Download PDF
Geburtshilfe Frauenheilkd 2014; 74(1): 51-54
DOI: 10.1055/s-0033-1360230
Guideline
GebFra Science
Georg Thieme Verlag KG Stuttgart · New York

S1-Guideline on Bacterial Vaginosis in Gynecology and Obstetrics

Long version – AWMF Guideline, registration no. 015/028, July 2013 Langfassung – AWMF-Register Nr. 015/028, Juli 2013S1-Leitlinie Bakterielle Vaginose in Gynäkologie und Geburtshilfe
W. Mendling
1   Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe, St. Anna Klinik, Wuppertal
,
J. Martius
2   Abteilung für Gynäkologie und Geburtshilfe, Krankenhaus Agatharied, Akademisches Lehrkrankenhaus der LMU München, Hausham
,
U. B. Hoyme
3   Chief physician of the Klinik für Frauenheilkunde und Geburtshilfe, St. Georg Klinikum, Eisenach
› Author Affiliations
Further Information

Publication History

Publication Date:
29 January 2014 (online)

Also available at
   Permissions and Reprints

1 Introduction

Normal vaginal flora of sexually mature women consists of lactobacilli, transient or commensal anaerobic and aerobic bacteria, and Candida species from skin and gut flora. The normal pH value of vaginal flora is 3.8–4.4. Lactobacilli predominate in the vaginal flora, primarily L. crispatus, L. gasseri, L. iners and L. jensenii, depending on ethnicity. Normal pH values differ significantly between ethnicities, ranging from 3.8 to 5.2. Some healthy women have no lactobacilli in their vaginal flora; the percentage of women with lactobacilli differs depending on ethnicity; the percentage for Caucasian women is around 9 %, for Hispanic and African women the percentage is more than 30 % with normal pH values of around 5 [14], [43]. At present, there are no studies into this issue for Europe.

Bacterial vaginosis (BV) is the most common microbiological disorder of the vaginal flora in sexually mature women. The prevalence of BV differs, depending on ethnicity; it is 2.4 times more common in women of African descent [13]. In Europe, the prevalence ranges from 5 % in women who come for regular gynecological check-ups to more than 30 % in women treated in clinics for sexually transmitted diseases. The reported prevalence in pregnant women is between 7 and 22 % [3], [9], [15], [22], [25].

Psychosocial stress is a significant risk factor for BV [39]. There are also indications of gene–environment interactions as additional risk factors and of gene polymorphisms affecting genetic control of the individualʼs immune response to BV [35]. The abnormal oral conditions of periodontal disease have been found to be significantly correlated with disturbed vaginal flora in BV [46]. Vitamin D deficiency was identified as a risk factor for BV in pregnant women [13].

Microarray technology has been used to detect microorganisms associated with BV; in addition to Gardnerella (G.) vaginalis and Atopobium (A.) vaginae, bacteria of the genera Megasphaera, Dialister, Mobiluncus, Prevotella, Leptotrichia, Sneathia, Peptostreptococcus and others were identified [4], [14]. There are several strains of G. vaginalis with different properties [6].

The most common cause of BV is probably sexual transmission [6], [7], [10], [42], [53]. Vitamin D deficiency is also being discussed as a risk factor for BV [13]. Typically, the numbers of H2O2-producing lactobacilli species are reduced in women with BV compared to women without BV [8].

Only around 50 % of affected women present with characteristic symptoms such as increased homogeneous vaginal discharge or a fishy odor on alkalinization [26]. Many women with BV remain asymptomatic. Increased vaginal discharge can cause vulvar irritation.

Supporting Information

 

  • References

  • 1 Amsel R, Totten PA, Spiegel CA et al. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983; 74: 14-22
    CrossrefPubMedGoogle Scholar
  • 2 Avonts D, Sercu M, Heyerick P et al. Incidence of uncomplicated genital infections in women using oral contraception or an intrauterine device: a prospective study. Sex Transm Dis 1990; 17: 23-29
    CrossrefPubMedGoogle Scholar
  • 3 Desseauve D, Chantrel J, Fruchart A et al. Prevalence and risk factors of bacterial vaginosis during the first trimester of pregnancy in a large French population-based study. Eur J Obstet Gynecol Reprod Biol 2012; 163: 30-34
    CrossrefPubMedGoogle Scholar
  • 4 Dols JAM, Smit PW, Kort R et al. Microarray-based identification of clinically relevant vaginal bacteria in relation to bacterial vaginosis. Am J Obstet Gynecol 2011; 204: 305.e1-305.e7
    PubMedGoogle Scholar
  • 5 Donders GGG, van Bulk B, Caudron J et al. Relationship of bacterial vaginosis and mycoplasmas to the risk of spontaneous abortion. Am J Obstet Gynecol 2000; 183: 431-437
    CrossrefPubMedGoogle Scholar
  • 6 Elsner P, Hartmann AA. Gardnerella vaginalis in the male upper genital tract: a possible source of reinfection of the female partner. Sex Transm Dis 1987; 14: 122-123
    CrossrefPubMedGoogle Scholar
  • 7 Eren AM, Zozaya M, Taylor CM et al. Exploring the diversity of Gardnerella vaginalis in the genitourinary tract microbiota of monogamous couples through subtle nucleotide variation. PloS One 2011; 6: e26732
    CrossrefPubMedGoogle Scholar
  • 8 Eschenbach DA, Davick PR, Williams BL et al. Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microbiol 1989; 27: 251-256
    PubMedGoogle Scholar
  • 9 Eschenbach DA, Hillier S, Critchlow C et al. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol 1988; 158: 819-828
    CrossrefPubMedGoogle Scholar
  • 10 Gardner HC, Dukes CD. Haemophilus vaginalis vaginitis: a newly defined specific infection previously classified non-specific vaginitis. Am J Obstet Gynecol 1955; 69: 962-976
    CrossrefPubMedGoogle Scholar
  • 11 Harmanli OH, Cheng GY, Nyirjesy P et al. Urinary tract infections in women with bacterial vaginosis. Obstet Gynecol 2000; 95: 710-712
    CrossrefPubMedGoogle Scholar
  • 12 Hauth JC, MacPherson C, Carey JC et al. Early pregnancy threshould vaginal pH and Gram stain scores predictive of subsequent preterm birth in asymptomatic women. Am J Obstet Gynecol 2003; 188: 831-835
    CrossrefPubMedGoogle Scholar
  • 13 Hensel KJ, Randis TM, Gelber SE et al. Pregnancy-specific association of vitamin D deficiency and bacterial vaginosis. Am J Obstet Gynecol 2011; 204: 41.e1-41.e9
    CrossrefPubMedGoogle Scholar
  • 14 Hickley RJ, Zhou X, Pierson JD et al. Understanding vaginal microbiome completely from an ecological perspective. Transl Res 2012; 160: 267-282
    CrossrefPubMedGoogle Scholar
  • 15 Hillier S, Holmes KK. Bacterial Vaginosis. In: Holmes KK, Sparling PF, Mardh P-A, Lemon SM, Stamm WE, Wasserheit JN, eds. Sexually transmitted Diseases. New York: McGraw-Hill; 1999: 563-586
    Google Scholar
  • 16 Hillier SL, Critchlow CW, Stevens CE et al. Microbiological, epidemiological and clinical correlations of vaginal colonisation by Mobiluncus species. Genitourin Med 1991; 67: 26-31
    PubMedGoogle Scholar
  • 17 Hillier SL, Kiviat NB, Hawes SE et al. Role of bacterial vaginosis-associated microorganisms in endometritis. Am J Obstet Gynecol 1996; 175: 435-441
    CrossrefPubMedGoogle Scholar
  • 18 Hillier SL, Martius J, Krohn M et al. A case-control study of chorioamniotic infection and histologic chorioamnionitis in prematurity. N Engl J Med 1988; 319: 972-978
    CrossrefPubMedGoogle Scholar
  • 19 Hillier SL, Nugent RP, Eschenbach DA et al. Association between bacterial vaginosis and preterm delivery of a low-birthweight infant. N Engl J Med 1995; 333: 1737-1742
    CrossrefPubMedGoogle Scholar
  • 20 Hooton TM, Fihn SD, Johnson C et al. Association between bacterial vaginosis and acute cystitis in women using diaphragmas. Arch Intern Med 1989; 149: 1932-1936
    CrossrefPubMedGoogle Scholar
  • 21 Hoyme UB, Eschenbach DA. Bakterielle Vaginose. Mikrobiologie, Diagnostik, Therapie und mögliche Komplikationen. Dtsch Med Wochenschr 1985; 110: 349-352
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Hoyme UB, Möller U, Saling E. Aktuelle Apekte der Thüringer Frühgeburtenvermeidungs-Aktion 2000. Zentralbl Gynäkol 2003; 125: 107-111
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Hoyme UB, Schwalbe N, Saling E. Die Effizienz der Thüringer Frühgeburtenvermeidungs-Aktion 2000 wird durch die Perinatalstatistik der Jahre 2001–2003 bestätigt. Geburtsh Frauenheilk 2005; 65: 284-288
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Hoyme UB, Brandt M, May TW et al. Sequentielle intravaginale Gabe von Metronidazol und Milchsäure zur Behandlung und Rezidivprävention bei bakterieller Vaginose. Geburtsh Frauenheilk 2009; 69: 395-400
    Article in Thieme ConnectPubMedGoogle Scholar
  • 25 Kiss H, Petricevic L, Husslein P. Prospective randomized controlled trial of an infection screening program to reduce the rate of preterm delivery. BMJ 2004; 329: 371-375
    CrossrefPubMedGoogle Scholar
  • 26 Klebanoff MA, Schwebke JR, Zhang J et al. Vulvovaginal symptoms in women with bacterial vaginosis. Obstet Gynecol 2004; 104: 267-272
    CrossrefPubMedGoogle Scholar
  • 27 Lamont RF, Duncan SLB, Mandal D et al. Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora. Obstet Gynecol 2003; 101: 516-522
    CrossrefPubMedGoogle Scholar
  • 28 Larsson PG, Bergmann B, Forsum U et al. Treatment of bacterial vaginosis in women with vaginal bleeding complications or discharge and haboring Mobiluncus. Gynecol Obstet Invest 1990; 29: 296-300
    CrossrefPubMedGoogle Scholar
  • 29 Larsson PG, Bergmann B, Forsum U et al. Mobiluncus and clue cells as predictors of PID after first trimester abortion. Acta Obstet Gynecol Scand 1989; 68: 217-220
    CrossrefPubMedGoogle Scholar
  • 30 Larsson PG, Forsum U. Bacterial vaginosis – a disturbed bacterial flora and treatment enigma. APMIS 2005; 113: 305-316
    CrossrefPubMedGoogle Scholar
  • 31 Larsson PG, Platz-Christensen JJ, Forsum U et al. Clue cells in predicting infections after abdominal hysterectomy. Obstet Gynecol 1991; 77: 450-452
    PubMedGoogle Scholar
  • 32 Lefevre JC, Averous S, Bauriaud R et al. Lower genital tract infections in women: comparison of clinical and epidemiological findings with microbiology. Sex Transm Dis 1988; 15: 110-113
    CrossrefPubMedGoogle Scholar
  • 33 Leitich H, Bodner-Adler B, Brunbauer M et al. Bacterial vaginosis as a risk factor for preterm delivery: a meta-analysis. Am J Obstet Gynecol 2003; 189: 139-147
    CrossrefPubMedGoogle Scholar
  • 34 Leitich H, Brunbauer M, Bodner-Adler B et al. Antibiotic treatment of bacterial vaginosis in pregnancy: a meta-analysis. Am J Obstet Gynecol 2003; 188: 752-758
    CrossrefPubMedGoogle Scholar
  • 35 Macones GA, Parry S, Elkousy M et al. A polymorphism in the promoter region of TNF and bacterial vaginosis: preliminary evidence of gene-environment interaction in the etiology of spontaneous preterm birth. Am J Obstet Gynecol 2004; 190: 1504-1508
    CrossrefPubMedGoogle Scholar
  • 36 Martius J, Krohn M, Hillier SL et al. Relationship of vaginal Lactobacillus species, cervical Chlamydia trachomatis, and bacterial vaginosis to preterm birth. Obstet Gynecol 1988; 71: 89-95
    PubMedGoogle Scholar
  • 37 McGregor JA, French JL, Seo K. Premature rupture of the membranes and bacterial vaginosis. Am J Obstet Gynecol 1993; 169: 463-466
    CrossrefPubMedGoogle Scholar
  • 38 Mendling W, Caserini M, Palmieri R. A randomised, controlled study to assess the efficacy and safety of nifuratel vaginal tablets on bacterial vaginosis. Sex Transm Infect 2013; 9 (Suppl. 01) A28
    PubMedGoogle Scholar
  • 39 Nansel TR, Riggs MA, Yu K-F et al. The association of psychosocial stress and bacterial vaginosis in a longitudinal cohort. Am J Obstet Gynecol 2006; 194: 381-386
    CrossrefPubMedGoogle Scholar
  • 40 Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol 1991; 29: 297-301
    PubMedGoogle Scholar
  • 41 Okun N, Gronau KA, Hannah ME. Antibiotics for bacterial vaginosis or trichomoniasis in pregnancy: a systematic review. Obstet Gynecol 2005; 105: 857-868
    CrossrefPubMedGoogle Scholar
  • 42 Pheifer TA, Forsyth PS, Durfee MA et al. Nonspecific vaginitis: role of Haemophilus vaginalis and treatment with metronidazole. N Engl J Med 1978; 298: 1429-1434
    CrossrefPubMedGoogle Scholar
  • 43 Ravel J, Gajer P, Abdo Z et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci USA 2011; 108 (Suppl. 01) 4680-4687
    CrossrefPubMedGoogle Scholar
  • 44 Reid G, Burton J, Devillard E. The rationale for probiotics in female urogenital healthcare. MedGenMed 2004; 29: 49
    PubMedGoogle Scholar
  • 45 Saling E. Problems in prevention of preterm birth – regrettable contradictions. J Perin Med 2011; 39: 223-225
    PubMedGoogle Scholar
  • 46 Sanu O, Lamont RF. Periodontal disease and bacterial vaginosis as genetic and environmental markers for the risk of spontaneous preterm labor and preterm birth. J Matern Fetal Neonatal Med 2011; 24: 1476-1485
    CrossrefPubMedGoogle Scholar
  • 47 Simhan HN, Caritis SN, Krohn M et al. The vaginal inflammatory milieu and the risk of early premature preterm rupture of membranes. Am J Obstet Gynecol 2005; 192: 213-218
    CrossrefPubMedGoogle Scholar
  • 48 Soper DE. Bacterial vaginosis and postoperative infections. Am J Obstet Gynecol 1993; 169: 467-469
    CrossrefPubMedGoogle Scholar
  • 49 Soper DE, Bump RC, Hurt WG. Bacterial vaginosis and trichomoniasis vaginitis are risk factors for cuff cellulitis after abdominal hysterectomy. Am J Obstet Gynecol 1990; 163: 1016-1023
    CrossrefPubMedGoogle Scholar
  • 50 Swidsinski A, Mendling W, Loening-Baucke V et al. Adherent biofilms in bacterial vaginosis. Obstet Gynecol 2005; 106: 1013-1023
    CrossrefPubMedGoogle Scholar
  • 51 Swidsinski A, Mendling W, Loening-Baucke V et al. An adherent Gardnerella vaginalis biofilm persists on the vaginal epithelium after standard therapy with oral metronidazole. Am J Obstet Gynecol 2008; 198: 97.e1-97.e6
    CrossrefPubMedGoogle Scholar
  • 52 Swidsinski A, Dörffel Y, Loening-Baucke V et al. Dissimilarity in the occurence of bifidobacteriaceae in vaginal and perianal microbiota in women with bacterial vaginosis. Anaerobe 2010; 16: 478-482
    CrossrefPubMedGoogle Scholar
  • 53 Swidsinski A, Dörffel Y, Loening-Baucke V et al. Gardnerella biofilm involves females and males and is sexually transmitted. Gynecol Obstet Invest 2010; 70: 256-263
    CrossrefPubMedGoogle Scholar
  • 54 Swidsinski A, Dörffel Y, Loening-Baucke V et al. Desquamated epithelial cells covered with a polymicrobial biofilm typical for bacterial vaginosis are present in randomly selected cryopreserved donor semen. FEMS Immunol Med Microbiol 2010; 59: 399-404
    PubMedGoogle Scholar
  • 55 Swidsinski A, Verstraelen H, Loening-Baucke V et al. Presence of a polymicrobial endometrial biofilm in patients with bacterial vaginosis. PLoS One 2013; 8: e53997
    CrossrefPubMedGoogle Scholar
  • 56 Varma R, Gupta JK. Antibiotic treatment of bacterial vaginosis in pregnancy: Multiple meta-analysis and dilemmas in interpretation. Eur J Obstet Gynecol Reprod Biol 2006; 124: 10-14
    CrossrefPubMedGoogle Scholar
  • 57 Verstraelen H, Verhelst R. Bacterial vaginosis: an update on diagnosis and treatment. Expert Rev Anti Infect Ther 2009; 7: 1109-1124
    CrossrefPubMedGoogle Scholar
  • 58 Verstraelen H, Verhelst R, Claeys G et al. Longitudinal analysis of the vaginal microflora in pregnancy suggests that L. crispatus promotes the stability of the normal vaginal microflora and that L. gasseri and/or L. iners are more conducive to the occurence of abnormal vaginal microflora. BMC Microbiol 2009; 9: 116
    CrossrefPubMedGoogle Scholar
  • 59 Watts DH, Eschenbach DA, Kenny GE. Early postpartum endometritis: the role of bacteria, genital mycoplasmas, and Chlamydia trachomatis. Obstet Gynecol 1989; 73: 52-60
    PubMedGoogle Scholar
  • 60 Watts DH, Krohn M, Hillier SL et al. Bacterial vaginosis as a risk factor for post-cesarean endometritis. Obstet Gynecol 1990; 75: 52-58
    PubMedGoogle Scholar
  • 61 Weissenbacher ER, Donders G, Unzeitig V et al. Fluomizin Study Group. A comparison of dequalinium chloride vaginal tablets (Fluomizin®) and clindamycin vaginal cream in the treatment of bacterial vaginosis: a single-blind, randomized clinical trial of efficacy and safety. Gynecol Obstet Invest 2012; 73: 8-15
    CrossrefPubMedGoogle Scholar
  • 62 Ya W, Reifer C, Miller LE. Efficacy of vaginal probiotic capsules for recurrent bacterial vaginosis: a double blind, randomized, placebo-controlled study. Am J Obstet Gynecol 2010; 203: 120.e1-120.e6
    PubMedGoogle Scholar
  • 63 Zozaya-Hinchliffe M, Lillis R, Martin DH et al. Quantitative PCR assessments of bacterial species in women with and without bacterial vaginosis. J Clin Microbiol 2010; 48: 1812-1819
    CrossrefPubMedGoogle Scholar