Improvement of abnormal vaginal flora in Ugandan women by self-testing and short use of intravaginal antimicrobials

Abstract

The vaginal composition of African women is more often lactobacillus-deficient compared to that of women from other areas around the world. Lactobacillus-deficient microflora is a known risk factor for serious health problems, such as preterm birth, cervix cancer, and entrapment of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). The aim of this study was to assess the effect of local vaginal antibiotic or antiseptic treatment on abnormal vaginal flora (AVF), aerobic vaginitis (AV), and bacterial vaginosis (BV) among women in rural, semi-urban, and urban areas in Uganda, as compared to placebo. In a double-blind, placebo-controlled, randomized trial, 300 women presenting for outpatient routine, follow-up, or medical care at Mulago Hospital in Kampala, Uganda, were enrolled to receive 6 days of treatment with vaginal rifaximin (RFX), dequalinium chloride (DQC), or placebo if they had an increased vaginal pH of >4.5 as determined by self-testing. At initial visit and at control visit after 4 weeks, a smear was taken for blinded wet mount microscopy to determine AVF, BV, AV, and Candida severity scores. As compared to placebo, both RFX or DQC treatments dramatically diminished BV prevalence and severity from the initial to follow-up visit: the BV score declined from 2.5 to 1.6 (p < 0.0001) and from 2.5 to 1.9 (p < 0.0001), respectively. Similarly, strong improvements in the AV score were seen in both treatment regimens: moderate and severe AV declined from AV scores of 6.3 to 3.6 (p = 0.003) and from 6.6 to 4.1 (p < 0.004), respectively. Also, women with AVF (deceased or absent lactobacilli) showed similar improvements when compared with placebo. Women with normal flora and Candida at the initial visit showed less Candida after 4 weeks in the group treated with DQC (p = 0.014). Even after a short duration of intravaginal treatment with local non-absorbable antiseptics or antibiotics produced significant, lasting improvements in the vaginal microbiome composition of women with disturbed vaginal microflora. As African women have high prevalences of BV, AV, and AVF, this approach could improve their odds to prevent health-compromising complications. Further studies assessing direct health outcomes are needed to substantiate this.

Candidiasis, Bacterial Vaginosis, Trichomoniasis and Other Vaginal Conditions Affecting the Vulva

“…If antibiotics are chosen, preference should be given to topical formulations, to those active against Gram negative bacilli and Gram-positive cocci, and as innocuous as possible to lactobacilli. The use of the antiseptic dequalinium chloride was less associated with Candida at the end of the treatment, when compared to antibiotics [118].…”

“…The cure rates achieved with the antiseptic dequalinium chloride are non-inferior to those of clindamycin [116]. It has the advantages of being less toxic for lactobacilli, and not increasing the risk of VVC, contrarily to antibiotics [118]. Additionally, it is not expected that bacteria develop resistance to it and can have some effect in other causes of "vaginitis" other than BV, thus making it at least partially useful for mixed infections, including AV, VVC and trichomoniasis [116].…”

“…Among gynaecological complications, there are studies relating it to an increased risk of having an abnormal Pap test and of acquiring STIs. The presence of inflammation and erosions, the lack of lactobacilli, and the associated increased levels of sialidase can easily explain the increased risk for STIs; diagnosing and treating AV can be highly relevant in populations at elevated risk, namely in Africa [87,118].…”

Bacterial vaginosis: prevalence, risk profile and association with sexually transmitted infections

“…The higher prevalence of BV in African women, for example, can be explained by the low occurrence of Lactobacillus species (lactobacillary grade III) producing hydrogen peroxide, which are less frequent in black women and have pathogenic defense activity. 20 Cervical cytology by Papanicolaou smears was also used to evaluate BV. The prevalence was 27.7%, which is lower than that detected by Gram staining.…”

Genital Tract Infections in an Isolated Community: 100 Women of the Príncipe Island

“…Certainly, it would have a tremendous impact in an isolated community which will, inevitably, one day open up for influxes from the rest of the world. In Uganda we recently achieved a significant improvement of the vaginal microflora by self-screening and treatment with locally applied intravaginal antiseptics or antibiotics [ 30 ].…”