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Aerobic Vaginitis
1.
AEROBIC VAGINITIS 2018 European (IUSTI/WHO) International Union against STI (IUSTI), WHO guideline Prof. Aboubakr Elnashar Benha university hospital, Egypt ABOUBAKR ELNASHAR ▪ Aerobic vaginitis (AV) ▪ Also known as desquamative inflammatory vaginitis (DIV) in its severest manifestation ▪ An underdiagnosed vaginal discharge syndrome ▪ Form of vaginal dysbiosis*. ▪ In contrast to BV; the AV/DIV spectrum is highly inflammatory with very different clinical features. *Qualitative and quantitative changes, their metabolic activity and their local distribution ABOUBAKR ELNASHAR
2.
EPIDEMIOLOGY ▪ PREVALENCE ▪ 5–10% in non-pregnant women ▪ 3-9% in pregnant women ABOUBAKR ELNASHAR ▪ RISK FACTORS 1. Multiple sexual partners 2. Inconsistent use of condoms – H2O2 – producing protection by lactobacilli against genital tract pathogens is reportedly blocked by semen. Consistent condom use could increase colonization of Lactobacillus crispatus in the vagina and protect against AV. Lactobacilli also function as immune modulators and reduce the levels of inflammatory cytokines like interleukin (IL)-1b and IL-6. 3. Use of IUCD– effect of IUD on vaginal flora is controversial. Short-term IUD use has not been shown to predispose women to AV. However, prior studies report vaginal colonization by Gram-positive cocci and E. coli with IUD use which can in turn increase predisposition to AV. Further studies are required to determine the association and identify the possible mechanism. 4. Long-term usage of antibiotics and pessaries. 5. Vaginal douching – cause a disequilibrium in the vaginal microflora or induce inflammation through physical or chemical irritation. ABOUBAKR ELNASHAR
3.
PATHOGENESIS ▪ An interplay between the infectious microorganisms & host immune mechanisms. 1. Decreased lactobacillary protection 2. Increased aerobic microorganisms: ▪ E coli ▪ Group B streptococci (GBS) ▪ S aureus ▪ Production of sialidase 3. An imbalance in local immune modulation, increased inflammatory cytokine reaction and genetic susceptibility ABOUBAKR ELNASHAR DIAGNOSIS ▪ Symptoms: ▪ Asymptomatic (10–20%) ▪ Yellowish & foul-smelling purulent discharge (70%) ▪ Rotten odour (20%) – negative whiff test ▪ Severe burning, stinging, linked to dyspareunia (12%) ▪ Intermittent vulval & vaginal pruritus (72.54%) ▪ Signs: ▪ Vaginal erythema and oedema (31.13%) ▪ Vaginal erosions and ulceration ▪ Cervix: erosion, hyperaemia, scattered bleeding points ▪ pH>4.5 (94.10%), can be as high as 6–8 ABOUBAKR ELNASHAR
4.
Purulent , Sticky yellow or green ABOUBAKR ELNASHAR ▪ DIV ▪ represents extreme form of AV with increased severity of signs and symptoms ▪ Patients are typically symptomatic; asymptomatic DIV occurs rarely. ▪ Mean duration of symptoms is 15–31 months with fluctuating severity ▪ 50% of patients are diagnosed in peri- or postmenopausal women. ABOUBAKR ELNASHAR
5.
Microscopy. ▪ The gold standard for diagnosis is wet mount microscopy. ▪ AV score combines 5 items ▪ creating a score from 0 to 10 ABOUBAKR ELNASHAR ▪ a 39-year-old patient who presented with vaginal discharge and dyspareunia of recent onset. ▪ Flocculent purulent discharge, erythema and erosions visible on per speculum examination ▪ Phase-contrast microscopy image of a wet mount 1. Note the absence of lactobacilli, presence of ‘toxic’leucocytes, full of lysozymic granules, coccoid bacterial flora and parabasal cell (400). ▪ Gram stained vaginal smear revealing leucocytes (arrows), near-absent lactobacilli and the presence of Gram-positive cocci seen discretely as well as in small chains (arrowhead) and scattered Gram-negative bacilli (1000) ▪ Multiplex polymerase chain reaction (PCR) was negative for Neisseria gonorrhoeae as well as Chlamydia trachomatis. ▪ Nucleic acid amplification test (NAAT) for trichomoniasis was negative. ABOUBAKR ELNASHAR
6.
ABOUBAKR ELNASHAR ▪ Cultures. ▪ Most women with AV have positive cultures for aerobic bacteria such as Streptococcus agalactiae, S. aureus, E. coli ▪ Positive culture does not indicate the woman has AV ▪ Not recommended for diagnosis. ▪ Culture with antimicrobial susceptibility testing may aid in TT ▪ Molecular detection. ▪ based on molecular biology ▪ correlate well with moderate- to-severe AV compared with microscopy ▪ Need confirmation in larger trials assessing sensitivity and specificity. ABOUBAKR ELNASHAR
7.
▪ The Guidelines Group recommends that the current best test to diagnose AV in women is microscopy (Grade 2, quality of evidence: Grade B). ABOUBAKR ELNASHAR ▪ DD 1. Trichomoniasis ▪ DIV occasionally presents with annular erythematous papules with a pale center involving cervix –appearance of colpitis macularis (27%), similar to trichomoniasis, or described as papular colpitis 2. Erosive lichen planus ▪ vaginal adhesions, synechiae and stenosis are extremely rare in DIV, in contrast to erosive lichen planus ▪ examination of other sites, i.e. the cutis, oral mucosa, scalp, and nails often shows evidence of lichen planus. ABOUBAKR ELNASHAR
8.
3. Atrophic vaginitis ▪ Inflammatory symptoms and signs are seen in both. ▪ Atrophic vaginitis is typically seen postmenopausally, but has been identified in lactational women as well. ▪ The only clinical point that may be useful in differentiation between the two conditions is the predominance of atrophic features (pale, dry vaginal mucosa with loss of rugae) in patients with atrophic vaginitis. ▪ It is noteworthy that in a woman with symptomatic atrophic vaginitis with vaginal dysbiosis, one must rule out the use of long-acting progesterone depot contraception, an iatrogenic cause of vaginal atrophy. ABOUBAKR ELNASHAR ABOUBAKR ELNASHAR TT: clindamycin cream for 7-21 d Local estrogen Local corticosteroid for 7-21 d Metronidazole Oral: 400–500 mg twice daily for 5–7d Or Intravaginal gel (0.75%) daily for5 days or Clindamycin cream Intravaginal (2%) daily for 7d
9.
Complications 1. An increasing number of coinfections &complications. 2. An increased risk of ▪ preterm delivery and ▪ chorioamnionitis in women with first trimester ABOUBAKR ELNASHAR TREATMENT ▪ Recommended regimens for AV: ▪ 2% clindamycin cream 5 g intravaginally for 7–21 days The Guidelines Group recommends that the current best treatment for uncomplicated AV in women is clindamycin cream. (Grade 2, quality of evidence:Grade C) Clindamycin is active against staphylococci and streptococci as well as anaerobes. ▪ In cases with a significant atrophy: Local oestrogens ▪ Local corticosteroids: hydrocortisone 300–500 mg for 7–21 days ABOUBAKR ELNASHAR
10.
▪ Other TT ▪ Antimicrobials: kanamycin ovules or moxifloxacin. ▪ Predfoam enema applied intravaginally (off-label use) for more severe cases ▪ Routine screening and treatment of male partner(s) is not indicated ▪ Follow up: Women with persistent or recurrent symptoms. ABOUBAKR ELNASHAR
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