Aerobic vaginitis Jane FondaAerobic vaginitis is an inflammatory vaginal microflora condition that is frequently confused with or appearing in conjunction with bacterial vaginosis (BV) and is thus not diagnosed or treated properly. Aerobic vaginitis can occur alongside BV, yeast, trich, and/or cytolytic vaginosis (lactobacilli overgrowth syndrome). While BV is anaerobic, aerobic vaginitis is the aerobic cousin.

The symptoms will provide clues, for example, BV does not cause inflammation or itching, whereas aerobic vaginitis (the ‘itis’ means inflammation), yeast infections and cytolytic vaginosis do. The most severe form of aerobic vaginitis is called desquamative inflammatory vaginitis.

It is estimated that between five and 10 per cent of women have aerobic vaginitis, with pregnant women also affected up to 11 per cent of the time. Asymptomatic women may have a prevalence of aerobic vaginitis up to 23 per cent.

Complications can include preterm labour, increased risk of contracting sexually transmitted infections, and abnormal Pap test results.

     Symptoms of aerobic vaginitis

  • Signs of inflammation of the vagina and/or vulva
  • Itching
  • Soreness
  • Possibly ulcers or erosions
  • Changed vaginal odour
  • Rotten, foul sort of odour (as opposed to fishy)
  • Burning
  • Stinging
  • Painful sex (dyspareunia)
  • Yellowish/greenish discharge
  • Thick discharge
  • pH of 5 or more
  • Possibly long-lasting symptoms after multiple unsuccessful treatments
  • Can be co-infected with BV, trich, yeast or lactobacilli overgrowth

     Diagnosis of aerobic vaginitis
Diagnosing this condition will require a doctor who does a wet mount in his or her office at the time of your appointment and PCR testing (ask for a multiplex PCR test). Your doctor can look under the microscope and see what microflora exists in your vagina, on the spot, including any overgrowth of lactobacilli and any existing pathogens. If your doctor does not have a microscope in the office, ask for the multiplex PCR  test, or ask to see a doctor that does have a microscope. The microscopy is your doctor’s best tool.

The ideal diagnosis is done using a phase-contrast microscope with a magnification of 400x (high power field). Evaluations must include the relative numbers of leucocytes, percentage of toxic leucocytes, background flora and proportion of epitheliocytes, with lactobacillus grade evaluated, to get the score for diagnosis.

  • Grade I – numerous lactobacilli, and no other bacteria
  • Grade IIa – mixed flora, but mostly lactobacilli
  • Grade IIb – mixed flora, but proportion of lactobacilli severely decreased due to an increase in other bacteria
  • Grade III – lactobacilli severely depressed or absent due to an overgrowth of other bacteria

Most common aerobic vaginitis bacteria

Scoring
     Aerobic vaginitis score of 0

  • Lactobacillary grade I and IIa
  • Leukocytes of <10/hpf
  • Sporadic or no toxic leucocytes
  • Unremarkable background flora or cytolytic vaginosis
  • Parabasal epitheliocytes non or <1 per cent

     Aerobic vaginitis score of 1

  • Lactobacillary grade of IIb
  • Leukocytes of >10/hpf and <10/epthithelial cell
  • <50 per cent of toxic leukocytes
  • Background flora of small coliform bacilli
  • Parabasal epitheliocytes of 10 per cent or less

     Aerobic vaginitis score of 2

  • Lactobacillary grade III
  • Leukocytes of >10/epithelial cell
  • >50 per cent of toxic leukocytes
  • Background flora of cocci or chains
  • Parabasal epitheliliocytes of >10 per cent

     The AV score is calculated thus:

  • AV score <3: no signs of aerobic vaginitis
  • AV score 3 or 4: light aerobic vaginitis
  • AV score 5 or 6: moderate aerobic vaginitis
  • AV score 6 or more: severe aerobic vaginitis

     Clinical features of aerobic vaginitis for physicians

  • Nugent scores – intermediate flora
  • pH – increased (more alkaline)
  • Sparsely populated with one or two enteric commensal flora like Streptococcus agalactiae, Staphylococcus aureus, or Escherichia coli
  • Increased signs of inflammation/anti inflammatory response
  • Increased leukocytes of >10
  • Absence of lactobacilli and microbiologically isolated organisms E. coli, S. aureus, group B Strep, and enterococci
  • Prominent signs of epithelial atrophy
  • Negative amino odour test
  • Red vaginal walls

     Treatments for aerobic vaginitis
Medical treatments include antibiotics for the bacterial component, steroids for inflammation, and possibly oestrogen therapy for atrophy. If Candida is present (which it can be, as a mixed infection), treatment with antifungals may be appropriate.

Local antibiotics are most suitable, and should be broad spectrum to cover enteric gram-positive and gram-negative aerobes (like kanamycin). Oral treatments with amoxiclav or moxifloxacin may be used, particularly if group B strep or MRSA is present. Oral antibiotic use is discouraged in women with aerobic vaginitis, with topical treatments favoured. This is due to low absorbency and high concentrations where it matters. Treatments should maximise survival of lactobacilli species, while effectively killing Gram-negative bacteria like E. coli, S. aureus and E. faecalis. A combination may be most appropriate, due to antibiotic resistance.

The most common causes of aerobic vaginitis are E. coli and E. faecalis. Many women have both a Candida albicans yeast infection combined with aerobic vaginitis, or infection with Trichomonas vaginalis, or bacterial vaginosis (Gardnerella vaginalis). It’s possible to have a mixed infection.

A rinse with povidone iodine (also known as iodopovidone) can provide quick relief of symptoms, but bacteria will return. Antibiotic vaginal gel and hydrocortisone suppositories may be effective in eradicating aerobic vaginitis, but it’s important to have the right antibiotic for the job. Some antibiotics are problematic and won’t work, and resistance is common in some countries but not others. Talk to your doctor, but before you take any antibiotics, do your homework.

     Antiseptic treatment for aerobic vaginitis
Two studies have demonstrated that vaginal treatment with dequalinium chloride (DQC) (a product used in throat gargle and lozenges) resulted in a clear reduction of symptoms, but whether this completely clears the infection over the long term was not demonstrated. 1 Over a 10-day, one dose per day treatment, 500mg was superior to 250mg in one study.

Povidone iodine douches were also used, as the product inhibits the growth of most major groups of Gram-positive and Gram-negative enteric bacteria involved in aerobic vaginitis.

      Antibiotic use and resistance in aerobic vaginitis
It depends what you have in your vagina as to what you get treated with, so read carefully!

Aminoglycosides

Kanamycin – good pick
Not absorbed when used topically and spares vaginal lactobacilli, in one study using 100mg daily for six days, after 13-16 days 100 per cent treated were still in remission. Another study found that there was a reduction in leukocytes, Enterobacteriaceae (97 per cent) and burning and itching.

Fluoroquinolones

Ciprofloxacin

  • Group B Strep (20 per cent resistance)

Norfloxacin

  • Group B Strep (20 per cent resistance)

Moxifloxacin – orally
One study found that an oral dose of 400mg once daily for six days saw (one course of therapy) 66 per cent of the women were cured, 29 per cent improved, and 5 per cent did not respond to therapy. After two courses, 85 per cent were cured, 10 per cent improved, and 5 per cent failed to respond. Those with a vaginal pH of 5 or more may require two courses.

Another study found that 400mg moxifloxacin for six days and another group received two courses, the cur rate a month after treatment was 90 per cent in the group that took one course, and 75 per cent in the group that took two courses, possibly due to loss of protective lactobacilli after that long of a treatment.

Macrolides

Erythromycin

  • Group B Strep (20 per cent resistance)

Clindamycin
Active against several aerobic Gram-positive cocci, anti-inflammatory effect, infection control may be short-lived and not cover all species in AV, prone to resistance formation in repeatedly treated patients, particularly in those with methicillin-resistant S. aureus (MRSA) and Group B Strep. Continued therapy appears to help control, but not cure, AV. May cure in many women if used initially for BV/AV treatment, as it treats both types of bacteria.

  • Group B Strep (20 per cent resistance)

Cotrimoxazole

  • E. coli (57-80 per cent resistance)
  • Pseudomonas spp.  (57-80 per cent resistance)
  • Enterobacter spp.  (57-80 per cent resistance)
  • S. aureus (67-83 per cent resistance)

Metronidazole
Unlikely to be useful, since bacteria associated with aerobic vaginitis are not anaerobic.

Tetracycline

  • E. coli (57-73 per cent resistance)
  • Pseudomonas spp. (57-73 per cent resistance)
  • Enterobacter spp. (57-73 per cent resistance)
  • S. aureus (67-83 per cent resistance)

Meclocycline
35mg, is not absorbed and spares vaginal lactobacilli, in one study after 13-16 days, treatment did not work

Penicillins

Amoxicillin

  • E. coli (80-86 per cent resistance)
  • Pseudomonas spp. (80-86 per cent resistance)
  • Enterobacter spp. (80-86 per cent resistance)
  • S. aureus (67-83 per cent resistance)

Aminoglycosides, third-generation cephalosporins, penicillins, quinolones, sulfonamides and tetracyclines
Very few of these antibiotics possess sufficient potency to kill more than 80 per cent of strains of common aerobic vaginal pathogens.

Carbapenems and clavulanic-beta-lactam combinations (amoxyclav)
Most effective sorts of antibiotics for aerobic vaginitis.

     Antibiotic use in aerobic vaginitis

  • Kanamycin ovule – 100mg (83mg of active compound) one per day for six days
  • 2% clindamycin topically
  • Fluoroquinolones
  • Group B Strep is sensitive to penicillin, ampicillan, amoxicillin, amoxicillin/clavulanic acid
  • E. faecalis usually treated with ampicillin

Practitioner’s scientific paper and treatment guidelines download

References
Jahic M, Mulavdic M, Nurkic J, Jahic E, Nurkic M. Clinical Characteristics of Aerobic Vaginitis and Its Association to Vaginal Candidiasis, Trichomonas Vaginitis and Bacterial Vaginosis. Medical Archives. 2013;67(6):428-430. doi:10.5455/medarh.2013.67.428-430.

Curr Infect Dis Rep. 2015 May;17(5):477. doi: 10.1007/s11908-015-0477-6. Selecting anti-microbial treatment of aerobic vaginitis. Donders GG, Ruban K, Bellen G.

  1.  Mendling, W., Weissenbacher, E.R., Gerber, S. et al. Arch Gynecol Obstet (2016) 293: 469. https://doi.org/10.1007/s00404-015-3914-8[2. Antimicrobial Activity of Dequalinium Chloride against Leading Germs of Vaginal Infections, Vera Della Casa, Harald Noll, Susanne Gonser, Philipp Grob, Federico Graf, Gabriele Pohlig, Arzneimittelforschung 2002; 52(9): 699-705 DOI: 10.1055/s-0031-1299954

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