 3 days. A very low concentration was still present 5 days after treatment in four patients. After 8 days no clindamycin was found. Clindamycin is rapidly eliminated from the vagina, within 3-8 days, after local administration. Our results indicate that treatment with probiotic lactobacilli could be problematic if carried out within 5 days after cessation of clindamycin treatment.

Place, publisher, year, edition, pages
Blackwell Publishing Ltd, 2011
Keyword
Treatment, clindamycin, bacterial vaginosis, concentration
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-68694 (URN)10.1111/j.1600-0463.2011.02742.x (DOI)000290626500007 ()
Available from: 2011-05-27 Created: 2011-05-27 Last updated: 2012-03-25Bibliographically approved

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