Bacterial vaginosis: an overview for 2009.

Bacterial vaginosis has been appreciated as a unique clinical entity for well over 50 years. Its essential manifestations are well established: a loss of the normal bacterial population of the vagina and their replacement by other species. Investigations into this condition have led to a better understanding of its prevalence and epidemiology. Microbiologic and biochemical studies have exposed the remarkably complex pathophysiologic events that occur with bacterial vaginosis. Several major morbidities accompany this condition. Advances have been made in treatment, including the recent availability of a new therapeutic agent, tinidazole. However, the root cause of the condition is elusive, and as a result managing bacterial vaginosis and its complications is unsatisfactory; moreover, data suggest that therapy now is less successful than in the past. This article brings together the current fund of knowledge about bacterial vaginosis in a way that offers clinicians a realistic view of our capabilities and concerns.

Effectiveness of two tinidazole regimens in treatment of bacterial vaginosis: a randomized controlled trial.

OBJECTIVE: To assess the effectiveness at 21-30 days after treatment of tinidazole administered orally at 1 g once daily for 5 days and 2 g once daily for 2 days, compared with placebo, in the treatment of bacterial vaginosis, using rigorous U.S. Food and Drug Administration (FDA)-recommended criteria to define cure. METHODS: A total of 235 women at 10 U.S. centers participated in this prospective, randomized, double-blinded, placebo-controlled trial. Presence or absence of all five following criteria was required to define diagnosis or cure of bacterial vaginosis: 1) clue cells were at least 20% of squamous cells in microscopic examination of vaginal fluid; 2) positive potassium hydroxide whiff test; 3) a homogeneous, thin, white-gray vaginal discharge; 4) vaginal pH greater than 4.5; and 5) Nugent score greater than or equal to 4 on Gram-stained vaginal fluid. Compliance, tolerability, and safety were assessed using patient diaries and interviews at 8-10 days and 21-30 days after treatment. Cochran-Mantel-Haenszel statistical analysis with Bonferroni adjustment was used to compare outcomes. RESULTS: Superior efficacy was demonstrated by tinidazole for the 1 g once daily for 5 days regimen (36.8% cured, P<.001, number needed to treat 3.2) and for the 2 g once daily for 2 days regimen (27.4% cured, P<.001, number needed to treat 4.5), when compared with placebo (5.1% cured) in the primary endpoint analysis. Using more traditional criteria for cure, efficacy was greater. Compliance with study therapy and tolerability were comparable in the three treatment groups. CONCLUSION: Both tinidazole regimens studied provided effective treatment for bacterial vaginosis. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00229216 LEVEL OF EVIDENCE: I.

Chronic endometritis in DMPA users and Chlamydia trachomatis endometritis.

OBJECTIVE: This study was conducted to determine the prevalence of Chlamydia trachomatis (CT) in the endometrium of depot medroxyprogesterone acetate (DMPA) users with and without breakthrough bleeding (BTB) (unscheduled bleeding) and/or chronic endometritis (CE). METHODS: Cross-sectional study. Endometrial biopsies were performed on 20 DMPA users who were having BTB and 20 DMPA users who were amenorrheic. The paraffin-embedded tissue sections were washed with xylene and ethanol to remove the paraffin. CT was identified in the endometrial samples using the COBAS AMPLICOR (Roche Diagnostics, Branchburg, NJ, USA) polymerase chain reaction (PCR) identification system. RESULTS: Chronic endometritis was the most common histologic finding (10/40, 25%) and occurred more often in women experiencing BTB (35% vs. 15%) (RR 1.62, CI 0.91-2.87). No patient with CE had CT infection of the endometrium or cervix. CONCLUSIONS: CT was not a cause of CE in this population of at-risk patients using DMPA. It is possible that CE in DMPA users reflects an inflammatory state, a function of an atrophic endometrium. This points to the possibility of nonsteroidal anti-inflammatory drugs as therapy for CE in this population rather than antimicrobials or hormonal medication.

Guidelines for the diagnosis, treatment and prevention of postoperative infections.

Bacterial contamination of the operative site is a common occurrence in obstetrics and gynecology. The widespread use of antibiotic prophylaxis has reduced but not eliminated serious postoperative infections. For most operations, a single dose of a limited-spectrum drug has been as effective as a multidose regimen. In the differential diagnosis it is important to consider cellulitis, abscess, necrotizing fasciitis and septic pelvic thrombophlebitis. Abscess and necrotizing fasciitis are expected to require invasive therapy in addition to antibiotics, while cellulitis and septic pelvic thrombophlebitis should respond to medical management alone. Although a postoperative fever is a warning sign of possible infection, it may also be caused by the antibiotics that are given for treatment. The use of prolonged courses of antibiotics once the patient is clinically well is discouraged. While clinical guidelines are provided for use in the diagnosis and management of postoperative infections, these recommendations are intended for general direction and not as an exclusive management plan.