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Efficient Treatment of Vaginitis

Vaginitis (vulvovaginitisis) represent a group of inflammatory diseases of the lower genital tract. Among the adult female population, vaginitis are the most common reason for visiting the doctor (1, 2, 3.). They are mostly diagnosed among sexually active women, but can also be found among young girls in puberty. It is estimated that at least 75% women get vaginitis at least once before menopause (4), but 50% infections occur at least one more time (1).

Depending on the causes, vaginitis can be divided to infectious and non-infectious vaginitis. The causes of non-infectious vaginitis are most commonly local allergy, poor intimate hygiene, vaginal irrigation, foreign agents (sand, tampon…) and vaginal dryness due to deficit of estrogen (perimenopause, menopause).

The infectious vaginitis represent a much larger group, and are represented in 90% of all cases. The causes of these infectious vaginitis are fungus (candida), bacteria ( Gram+  and Gram – ), viruses and protozoa. Very often these diseases are due to multiple causes, and then we have mixed vaginitis.

There are different combinations of causes of these diseases. The most common are the combinations of bacteria and fungi, but just as common are the combinations of two different bacteria or two different candida (candida albicans and candida non-albicans).

The fungi vaginitis represent 46.7% of all vaginitises. Candida albicans is the most frequent cause, but recently there is an increase of infections caused by candida glabrata (up to 18%). Candida glabrata  is more frequent in older women, in recurrent fungi infections and in women with diabetes. The effect of anti mycotics (drugs used in treatment of fungi) is not the same in all kinds of candida.

Bacterial vaginitis are represented with 21.9%, mixed with 22.5%, Bacterial vaginosis by 9.5% and sexually transmitted diseases by 1.8%. (6)

Vaginal  candidiasis are the most common cause of vaginitis in Europe, and the second most common in the USA. They are the result of infection caused by Candida albicans in 80 to 90% of cases (2). The most common risk factors are: early sexual activities, the use of the diaphragm and spermicides, pregnancy and the use of wide specter antibiotics (2).

Vaginitis is usually manifested by vaginal discharge, vaginal itching, feeling of pricking, pain or irritation during sexual intercourse ( dispareunia ) or urinating. The therapy for vaginitis are antimycotics and antibiotics.  Tha antimycotics used are azoles and nystatin.

Azoles are synthetic antimycotic drugs with a wide specter. The derivates of azoles are classified as imidazoles or triazoles depending on the presence of two or three atoms of nitrogen in the five member azole ring. They are used in the treatment of local and systemic fungus infections. The main representatives of this group of antimycotics are clotrimazole, myconazole, econazole and ketokanazole. Azoles are not equally efficient on all kinds of scandida.

Nystatine Nystatine is a poliene antimycotic that is fungistatic and fungicidic in relation to a great number of fungi; Candida ( albicans and non-albicans- Candida glabrata, Candida tropicalis, Candida krusei etc. ), Hystoplasma, Coccdioides and Kryptococci. The characteristic of nystatine  being efficient on all kinds of Candida is very important because the non-albicans traits of Candida are less sensitive to standard imidazoles.

Antibiotics used in treatment of local vaginitis are Neomycin and Polumixine B.

Neomycin is an aminiglycozide antibiotic with bactericide influence upon G+ and G- aerobe bacteria. It works in such a way that it blocks the synthesis of proteins by combining with small subunits of ribosomes of the bacterial cells. The traits sensitive to neomycine: G+: Corynebacterium, Listeria monocytogenes and Staphylococcus meti-S; G-:

Acinetobacter, Branhamella catarrhalis, Campylobacter, Citrobacter freundii, Citrobacter koseri, Enterobacter aerogenes, Enterobacter cloacae, Echerichia coli, Haemophylus influenzae, Klebsiella, Morganella morganii, Proteus mirabilis, Proteus vulgaris, Providencia rettgeri, Serratia, Shigella, Yersinia and Pasteurella, as moderately sensitive.

Polymixine B is a polypeptide antibiotic with a bactericide effect upon G- bacteria. It produces the disorganization of the cytoplasmatic membrane of the bacterial cells. Sensitive to polymixine b are: Acinetobacter, Aeromonas, Alcaligenes, Citrobacter freundii, Citrobacter koseri, Enterobacter, Echerichia coli, Klebsiella, Moraxella, Pseudominas aeruginosa, Salmonella, Shigella, Stenotorphomonas maltophylia (9).

Is the eradication of pathogens sufficient for long term cure of vaginitis?

No! Healthy vaginal flora contains 108-9 bacteria/ml vaginal discharge, 5 to 10 kinds of micro organisms are in balance in the vaginal flora. The most dominant kind are Lactobacilli (107 vaginal secretion) and represent 90% of all kinds of bacteria. They are GRAM POSITIVE bacteria of the Lactobacillus trait, also called Doederleins bacilli. They have a protective role, due to the following characteristics: production of lactic acid ( pH < 4.5 ), production of (H2O2), forming of the protective film, production of biosurfactants that prevent the binding of pathogens to the vaginal mucosa, co-aggregation with pathogens preventing their reproduction, stimulation of the host immunity (13).

In the case of vaginal infection, there is a growth of pathogens versus lactobacilli, so there is no protection of the Lactobacilli and there is a disbalance of the vaginal eco system.

In the case of vaginal infection treated non selectively by antiseptics or aggressive anti infective agents, there is a massive eradication of pathogens, but also Doderleins bacilli, and again there is no protection of the Lactobacilli, and as a result there is cure with a great risk of relapse and recidives. So, in conclusion, short term eradication of pathogens is good, but not sufficient!

In the case of vaginal infection treated by an efficient anti infective agent which preserves the vaginal flora there is an eradication of pathogens, but with the protection of Lactobacillus, so we have recovery with the return of the balance of the vaginal eco system,

That means that the therapy which preserves the vaginal eco system gives us long term healing (13, 14).

The efficient treatment of vaginitis means there is a complete eradication of the pathogens. That is achieved by using antibiotics and antimycotics. It is important to protect the Lactobacillus, which in turn means no relapses or recidives of vaginitis. That is achieved by using agents that have no effect on Lactobacillus ( Nystatin, Neomycin, Polymixin B… ).

LITERATURE

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  2. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000; 62: 1095-104
  3. Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. 2004; 70: 2125-32.
  4. Sobel JD. Vaginitis. N Engl J Med. 1997; 337: 1896-903.
  5. Macsween KF, Ridgway GL. The laboratory investigation of vaginal discharge. J Clin Pathol. 1998; 51: 564-7.
  6. Brook I. Microbiology and management of polymicrobial female genital tract infections in adolescents. J Pediatr Adolesc Gynecol. 2002; 15: 217-26.
  7. Donder GG, Vereecken A, Bosmans E, Dekeersmaecker A, Salembier G, Spitz B. Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: aerobic vaginitis. BJOG. 2002; 109: 34-43.
  8. Tempera G, Abbadessa G, Bonfiglio G, Cammarata E, Cianci A, Corsello S et al. Topical kanamycin: an effective therapeutic option in aerobic vaginitis. J Chemother. 2006; 18: 409-14.
  9. Summary of the characteristics of the drug Polygynax, 2009
  10. PSUR (periodic report of the safety of the drug) Polygynax, 2010
  11. Anonymous, Sexually Transmitted Diseases. Treatment Guidelines, 2006 MMWR 2006; August 4, 55: RR-11
  12. Sherrard J. European guideline for the management of vaginal discharge. Int J STD AIDS. 2001; 12: 73-7.
  13. Bergogne-Berezin. Normal vaginal flora, vaginitis and bacterial vaginoses: diagnostic and therapeutics. Antibiotics 2007;9:139-144
  14. Serov V N. Using Polygynax to treat non-specific bacterial and fungal vaginitis. Russian Gyneco-Obstetrican Journal Association. 2001; 1:64-67.
  15. Kira EF et al. Biocenosis and functional activity of the vaginal epithelium in the local treatment of aerobic vaginitis with Polygynax and Tergynan. Journal of Obstetrics and Female Pathology. 2010, Volume LIX (5th Edition).
  16. Verrière F. Effectiveness of POLYGYNAX in the treatment of vaginitis: a prospective multicentre study. Obstetrics and Gynecology. The Official Journal of the Bulgarian Society of Obstetrics and Gynecology. 2011;1(50):32-7.
  17. Nosocotech. In vitro measurements of the activity of two antibiotics and an antifungal agent with respect to 17 bacterial strains. Evaluation of their association in many pharmaceutical products for gynecologic specialties. Lyon, France. February 25, 2009.
  18. Boisnic S. Evaluation of the anti-inflammatory effect of Polygynax® in an experimental model of human mucosa maintained in survival. 2009, P25 , 33rd Congress of CNGOF.