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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 5
| Issue : 2 | Page : 79-82 |
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Prevalence of bacterial vaginosis and their antibiotic susceptibility among women attending different private clinics in Tripoli, Libya
Ahmed Atia
Department of Anesthesia and Intensive Care, Faculty of Medical Technology, The University of Tripoli, Tripoli, Libya
| Date of Submission | 17-Feb-2021 |
| Date of Acceptance | 11-Jun-2021 |
| Date of Web Publication | 23-Jul-2021 |
Correspondence Address:
Dr. Ahmed Atia
Department of Anesthesia and Intensive Care, Faculty of Medical Technology, The University of Tripoli, Tripoli
Libya
 Source of Support: None, Conflict of Interest: None  | 2 |
DOI: 10.4103/ljms.ljms_9_21
Background: Bacterial vaginosis is a worldwide issue due to the raised risk of acquisition of sexually transmitted infections. The aim of the study was to assess the incidence of bacterial vaginosis and their antimicrobial pattern in women attending different private clinics in Tripoli, Libya. Methods: A cross-sectional study was conducted among 204 women between January and October 2020. Gram-stained vaginal swabs were examined microscopically, characterized by colony morphology, and their antimicrobial susceptibility pattern was determined. Results: The overall prevalence of bacterial vaginosis was 41%. Out of 48 bacterial isolates, 76.1% were gram-positive and 23.8% were Gram-negative bacteria. The overall drug resistance level of gram-positive bacteria was high against penicillin, co-amoxiclav, and amoxicillin. Vancomycin and imipenem were the most active drugs against Gram-positive bacteria. High level of drug resistance of Gram-negative bacteria against co-amoxiclav. Ceftriaxone, cefotaxime, and amikacin were the most active drugs against Gram-negative bacteria. Conclusions: The prevalence of bacterial vaginosis was high. Routine culture of vaginal samples should be performed on patients with vaginitis and the drug susceptibility pattern of each isolate should be determined.
Keywords: Antimicrobial, bacteria, Tripoli, vaginosis
How to cite this article:
Atia A. Prevalence of bacterial vaginosis and their antibiotic susceptibility among women attending different private clinics in Tripoli, Libya. Libyan J Med Sci 2021;5:79-82 |
How to cite this URL:
Atia A. Prevalence of bacterial vaginosis and their antibiotic susceptibility among women attending different private clinics in Tripoli, Libya. Libyan J Med Sci [serial online] 2021 [cited 2023 Mar 27];5:79-82. Available from: https://www.ljmsonline.com/text.asp?2021/5/2/79/322210 |
| Introduction | |  |
Vaginitis is a vaginal infection in which the most common vaginitis is bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis.[1] Approximately 5–10 million women worldwide seek gynecological consultation every year for vaginitis.[2] Bacterial vaginosis is noted as a change in the vaginal microflora balance characterized by an increase in vaginal pH, a decrease in lactobacilli, primarily hydrogen peroxide producing species, and an increase in the number and/or form of facultative and anaerobic bacteria.[3] Although the prevalence of bacterial vaginosis varies widely within the same region and even within similar population groups from country to country, it has been estimated to range from 8% to 75%.[4] Bacterial vaginosis can occur in any age group, but it is more prevalent in reproductive-age females globally.[1] No attention has been paid to bacterial vaginosis for many decades, as it is regarded as a trivial disease. However, in terms of the loss of working days and medical expenses, it is a morbid illness.[2] In addition, the risk of contracting human immunodeficiency virus and other sexually transmitted infections, type 2 herpes simplex virus, miscarriage, preterm labor, preterm delivery, and postpartum complications such as endometritis and wound infections in pregnant women are increased.[5],[6],[7],[8],[9],[10],[11] This also improves the viral shedding of HIV.[12],[13]
Using clinical criteria or in the laboratory, the diagnosis of bacterial vaginosis can be made by scoring bacterial morphotypes from a Gram stain of vaginal fluid, where a score of 0–3 was average vaginal flora, a score of 4–6 was intermediate vaginal flora, and a score of 7–10 was considered diagnostic for bacterial vaginosis.[14],[15]
Aerobic microorganisms reported as major causes of bacterial vaginitis from cultures of vaginal swabs have also been isolated and characterized by several reports. Escherichia More Details coli, Pseudomonas spp., Staphylococcus aureus, Mycoplasma hominis, and Ureaplasma urealyticum have been reported as the most frequently isolated microorganisms from patients with aerobic vaginitis.[16],[17] While numerous health problems are associated with bacterial vaginosis and are a major global concern, neither intensive research nor successful control programs in Libya have focused on it. Showing evidence of the prevalence of bacterial vaginosis in our populations may help in identifying the most causative agent and hence improving the rational use of antimicrobials. The aim of this study was, therefore, to determine the prevalence of bacterial vaginosis among women attending gynecology clinics and antenatal clinics.
| Methods | | |
Study design
A hospital-based cross-sectional study was conducted from January to October 2020 at different private clinics in Tripoli, Libya. The study was approved by the scientific committee of the Faculty of Medical Technology, Tripoli University, Libya. All women willing to contribute in the study with confirmed diagnosis of vaginal infections and no history of antibacterial treatment within 2 weeks before their attendance constituted the inclusion criteria. Women with genital malignancy were excluded from the study. Before collecting data, participants provided written informed consent. Each responder was given the option of declining to participate in the study or withdrawing at any moment during the study period. To protect the confidentiality, all information acquired from study participants was coded.
Specimen collection and transportation
On involvement to the study, physicians performed clinical checkups of each participant and recorded signs of vaginal abnormalities. During examinations, vaginal specimens were collected, under aseptic technique, from the study participants using sterile rayon-tipped applicator stick swabs by skilled nurses. All vaginal swabs were then transferred without delay to the microbiology laboratory of Al-Usra private clinic.
Bacterial inoculation and identification
Each vaginal swab was inoculated onto blood agar base to which 10% blood was incorporated, MacConkey agar, and chocolate agar before slide preparation for the isolation and characterization of aerobic bacteria. Blood agar and chocolate agar plates were incubated at 35°C–37°C up to 48 h in incubator. MacConkey agar was incubated at 35°C–37°C up to 48 h aerobically. Preparation and performance evaluation of culture media were done as per the instruction of the manufacturer. Pure isolates of the bacterial pathogen were characterized by colony morphology, Gram stain, and hemolytic reactions on blood agar plates.
Antimicrobial susceptibility testing
The in vitro antibacterial susceptibility testing of bacterial isolates was performed by the Kirby-Bauer disc diffusion method. The following antimicrobial agents were employed: Penicillin (10 μg), cefoxitin (30 μg), trimethoprim/sulfamethoxazole (25/23.75 μg), ceftriaxone (30 μg), clindamycin (2 μg), erythromycin (15 μg), gentamycin (10 μg), ciprofloxacin (5 μg), tobramycin (10 μg), vancomycin (10 μg), imipenem (30 μg), amoxicillin (10 μg), amoxicillin/clavulanate (20/10 μg), and amikacin (30 μg). Sensitivity test results were interpreted according to the Clinical and Laboratory Standards.
Statistical analysis
All data from the investigation were entered and analyzed using SPSS version 22 (SPSS Inc., Chicago, Ill., USA). Descriptive statistics were used to analyze the results. P < 0.05 was considered significant, as tested by student t-test analysis.
| Results | | |
Prevalence of bacterial vaginosis
A total of 204 women were included in the study. The overall prevalence of bacterial vaginosis was 41% (84/204). Bacterial vaginosis and its association with age are presented in [Table 1]. Women with age between 25 and 44 years old, had somewhat high prevalence (48.2%) of bacterial vaginosis, while in ages between 15 and 24 years, the prevalence was around 31.6%. This finding depicted that bacterial vaginosis was not significantly associated with age.
Spectrum of bacteria causing aerobic vaginosis
A total of 84 bacterial isolates were recovered from vaginal swabs, of which 64 (76.1%) were Gram-positive and 20 (23.8%) were Gram-negative bacteria. Of the Gram-negative bacteria, E. coli was dominant. S. aureus and Streptococcus agalactiae were the dominant Gram-positive bacteria [Table 2].
Drug susceptibility pattern of bacterial isolates
[Table 3] summarizes the overall drug susceptibility pattern of the Gram-positive bacteria against the nine antibacterial drugs tested. Among the agents tested, the highest overall resistance rate of Gram-positive bacteria was observed against penicillin (62.5%), followed by co-amoxiclav (31.1%), amoxicillin (31.1%), and cefotaxime (31.1%). Vancomycin and imipenem were the most active of the drugs tested against Gram-positive bacteria. S. agalactiae, the most frequently isolated Gram-positive bacterium, was 60%, 60%, and 53.3% sensitive to penicillin, imipenem, and cefotaxime, respectively. | Table 3: Percentage of in vitro antibacterial susceptibility pattern of gram-positive bacteria isolates (n=32)
Click here to view |
The overall drug susceptibility pattern of Gram-negative bacteria against the seven antibacterial agents tested is summarized in [Table 4]. Co-amoxiclav exhibited the highest overall drug resistance rate (40%) against Gram-negative bacteria. Ceftriaxone, cefotaxime, and amikacin with an overall sensitivity rate of 100% were better active against Gram-negative bacteria. As far as species-specific antimicrobial resistance rates are concerned, E. coli, the most frequently isolated bacterium, showed resistance to only co-amoxiclav (40%). | Table 4: Percentage of in vitro antibacterial susceptibility pattern of Gram-negative bacteria isolates (n=10)
Click here to view |
| Discussion | | |
In the current report, the overall prevalence rate of bacterial vaginosis as confirmed by gram-stain was 41%. Even though the prevalence rate of bacterial vaginosis in the existing study was well within the reported range, that is 8%–75%, it was higher than the existence rates of bacterial vaginosis reported by comparable earlier studies.[4],[16] Previous studies reported prevalence rates of bacterial vaginosis in the range of 15.4%–19.4%.[18] Lower incidence rates of bacterial vaginosis than those in the present study were also reported from other sub-Saharan nations, such as Kenya (37%), Botswana (38%), and Zimbabwe (32.5%).[19],[20] Sociodemographic characteristics, sexual activity, reproductive health details, and behavioral and genital hygiene have been reported as causes of variance in the prevalence rates of bacterial vaginosis.[21],[22]
Bacterial vaginosis is a state that occurs when the overgrowth of anaerobic bacteria, primarily Gardnerella vaginalis and Mobiluncus spp., substitutes lactobacilli. In some studies, however, other bacteria (E. coli, Klebsiella spp., Acinetobacter spp., Staphylococcus spp., enterococci, and S. agalactiae (group B streptococci) have been named “intermediate flora” or have been included in other studies of bacterial vaginosis.[8],[23]
Others also stated them as distinct bacterial floras that cause aerobic vaginitis, which has been thought to be a better candidate than bacterial vaginosis as a cause of complications of pregnancy such as membrane premature rupture and premature delivery.[24] In the present study, vaginal swabs were cultured with regard to the above findings and 42 bacterial isolates of Gram-positive and Gram-negative bacteria were recovered. The type and frequency of bacterial isolates reported in the present study were more diverse than in the Lakshmi et al. study. Further research should also be performed to distinguish between the effects of bacterial vaginosis and aerobic vaginitis on pregnancy outcomes.[1]
Co-amoxiclav had the highest drug resistance score of 40% for Gram-negative bacterial isolates. E. coli, the Gram-negative bacterium most commonly isolated, displayed a high degree of resistance to co-amoxiclav. Similarly, Gram-positive bacterial isolates' overall drug resistance rates ranged from 31.1% for cefotaxime to 62.5% for penicillin. S. Agalactia, the most often isolated gram-positive bacterium, demonstrated a high degree of resistance to the widely prescribed medications, erythromycin, and penicillin. Our outcome was consistent with studies carried out in Ethiopia and Pakistan.[16],[25] The availability of nonprescription antimicrobials and incorrect dosing schedules may explain the isolation of high drug resistance levels in the current study.
A limitation of this study that it was conducted in Tripoli city only, therefore we cannot generalize these results to all Libyan women.
| Conclusions | | |
The prevalence of bacterial vaginosis was very high and the hygiene of individuals was impaired. Inclusive healthcare education aimed at minimizing bacterial vaginosis is beneficial. Inclusion of vaginal culture and sensitivity tests along with the microscopic and clinical diagnosis of bacterial vaginitis initiates isolation and classification of aerobic bacteria involved in causing aerobic vaginitis. Patients with vaginitis should be regularly cultured with vaginal samples and the drug susceptibility pattern of each isolate should be established.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lakshmi K, Aishwarya JR, Chitralekha S, Menezes GA. Review on infectious vaginitis. Res J Pharm Biol Chem Sci 2013;4:679-88.  |
| 2. | Donders 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. |
| 3. | Eschenbach DA, Thwin SS, Patton DL, Hooton TM, Stapleton AE, Agnew K, et al. Influence of the normal menstrual cycle on vaginal tissue, discharge, and microflora. Clin Infect Dis 2000;30:901-7. |
| 4. | Murta EF, Silva AO, Silva EA, Adad SJ. Frequency of infectious agents for vaginitis in non- and hysterectomized women. Arch Gynecol Obstet 2005;273:152-6. |
| 5. | Myer L, Denny L, Telerant R, Souza MD, Wright TC Jr., Kuhn L. Bacterial vaginosis and susceptibility to HIV infection in South African women: A nested case-control study. J Infect Dis 2005;192:1372-80. |
| 6. | Martin HL, Richardson BA, Nyange PM, Lavreys L, Hillier SL, Chohan B, et al. Vaginal lactobacilli, microbial flora, and risk of human immunodeficiency virus type 1 and sexually transmitted disease acquisition. J Infect Dis 1999;180:1863-8. |
| 7. | Cherpes TL, Meyn LA, Krohn MA, Lurie JG, Hillier SL. Association between acquisition of herpes simplex virus type 2 in women and bacterial vaginosis. Clin Infect Dis 2003;37:319-25. |
| 8. | Hay PE, Lamont RF, Taylor-Robinson D, Morgan DJ, Ison C, Pearson J. Abnormal bacterial colonisation of the genital tract and subsequent preterm delivery and late miscarriage. BMJ 1994;308:295-8. |
| 9. | Centers for Disease Control and Prevention, Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR 2006;55:50-4. |
| 10. | Minkoff H, Grunebaum AN, Schwarz RH, Feldman J, Cummings M, Crombleholme W, et al. Risk factors for prematurity and premature rupture of membranes: A prospective study of the vaginal flora in pregnancy. Am J Obstet Gynecol 1984;150:965-72. |
| 11. | Gravett MG, Nelson HP, DeRouen T, Critchlow C, Eschenbach DA, Holmes KK. Independent associations of bacterial vaginosis and Chlamydia trachomatis infection with adverse pregnancy outcome. JAMA 1986;256:1899-903. |
| 12. | Cu-Uvin S, Hogan JW, Caliendo AM, Harwell J, Mayer KH, Carpenter CC, et al. Association between bacterial vaginosis and expression of human immunodeficiency virus type 1 RNA in the female genital tract. Clin Infect Dis 2001;33:894-6. |
| 13. | Cohn JA, Hashemi FB, Camarca M, Kong F, Xu J, Beckner SK, et al. HIV-inducing factor in cervicovaginal secretions is associated with bacterial vaginosis in HIV-1-infected women. J Acquir Immune Defic Syndr 2005;39:340-6. |
| 14. | Amsel R, Totten P, Spiegel C, Chen K, Eschenbach D, Holmes K. Nonspecific vaginitis. American J Med 1983;74:14-22. |
| 15. | Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991;29:297-301. |
| 16. | Mulu W, Yimer M, Zenebe Y, Abera B. Common causes of vaginal infections and antibiotic susceptibility of aerobic bacterial isolates in women of reproductive age attending at Felegehiwot Referral Hospital, Ethiopia: A cross sectional study. BMC Womens Health 2015;15:42. |
| 17. | Abdelaziz ZA, Ibrahim ME, Bilal NE, Hamid ME. Vaginal infections among pregnant women at Omdurman Maternity Hospital in Khartoum, Sudan. J Infect Dev Ctries 2014;8:490-7. |
| 18. | Mohammed MA, Alnour TM, Shakurfo OM, Aburass MM. Prevalence and antimicrobial resistance pattern of bacterial strains isolated from patients with urinary tract infection in Messalata Central Hospital, Libya. Asian Pac J Trop Med 2016;9:771-6. |
| 19. | Marx G, John-Stewart G, Bosire R, Wamalwa D, Otieno P, Farquhar C. Diagnosis of sexually transmitted infections and bacterial vaginosis among HIV-1-infected pregnant women in Nairobi. Int J STD AIDS 2010;21:549-52. |
| 20. | Romoren M, Velauthapillai M, Rahman M, Sundby J, Klouman E, Hjortdahl P. Trichomoniasis and bacterial vaginosis in pregnancy: Inadequately managed with the syndromic approach. Bull World Health Organ 2007;85:297-304. |
| 21. | Kurewa NE, Mapingure MP, Munjoma MW, Chirenje MZ, Rusakaniko S, Stray-Pedersen B. The burden and risk factors of sexually transmitted infections and reproductive tract infections among pregnant women in Zimbabwe. BMC Infect Dis 2010;10:127. |
| 22. | Schwebke JR, Richey CM, Weiss2 HL. Correlation of behaviors with microbiological changes in vaginal flora. J Infect Dis 1999;180:1632-6. |
| 23. | Bump RC, Buesching WJ 3 rd. Bacterial vaginosis in virginal and sexually active adolescent females: Evidence against exclusive sexual transmission. Am J Obstet Gynecol 1988;158:935-9. |
| 24. | McDonald HM, O'Loughlin JA, Jolley PT, Vigneswaran R, McDonald PJ. Changes in vaginal flora during pregnancy and association with preterm birth. J Infect Dis 1994;170:724-8. |
| 25. | Donders G, De Wet HG, Hooft P, Desmyter J. Lactobacilli in Papanicolaou smears, genital infections, and pregnancy. Am J Perinatol 1993;10:358-61. |
[Table 1], [Table 2], [Table 3], [Table 4]
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