BACTERIAL VAGINOSIS IN MARRIED FEMALE HOSPITAL POPULATION

Abstract

terial vaginosis is a major health issue of females in reproductive age group. The study population comprised of 332 symptomatic married females with vaginal discharge. Patients selected randomly at Gynecology and Obstetrics out-patient department of Holy Family Hospital Rawalpindi. Mean age of 28.01 ± 0.29 years of female patients presented with different symptoms of vaginal discharge. Maximum number of patients presented with low backache (83.73%), lower abdominal pain (81.62%), rash/itching (70.78%), unwell feeling (68.67%), Pain in thighs (68.37%).The lowest symptom observed were dysparunia (50.90%), feverish feeling (22.89%) and intermenstural bleeding in least number of patients (13.85%). Commonest combination of symptoms observed was low backache with lower abdominal pain (72.28%) and along with rash/itching (53.61%). The least observed combination was dysparunia with intermenstural bleeding (8.73%). The patients were clinically ascertained with vaginal examination for the variation in the color, consistency and smell of vaginal discharge. Whitish (41.56%), translucent (21.38%), yellowish (12.95%) and clear (24.09%) color of vaginal discharge was observed. Consistency of discharge varied from thick and homogenous (45.18%), to watery (24.69%) and normal viscous (30.12%) discharge. Along with color and consistency smell was observed as foul smelling (40.66%), pungent (15.05) and no particular odor (44.27%). A non significant negative trend with increase in age was observed on the clinical observations according to age groups. Patients were assessed for the condition of the cervix which appeared as healthy (16.26%), red and swollen (31.32%), red and swollen with ectopy (50%) and healthy with ectopy (2.40%). The condition of the cervix was analyzed for the color, consistency and smell of vaginal discharge which was highly significant (P<0.0001) for the smell of discharge. Bacterial vaginosis which is a clinical entity was diagnosed depending on the clinical and laboratory parameters implementing Amsel Clinical Criteria and Nugent Scoring System. According to Amsel criteria 24.69% patients were positive for BV. Parameters of Amsel criteria, Clue cells (37.34%), pH >4.5 (57.22%), homogenous vaginal discharge (45.16%) and Amine odor or whiff test (40.66%) were observed. Patients fulfilling three parameters were 15.96% and all four parameters were 8.73%. According to the age groups all parameters of Amsel analysis observed showed a non significant negative trend. With Nugent scoring system BV was analyzed in 42.16% patients. The bacterial morphotypes, Lactobacillus spp, Gardnerella vaginalis and Mobiluncus spp., were calculated and scored according to Nugent scoring. Patients considered as normal or negative were falling between score 0-3 were 57.83%, whereas patients considered as intermediate as positive were between the score 4-6 were 25% and patients with >7 score were 17.15%. Different parameters which included clue cells, epithelial cells, polymorphnuclear neutrophils, Lactobacilli spp, Gardnerella vaginalis , Mobiluncus spp. and pH of vaginal discharge according to the condition of cervix have important role in the identification of different infections in the patients. These parameters were calculated on direct vaginal smear and even distribution was observed in all conditions of cervix with exception of Mobiluncus spp, significant difference (P<0.04) was observed in comparison between healthy and healthy with ectopy. Vaginal, cervical and fundal 14 characteristics of patients were assessed, in relation to the number of polymorphnuclear neutrophils. It was observed that majority of patients fall in the category of 6-15 and 26- 35+ PMN on direct smear gram staining (x1000 magnification) with various vaginal, cervical and fundal conditions which were not significant. High vaginal and endocervical swabs obtained were studied for microorganisms present in the vaginal discharge. All samples were inoculated on different culture media’s and different isolates were obtained after incubation under aerobic conditions except for Neisseria gonorrheae which required anaerobic condition. Total single bacterial isolates obtained were 59.03%, Fungal (Candidiasis) 17.16%, Mixed growth (bacterial and fungal) 11.14% and no growth was 12.65%. Single isolates obtained were Escherichia coli (25%), Candida spp. (17%), Klebsiella spp. (10%), Neisseria gonorrheae (9%), Streptococcus agalactiae (7%), Staphylococcus aureus (4%) and Pseudomonas aeruginosa (3%). Among the mixed isolates Escheriachia coli + Candida spp. (6%), Streptococcus agalactiae + Candida spp. (3%), Staphylococcus + Candida spp. (2%). According to the age group 27-31 years of patients had maximum number of various isolates. All isolates identified were tested against various groups of antibiotics for the sensitivity, resistance and intermediate sensitivity. Various groups of antibiotics used were Pencillin (Ampicillin, Tazocin/Pipracillin), Macrolide (Erythromycin), Aminoglycoside (Gentamycin), Tetracyclin, Carbepenem (Imepenum), Quinolones (Ciprofloxacin, Levofloxacin) and Cephalosporins (Cefixime, Cefotaximine, Ceftazadime, Ceftraxone). Sensitivity pattern revealed that all isolates showed good sensitivity to Imepenum, Ciprofloxacin, Levofloxacin and cephalosporins. Sensitivity pattern to all conventional drugs gave more resistance as compared to sensitive effect of drugs. Effect of vaginal discharge in different phases of menstrual cycle, hygienic practices and various related features associated to different bacterial and fungal infection was observed. It became apparent that vaginal discharge increased in 88.55% of patients in the luteal phase mostly in bacterial infection 52.40%. The discharge decreased in follicular phase (51.20%) and ovulatory phase (37.34%). Patients with candidiasis and mixed vaginal infection complained of lesser amount of discharge in all phases of menstrual cycle. The use of various sanitary pads in vaginal infection was an important factor. Bacterial infection was prevalent among patients using different types of sanitary pads. However use of Always showed that bacterial infection was least compared to cotton or cloth. Infections with different organisms was observe due to different bathing and cloth changing habit which was highly significant (P<0.001). Majority of patients 77.71% complained of increased discharge due to coitus and standing and strenuous work 76.80%. Lesser number of patients observed to have discharge due to excitement (26.20%) and tension and anxiety (24.36%). Number of episodes regarding recurrent infections was significant (P<0.03). Whereas, duration of infection and any previous treatment for the infection was not significant. Sexually transmitted infections Chlamydia trachomatis IgG and IgM was observe in serum in 182 patients and Neisseria gonorrheae on Thayer Martin Media in 332 patients. It was observed as Gonorrheae was 9.33%, IgG was 36.81% and IgM was 39.01%. Combined infection (18%) was observed out of 182 patients. It was also 15 observed that majority of patients with IgG (17.50%) and IgM (15.93%) in the age group 22-26 years and IgG (11.53%), IgM (9.89%) in the age group 27-31 years respectively. Interestingly majority of patients had matric level education and the second highest percentage was observed in graduates and patients with no schooling. The economics also had important role as the financial level increased the sexually transmitted infections decreased. The most common symptom with which the patient positive with Chlamydial infection presented was low backache followed by un-well feeling and rash/ itching. Least common complaint was dysparunia and intermenstural bleeding. The most common color observed was whitish and translucent and normal clear was observed in lesser number of patients. Majority of patients had thick and homogenous vaginal discharge with red and swollen cervix along with cervical friability. All infections, Chlamydial, gonococcal, bacterial and fungal singly and as mixed infection were assessed on patients educational status and husbands income. It was observed as the economic status increased the educational status increased and was highly significant (P<0.0001). Chlamydial infection (P<0.02), Bacterial infection (P<0.0001) and fungal infection (P<0.0001) singly decreased with advancing education and economic status. Gonococcal infection was not significant among the groups. Among co-infections Bacterial + Candida infection (P<0.0004), Bacterial + Chlamydial infection (P<0.006) and patients with no infection (P<0.0005) was observed as the educational status and economic status increased the infection decreased. Patients were calculated for the outcome of conception which live births (64.61%) and pregnancy loss (35.38%). In the pregnancy loss highest percentage was of abortion (22.30%). Maximum percentage of live births 44.61% was observed in patients with bacterial and Candida infection while pregnancy loss was also highest in these patients, which was 22.30%. Among these patients majority had abortions 14.10% (n=110) and miscarriage, still birth and ectopic pregnancy were less in number. Spoken information regarding the husband’s symptoms, sexual partners and any addiction was gathered from the females coming to the outpatient department with vaginal discharge. It was observed that females who were suffering from various infections, Chlamydial (36.18%), Gonorrhea (9.33%) and Bacterial vaginosis (42.16%), their husbands had complaints regarding urethral discharge. High percentage of female patients with gonorrhea, their husband (58.06%) had complained of urethral discharge and out of these male partners 35.48% had ulcer on urethra and of these male partners 83.87% had more than one sexual partner. The second highest percentage of urethral discharge (40.12%) and ulcer on urethra (14.92%) was informed in male partners of patients positive with Chlamydial infection, these partners (43.28%) had more than one sexual partner. The lowest percentage of male partner problem was seen in patients with Bacterial vaginosis (37.14%). Of these, 47.14% had more than one sexual partner. It was concluded that all patient attending the out-patient department with variable complaints of vaginal discharge `had some kind of infection, Bacterial vaginosis, Bacterial vaginitis or a sexually transmitted infection or a combination of infections with resistance to conventional drugs and effect