I recently heard an informative lecture at the 2016 ACOG Annual Clinical Meeting about new research and treatment of chronic vaginitis. Dr Chemen Tate from the Indiana University School of Medicine spoke about the different causes of chronic vaginal infections. While most people associate vaginal infections with yeast, the actual leading cause of vaginal infections is Bacterial vaginitis, which comprises 50% of infections, compared with only 25% for yeast.
Bacterial vaginitis causes an increased discharge with a bad smelling odor. It is usually not associated with inflammation. There is found to be a reduction of the amount of lactobacilli, which usually serve to protect the vagina. (Those are the same helpful bacteria that are found in yoghurt). BV can weaken the body’s defenses and promote other infections including herpes, chlamydia, trichomonas, HIV and gonorrhea. It is highly recurrent, and 30% of women who are treated for it will have a return of symptoms within 3 months, or 3 to 4 episodes a year. This can be very distressing. Return of symptoms may be due to reinfection or a failure of treatment. Why does this happen?
Research has determined that bacterial biofilms are organized microcolonies on a surface that create a protective mode of growth allowing for survival in a hostile environment. For example, electron microscopy of the surfaces of infected medical devices have shown the presence of large numbers of slime-encased bacteria. Tissue taken from chronic infections have shown the presence of biofilm bacteria surrounded by a protective exopolysaccharide matrix. Other examples of biofilm infections include dental carries, prosthetic device infections and cystic fibrosis lung infections.
Biofilm infections are resistant to antibiotics and host defense mechanisms. Antibiotic therapy typically reverses the symptoms caused by the infection but may fail to kill the biofilm. Bacterial Vaginosis is a biofilm infection. An adherent vaginosis biofilm persists on the vaginal epithelium after standard treatment with oral metronidazole. What new treatments can be successful against this resistant infection?
We should council our patients that in many cases bacterial vaginitis is chronic and will come back. When the infection returns treatment needs to be adjusted to be more effective. New recommended treatment is longer treatment, and includes Metrogel, oral metronidazole, tinidazole, or clindamycin vaginal for two weeks. For a patient who has a previous history of long term symptoms, the two week treatment is to be followed by once weekly Metrogel, or twice weekly oral metronidazole or tinidazole for six months. Using the appropriate treatment for this chronic problem can be expected to cure it 80% of the time. Investigation is ongoing in this field and future therapies that attack biofilms directly may show even better results.