ORAL VERSUS VAGINAL METRONIDAZOLE IN THE TREATMENT OF SYMPTOMATIZING BACTERIAL VAGINOSIS IN WOMEN DURING CHILD BEARING PERIOD

Abstract

Bacterial vaginosis (BV) is a condition characterized by the partial loss of the endogenous vaginal lactobacilli on the one hand, and polymicrobial anaerobic overgrowth on the other hand. Anaerobic flora, consist of Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus spp, Bacteroides spp, Prevotela spp, Peptostreptococcus spp, Fusobacterium spp and Porphyromonas spp. The concentration of bacteria increases from 100 to 1000 fold in women with BV compared to healthy women (Marrazzo et al., 2010). Incidence of bacterial vaginosis increases with frequent vaginal douching (Ness et al., 2007); stress and smoking as it suppresses the immune system so facilitate the infection (Brotman et al., 2008). Also some sexual behaviors related characteristics associated with bacterial vaginosis including young age at coitarche, life time number of sex partners, a recent history of new sex partner (Hay and Ugwumadu, 2009); and receptive oral or anal sex (Muzny et al., 2013). Presence of sexually transmitted disease (e.g. Gonorrhea, Chlamydia, Syphilis and Trichomoniasis) increase risk of infection with bacterial vaginosis (Martin et al., 1999).A major risk factor for B.V is the use of an intrauterine device(Madden et al., 2012). The presence of bacterial vaginosis may lead to many complications e.g. Pelvic Inflammatory Disease (Judlin, 2010); post-operative vaginal cuff cellulitis (Larsson and Carlsson, 2002) and urinary tract infections ( Sumati and Saritha 2009). Also it increases susceptibility to HIV infection (Spear et al., 2007) and presence of cervical intraepithelial neoplasia (Nam et al., 2009). B.V infection in pregnant women is associated with serious complications such as late miscarriage , preterm labor, preterm pre labor rupture of membranes(PPROM),clinical chorioamionitis, post-partum endometritis and wound infections ( Schmidt et al., 2006). There are many methods used in treatment of bacterial vaginosis including: 1-Antibiotic methods e.g. metronidazole which is the commonest and clindamycin (both given either orally or vaginally).Tinidazole and secnidazole may be used also in treatment either alone or as adjuvant with metronidazole to enhance its efficacy (Menard, 2011). 2- Non antibiotic methods including probiotics, prebiotics, and some local vaginal applications which promote vaginal acidification (Menard, 2011). This study was conducted to evaluate the efficacy of oral in comparison with vaginal Metronidazolein the treatment of bacterial vaginosis infection. A total of non pregnant 50 women with BV were selected from those attending the outpatient Gynecologic Clinics in Ain Shams Maternity University Hospital. Diagnosis of BV was based on Amsel’s criteria, defined as the presence of at least three out of the following four criteria: 1- Thin, gray and homogeneous vaginal discharge.2-Vaginal pH>4.5. 3- The presence of clue cells in wet smear. 4- Unpleasant fishy odor before or after addition of 10% KOH. The inclusion criteria in this study included women aged 20-40 years infected with bacterial vaginosis as diagnosed by Amsel's criteria. While the Exclusion Criteriaincluded: pregnant women, Breast feeding women, patients with history of clinical disease that predispose to infection (DM, steroid therapy...etc), history of vaginal bleeding during the course of treatment, recent vaginal douching or intercourse (within 24 hours), evidence of other genital infections and known hypersensitivity to metronidazole. Those who fulfilled the inclusion criteria (N=50) were divided into two equal groups each included 25 patients randomized into either one of the two groups using a computer- generated randomization sheet. A number of 50 concealed opaque envelopes were prepared by an independent subject before starting the study, in the first group (oral metronidazole), each envelope included 14 tablets of 500mg metronidazole oral tablets, while in the second group (vaginal metronidazole) each envelope included 5 vaginal suppositories of 500 mg metronidazole vaginal suppository. Each patient received a closed sequentially numbered opaque sealed envelope (SNOSE) containing the drug prescribed. The envelopes were opened on the day of the start of the treatment by one of the study officers. Then an informed consent, full medical history taking, clinical and pelvic examination were done.