Negative associations between folate and bacterial vaginosis in the NHANES 2001 to 2004.

BACKGROUND: Bacterial vaginosis (BV) is one of the most common infections among women of reproductive age and accounts for 15-50% of infections globally. The role played by folate in the pathogenesis and progression of BV is poorly understood. The aim of this study was to investigate the association between serum folate, red blood cell (RBC) folate, and BV in American women. METHODS: 1,954 participants from the 2001-2004 National Health and Nutrition Examination Survey (NHANES) program were included in this study. Multiple logistic regression was used to analyze the association between serum folate, RBC folate, and BV, and covariates including race, age, education level, and body mass index were used to construct adjusted models. Stratified analysis was used to explore the stability of the above associations in different populations. RESULTS: In the present cross-sectional study, we found that serum folate and RBC folate were inversely associated with the risk of BV. In the fully adjusted model, the risk of BV was reduced by 35% (OR=0.65, 95% CI: 0.51~0.83, p=0.0007) in the highest serum folate group and 32% (OR=0.68, 95% CI: 0.53~0.87, p=0.0023) in the highest RBC folate group compared to the lowest group. CONCLUSIONS: The results of this study indicated that serum folate and RBC folate were inversely associated with the risk of BV folate supplementation may play an important role in the prevention and management of BV.

Bacterial vaginosis: An insight into the prevalence, alternative treatments regimen and it's associated resistance patterns.

Bacterial Vaginosis (BV) is a complex polymicrobial infection of vagina that shifts the paradigms of vaginal flora from lactobacilli to opportunistic pathogens. BV is catagorized by greyish white discharge, pH greater than 4.5. It results in the preterm labor, abortion, pelvic inflammatory disorders, post cesarean infections. BV is associated with Sexually Transmitted Diseases (STDs) or immune deficiency disorders like Human Immunodeficiency Virus, Human Papilloma Virus, Herpes Simplex Virus 1 and 2, and Neisseria gonorrhoeae. The prevalence rate is about 21.2 million (29.2%) worldwide. BV is more frequent in black females as compared to white females, independent of geographical distribution. Globally, BV is treated with the current recommended antibiotic therapy including Metronidazole and Clindamycin. The recurrence rates are 76% and occur within 06 months of treatment due to antibiotic resistance against pathogenic bacteria and their biofilms. The antibiotic resistance is a global health issue which directs the attentions towards other treatments. One of these is the treatment of sex partners, thus helping to stop the recurrence rates in females. However, this method does not show any positive results. Probiotic therapy is an incorporation of Lactobacilli orally or intravaginally for the recolonization of healthy microbes. This therapy has exhibited promising results but some studies revealed that Probiotic therapy does not control the recurrence rate. The other methods are in trials period and none of them are used clinically or commercially available for the treatment. The thermoplastic polyurethane (TPU) intravaginal rings contain lactic acid and metronidazole showed promising results in trials of BV treatment. The vaginal acidifiers are used as an alternative method to maintain the vaginal pH but the process of douching is a major limitation. The activated charcoal is used to treat BV patients in clinical trials showed decrease in the pH with only 3.1% loss of lactobacilli. Phage therapy is a reemerging field to overcome the bacterial resistance. They are host specific and easier to handle. They can be used naturally, synthetically; phage cocktails and phage-antibiotics combination can be used. Phages show auspicious results for the treatment of bacterial infections as compared to antibiotics as they also treat biofilms. This is one of the promising therapy in future to treat infections with no side effects. Phage therapy can be used in pharmaceuticals according to Food and Drug Administration (FDA) guidelines. Taken together, it is suggested that large funding is required by pharmaceutical sector or government for further investigation of bacteriophages to be used against BV pathogenesis.

A review of the literature regarding nutritional supplements and their effect on vaginal flora and preterm birth.

PURPOSE OF REVIEW: The aim of this review was to evaluate recently published review articles which examine the use of nutritional supplements to prevent preterm birth (PTB) by modifying vaginal bacteria. RECENT FINDINGS: Probiotics, vitamin D and vitamin C were all identified as nutritional supplements that have the potential to alter bacterial flora and consequently reduce PTB and treat or prevent genital infections. Evidence shows that probiotics may reduce the incidence of PTB as well as being effective at treating bacterial vaginosis, a known cause for PTB. Low vitamin D levels may be associated with bacterial vaginosis, although no evidence was identified which demonstrated that vitamin D supplementation reduced the risk of having bacterial vaginosis or PTB.There is little evidence regarding vitamin C supplementation, although it does suggest a possible benefit with regard to preterm rupture of membranes; however, this did not appear to reduce rates of PTB. SUMMARY: Although there is evidence that taking probiotics in pregnancy may reduce the incidence of PTB, it is mainly derived from small, poor quality studies. Vitamin D and vitamin C may have potential benefits, but these remain to be proven. Large randomized controlled trials are needed to more accurately evaluate the potential benefits of these low-cost interventions for reducing PTB and its consequences.

[Vitamin D and pregnancy]. / Vitamine D et grossesse.

Vitamin D insufficiency is characterized, since 2005, by 25(OH)D concentration less than 75 nmol/L (or 30 ng/mL). Vitamin D could interfere with many mechanisms involved in preeclampsia's pathogenesis including trophoblastic invasion and immunomodulation as well as blood pressure control and proteinuria. Occurrence of preeclampsia and gestational diabetes seems to be linked to vitamin D deficiency but recent data in the literature are contradictory. Vitamin D supplementation during pregnancy is controversial. Some societies consider it unnecessary and others recommend up to 2000 UI/d. There is no reported case of teratogenicity linked with vitamin D intake.

Gardnerella, Trichomonas and Candida in cervical smears of 58,904 immigrants participating in the Dutch national cervical screening program.

OBJECTIVE: To report the prevalence of Gardnerella, Trichomonas and Candida in the cervical smears of 9 immigrant groups participating in the Dutch national cervical screening program. STUDY DESIGN: Cervical smears were taken from 58,904 immigrant participants and 498,405 Dutch participants. As part of the routine screening process, all smears were screened for the overgrowth of Gardnerella (i.e. smears with an abundance of clue cells) and for the presence of Trichomonas and Candida. The smears were screened by 6 laboratories, all of which use the Dutch KOPAC coding system. The odds ratio and confidence interval were calculated for the 9 immigrant groups and compared to Dutch participants. RESULTS: Immigrants from Suriname, Turkey and the Dutch Antilles have a 2-5 times higher prevalence of Gardnerella and Trichomonas when compared to native Dutch women. Interestingly, the prevalence of Trichomonas in cervical smears of Moroccan immigrants is twice as high, yet the prevalence of Gardnerella is 3 times lower than in native Dutch women. CONCLUSIONS: Immigrants with a high prevalence of Gardnerella also have a high prevalence of Trichomonas. In the context of the increased risk of squamous abnormalities in smears with Gardnerella, such slides should be screened with extra care.

What would we do without metronidazole?

Metronidazole is a treatment of choice for several types of infections, but coexisting conditions or concomitant medications may preclude its use. Although tinidazole, a newer nitroimidazole, may be an option in cases where drug interactions make the use of metronidazole inadvisable, similar absolute contraindications exist. In situations where nitroimidazole use is contraindicated or inadvisable, clinicians may have difficulty deciding on efficacious treatment options. For the treatment of trichomoniasis, alternatives include furazolidone, clotrimazole, nonoxynol-9 or paromomycin. Alternatives for bacterial vaginosis include clindamycin topically or systemically. For giardiasis, alternative options include paromomycin, nitazoxanide or the antihelminthic benzimidazoles. Alternatives for Clostridium difficile are varied, including oral vancomycin, nitazoxanide and rifaximin. Although options are limited, alternative therapies for treatment of patients with absolute contraindications to the nitroimidazole antibiotics are available.

Maternal vitamin A and ß-carotene supplementation and risk of bacterial vaginosis: a randomized controlled trial in rural Bangladesh.

BACKGROUND: Bacterial vaginosis (BV) in pregnancy is linked to preterm birth, but its risk factors are not well understood. Micronutrient deficiencies may be associated with an increased risk of this condition. OBJECTIVE: We assessed the effect of weekly vitamin A or ß-carotene supplementation during pregnancy until 3 mo postpartum on BV risk in rural northeastern Bangladesh. DESIGN: In this cluster-randomized, placebo-controlled trial, 33 clusters (n = 33) were randomly assigned to 3 groups. Women (n = 1812) were examined for BV by using self-administered swabs and the Nugent scoring method in early pregnancy, at 32 wk of gestation, and at 3 mo postpartum. RESULTS: The prevalence of BV in early pregnancy, before supplementation, was 7.6% (95% CI: 6.3%, 9.1%) overall. Neither the prevalence nor the incidence of BV in the third trimester differed by supplement group. However, the prevalence (OR: 0.71; 95% CI: 0.52, 0.98) and incidence (RR: 0.58; 95% CI: 0.41, 0.81) of BV at 3 mo postpartum was lower among women in the vitamin A group (9.1% and 6.7%, respectively) than in the placebo group (12.4% and 11.8%, respectively), but not in the ß-carotene group. Both vitamin A and ß-carotene reduced the prevalence and incidence of BV at both time points (ie, third trimester and 3 mo postpartum) by 30-40% compared with placebo (all P < 0.05). CONCLUSIONS: Weekly vitamin A supplementation reduced the risk of maternal BV in this rural Bangladeshi population. Enhancement of vitamin A status before and during pregnancy may reduce the risk of BV in areas with vitamin A deficiency. This trial is registered at clinicaltrials.gov as NCT00198822.

Aerobic vaginal pathogens and their sensitivity pattern.

BACKGROUND: The vaginal flora is a complicated environment, containing dozens of microbiological species in variable quantities and relative proportions. The frequent cause of vaginal discharge is an infection or colonization with different microorganisms. Some pathologic conditions causing vaginitis are well defined yet, 7-72% of women with vaginitis may remain undiagnosed and such forms of abnormal vaginal flora neither considered as normal, nor can be called bacterial vaginosis have been termed as 'intermediate flora' and its management probably differ from that of bacterial vaginosis. It is of crucial importance in pregnant females at risk of preterm delivery. The present study has been conducted especially to elucidate this type of aerobic vaginal isolates and their culture and sensitivity towards currently used antibiotics. This study was conducted at the Microbiology Department of Fauji Foundation Hospital, Rawalpindi over a period of two years (April 2004-March 2006). METHODS: One thousand, nine hundred and twenty three high vaginal swabs, both from indoor and outdoor patients were collected, cultured and their susceptibility to various antibiotics was determined. RESULTS: Significant growth was obtained in 731 samples. The highest frequency of infection (39.5%) was observed at 31-40 years followed by 41-50 years (35.8%). About 76% were from outdoor and 24% were from indoor patients. Staphylococcus aureus was the most prevalent vaginal pathogen at 11-60 yrs & with highest prevalence at 31-40 years followed by 41-50 years. It was a predominant pathogen in both indoor (35%) as well as outdoor (41.6%) patients, followed by enteric gram-negative bacilli and other gram-positive cocci. There were very few antibiotics among the conventionally available aminoglycosides, third generation cephalosporins, penicillin, quinolones, sulfonamides and tetracyclines possessing good sensitivity (> 80%) against any one the common aerobic vaginal pathogens. The effective chemotherapeutics agents belong to the groups of carbapenems and beta-lactams beta-lactamase inhibitor combinations. CONCLUSIONS: The high prevalence of gynaecological infections demands that the patients with gynaecological symptoms be investigated thoroughly. Culture must invariably be done. Currently the antibiotics showing good sensitivity are very expensive. So there is a need for an effective antimicrobial policy. Effective drug should be reserved for the treatment of serious life threatening situations only.

The effect of treatment for vaginal yeast infection on the prevalence of bacterial vaginosis in early pregnancy.

Both bacterial vaginosis and candidiasis are commonly seen in pregnancy, with marked differences in pregnancy outcome. The aim of this study was to assess the effect of antifungal treatment on the prevalence of bacterial vaginosis in early pregnancy. This prospective randomized study included 126 women in early pregnancy with heavy vaginal yeast colonization and 88 healthy controls. Vaginal flora was evaluated on initial visit and on two check-ups for the presence of bacterial vaginosis. Half of the heavily colonized patients received an antimycotic agent (clotrimazole). The prevalence of vaginosis was compared among the three groups. Xi (2)-test and Fisher's exact test were used for statistical analysis. Three of 72 (4.2%) yeast-free controls, two of 79 (2.5%) yeast infected but not treated patients, and nine of 63 (14.3%) infected and treated patients presented with bacterial vaginosis 4 weeks after the initial visit. There was a statistically significant increase in the prevalence of bacterial vaginosis (p<0.03) in yeast infected and treated patients as compared to colonized and untreated patients. Treatment of candidiasis in early pregnancy may contribute to an increased rate of bacterial vaginosis.

Alternative therapies for bacterial vaginosis: a literature review and acceptability survey.

OBJECTIVE: This article reviews current research into non-antibiotic treatments for bacterial vaginosis and assesses interest in the use of alternative therapies for women's health in a non-representative sample of women. DESIGN: Literature review and online survey. SUBJECTS: A convenience sample of 192 women was selected from an online community devoted to the discussion of women's health. RESULTS: Data on alternative treatments for bacterial vaginosis are mixed. Studies have shown both positive and null effects for probiotic- and lactic acid-based treatments. The results of antiseptic studies were more uniformly positive, but the studies were generally not placebo-controlled. Women in the survey population were both interested in and experienced with alternative and complementary therapies for reproductive health problems--44% of them had used home or natural remedies to treat vaginal infections or menstrual problems, and only 20% indicated that antibiotics and antifungals would be their treatment of choice. CONCLUSIONS: Women are interested in alternative treatments for women's health problems such as yeast infections and bacterial vaginosis. Although such treatments have been investigated, further research--particularly in the form of high-quality, randomized, controlled trials--is strongly indicated.

Bacterial vaginosis and intravaginal practices: association with HIV.

OBJECTIVES: To determine the prevalence of bacterial vaginosis and to identify risk factors associated with this condition among urban women in Harare, Zimbabwe. DESIGN: A cross sectional study. MAIN OUTCOME MEASURES: Prevalent bacteria vaginosis (BV), HIV and intravaginal practices. SETTING: Urban primary health care clinics in Harare. SUBJECTS: 177 pregnant and 212 non pregnant women attending mother and child health care clinics. INTERVENTIONS: The women were recruited, counselled, interviewed, examined and tested for reproductive tract infections including HIV. Those with reproductive tract infections were given free treatment. RESULTS: The prevalence of bacterial vaginosis was 36% among HIV seropositive women and 26% among those seronegative. Fifty one per cent of the women practiced intravaginal cleansing, while another 28% reported use of intravaginal herbs. Women reporting intravaginal cleansing and/or use of intravaginal herbs were more likely to have bacterial vaginosis (OR 6.2 CI 3.6 to 10.7) and (OR 1.5 CI 1.1 to 2.5) and to be HIV seropositive (OR 1.8 CI 1.2 to 2.8) and (OR 1.8 CI 1.1 to 2.9) respectively. Other factors associated with bacterial vaginosis were malodorous vaginal discharge (OR 5.8 CI 2.9 to 10.7), genital warts (OR CI 3 CI 1.1 to 10.1) and Trichomonas vaginalis (OR 25.5 CI 11.6 to 56.7). CONCLUSIONS: BV was shown to be a common condition among the women the majority of whom indulged in intravaginal practices. HIV infection among women with BV and those that practiced intravaginal cleansing and/or use of herbs was significantly higher. Although causal relationship could not be established in this cross sectional study the results suggest that BV may facilitate HIV infection and we suggest the inclusion of information regarding risks associated with intravaginal practices into health education information disseminated to women.

[Vaginal candidiasis: etiology and sensitivity profile to antifungal agents in clinical use]. / Candidiasis vaginal: etiología y perfil de sensibilidad a agentes antifúngicos de uso clínico.

Candida vaginitis is one of the most frequent infection of the female genital tract with a high incidence. Approximately 75% of sexually active women suffer at least one episode of Candida vaginitis and 10% of them have recurrent episodes. Pregnancy, diabetes mellitus and antibiotic treatment are the most common predisposing factors, C. albicans is the etiologic agent most frequently found. The widespread reports of fluconazole resistance in Candida species and the selection of non Candida albicans prompted the study of species distribution of vulvovaginal candidiasis and their in vitro susceptibility against current antifungal agents. A total of 314 women with vaginal infection were studied. Yeasts were isolated from 104 patients with vulvovaginal candidiasis. The following species were identified: C. albicans 87.5%, C. glabrata 8.6% and 3.9% included C. krusei, C. famata, C. tropicalis and S. cerevisiae. The minimal inhibitory concentration (MIC) was determined for nystatin, isoconazole, fluconazole and ketoconazole, using a broth microdilution method based on NCCLS procedure. Although most of the isolates were C. albicans, the high percentage of C. glabrata recovered suggests the need to identify the yeasts isolated. Fluconazole resistant C. albicans were isolated in 13.46% of the cases. Thus, further studies are required to correlate the possible role of these strains in recurrent vulvovaginal candidiasis.