What is Gardnerella vaginalis. How does it relate to bacterial vaginosis. What are the risk factors for developing bacterial vaginosis. How is Gardnerella infection diagnosed and treated. What are the potential complications of untreated bacterial vaginosis.

The Microbiome of the Vagina: Gardnerella’s Role in Bacterial Vaginosis

Gardnerella vaginalis is an anaerobic bacterium that plays a significant role in the vaginal microbiome. While it can be part of the normal vaginal flora, an overgrowth of Gardnerella can lead to a condition known as bacterial vaginosis (BV). This common vaginal infection affects millions of women worldwide and is characterized by an imbalance in the vaginal bacterial ecosystem.

The vaginal microbiome is typically dominated by Lactobacillus species, which help maintain a healthy environment. However, when Gardnerella and other anaerobic bacteria proliferate, they can disrupt this delicate balance, leading to BV. This shift in the microbial community can cause various symptoms and potential health risks for affected women.

Key Facts About Gardnerella and Bacterial Vaginosis

• Gardnerella vaginalis was discovered in 1955 by Hermann L. Gardner
• BV is the most common cause of vaginal discharge in women of reproductive age
• Up to 50% of women may have Gardnerella present without symptoms of BV
• The prevalence of BV ranges from 5% to 70% in different populations
• African American women have a higher incidence of BV compared to Caucasian women

The Epidemiology of Gardnerella Infection and Bacterial Vaginosis

Understanding the prevalence and distribution of Gardnerella infection and BV is crucial for developing effective prevention and treatment strategies. Epidemiological studies have revealed interesting patterns in the occurrence of these conditions.

Is Gardnerella vaginalis always associated with bacterial vaginosis? No, studies have shown that G. vaginalis can be detected in up to 50% of women without symptoms of BV. This suggests that the presence of Gardnerella alone does not necessarily indicate an infection or imbalance in the vaginal microbiome.

The prevalence of BV varies widely across different populations, with estimates ranging from 5% to 70% of women. This variation may be due to factors such as ethnicity, socioeconomic status, sexual behaviors, and hygiene practices. Notably, African American women have been found to have a higher incidence of BV compared to Caucasian women, although the reasons for this disparity are not fully understood.

Pathophysiology: How Gardnerella Contributes to Bacterial Vaginosis

The development of bacterial vaginosis involves complex interactions between Gardnerella vaginalis and other microorganisms in the vaginal environment. Understanding these processes is essential for developing targeted treatments and preventive measures.

The Biofilm Theory

How does Gardnerella initiate the process of bacterial vaginosis? It is believed that G. vaginalis plays a crucial role in the early stages of BV by forming a biofilm. This biofilm serves as a foundation for other opportunistic bacteria to colonize and proliferate, leading to the characteristic microbial imbalance seen in BV.

Virulence Factors of Gardnerella

Gardnerella vaginalis possesses several virulence factors that contribute to its pathogenicity:

1. Vaginolysin: A pore-forming toxin specific to human cells
2. Proteases and sialidases: Enzymes that aid in bacterial invasion and colonization
3. Adhesion factors: Allow Gardnerella to compete with Lactobacilli for dominance

These virulence factors enable Gardnerella to adhere to vaginal epithelial cells, compete with beneficial bacteria, and create an environment conducive to the overgrowth of anaerobic microorganisms.

Clinical Presentation and Diagnosis of Gardnerella-Associated Bacterial Vaginosis

Recognizing the signs and symptoms of bacterial vaginosis is crucial for timely diagnosis and treatment. While some women may be asymptomatic, many experience characteristic symptoms that prompt them to seek medical attention.

Common Symptoms of Bacterial Vaginosis

• Thin, grayish-white vaginal discharge
• Fishy odor, especially after sexual intercourse
• Burning sensation during urination
• Itching or irritation in the vaginal area

How is bacterial vaginosis diagnosed? Diagnosis typically involves a combination of clinical assessment and laboratory tests. The presence of clue cells – vaginal epithelial cells covered with rod-shaped bacteria – is a hallmark of BV. Additionally, the Amsel criteria or Nugent scoring system may be used to confirm the diagnosis.

Diagnostic Criteria for Bacterial Vaginosis

The Amsel criteria require the presence of at least three of the following four signs:

1. Thin, homogeneous vaginal discharge
2. Vaginal pH greater than 4.5
3. Positive whiff test (fishy odor when potassium hydroxide is added to vaginal secretions)
4. Presence of clue cells on microscopic examination

The Nugent scoring system involves grading a Gram-stained vaginal smear based on the presence of different bacterial morphotypes, with a score of 7 or higher indicating BV.

Treatment Approaches for Gardnerella-Associated Bacterial Vaginosis

Effective treatment of bacterial vaginosis is essential to alleviate symptoms, restore the normal vaginal microbiome, and prevent potential complications. The primary goal of treatment is to reduce the overgrowth of anaerobic bacteria, including Gardnerella vaginalis, while promoting the recolonization of Lactobacilli species.

Antibiotic Therapy

What are the first-line treatments for bacterial vaginosis? The most commonly prescribed antibiotics for BV include:

• Metronidazole: Available as oral tablets or vaginal gel
• Clindamycin: Can be administered orally or as a vaginal cream
• Tinidazole: An oral antibiotic similar to metronidazole

The choice of antibiotic and route of administration depends on factors such as patient preference, adherence, and potential side effects. Treatment duration typically ranges from 5 to 7 days for oral medications and 3 to 5 days for vaginal preparations.

Alternative and Complementary Approaches

In addition to antibiotic therapy, several alternative and complementary approaches have been explored for managing BV:

• Probiotics: To restore and maintain a healthy vaginal microbiome
• Boric acid suppositories: May help in cases of recurrent BV
• Hydrogen peroxide vaginal douches: Limited evidence supports their use
• Lifestyle modifications: Such as avoiding douching and using condoms during sexual intercourse

While these approaches may provide some benefit, it’s important to note that they should not replace standard antibiotic treatment without consulting a healthcare provider.

Potential Complications and Health Risks Associated with Untreated Bacterial Vaginosis

Although bacterial vaginosis is often considered a mild condition, untreated cases can lead to various complications and increase the risk of other health problems. Understanding these potential risks underscores the importance of timely diagnosis and treatment.

Reproductive Health Complications

How does bacterial vaginosis affect pregnancy outcomes? Untreated BV during pregnancy has been associated with several adverse outcomes, including:

• Preterm birth
• Low birth weight
• Premature rupture of membranes
• Postpartum endometritis

These risks highlight the importance of screening and treating BV in pregnant women, particularly those with a history of preterm birth.

Increased Susceptibility to Sexually Transmitted Infections

Women with untreated bacterial vaginosis may be at higher risk for acquiring and transmitting certain sexually transmitted infections (STIs). This increased susceptibility is thought to be due to the disruption of the normal vaginal flora and changes in the vaginal environment.

STIs associated with increased risk in women with BV include:

• Human Immunodeficiency Virus (HIV)
• Herpes Simplex Virus (HSV)
• Chlamydia trachomatis
• Neisseria gonorrhoeae

The link between BV and increased STI risk underscores the importance of comprehensive sexual health care and regular screenings for women.

Prevention Strategies and Lifestyle Modifications for Reducing Gardnerella Overgrowth

While bacterial vaginosis can affect any woman of reproductive age, certain lifestyle factors and behaviors may increase the risk of developing this condition. By understanding these risk factors and implementing preventive measures, women can take proactive steps to maintain a healthy vaginal microbiome and reduce the likelihood of Gardnerella overgrowth.

Modifiable Risk Factors for Bacterial Vaginosis

Several factors have been associated with an increased risk of BV:

• Multiple sexual partners
• New sexual partner
• Lack of condom use
• Douching
• Smoking
• Use of intrauterine devices (IUDs)
• Frequent use of scented hygiene products

By addressing these modifiable risk factors, women can potentially reduce their risk of developing BV.

Preventive Measures and Healthy Habits

What steps can women take to maintain a healthy vaginal microbiome? Consider the following recommendations:

1. Practice safe sex: Use condoms consistently and limit the number of sexual partners
2. Avoid douching: This practice can disrupt the natural balance of vaginal bacteria
3. Use gentle, unscented hygiene products: Harsh soaps and scented products can irritate the vaginal area
4. Wear breathable underwear: Cotton underwear allows for better air circulation
5. Wipe from front to back: This helps prevent the introduction of bacteria from the anal area to the vagina
6. Consider probiotics: Some studies suggest that probiotic supplements may help maintain a healthy vaginal microbiome
7. Quit smoking: Smoking has been associated with an increased risk of BV

By incorporating these habits into their daily routines, women can promote a healthy vaginal environment and potentially reduce their risk of developing bacterial vaginosis.

The Role of the Interprofessional Team in Managing Gardnerella Infections

Effective management of Gardnerella infections and bacterial vaginosis requires a collaborative approach involving various healthcare professionals. An interprofessional team can provide comprehensive care, addressing not only the immediate symptoms but also the underlying factors contributing to recurrent infections and potential complications.

Key Members of the Interprofessional Team

• Primary Care Physicians: Often the first point of contact for women experiencing symptoms
• Obstetricians and Gynecologists: Specialists in women’s reproductive health
• Nurse Practitioners and Physician Assistants: May provide routine care and patient education
• Microbiologists: Assist in laboratory diagnosis and identification of pathogens
• Pharmacists: Provide guidance on medication use and potential drug interactions
• Sexual Health Counselors: Offer advice on safe sex practices and risk reduction

Improving Care Coordination and Patient Outcomes

How can the interprofessional team enhance the delivery of care for patients affected by Gardnerella infections? Consider the following strategies:

1. Regular team meetings to discuss complex cases and treatment strategies
2. Development of standardized protocols for diagnosis and treatment
3. Implementation of electronic health records to improve communication between team members
4. Ongoing education and training to stay updated on the latest research and guidelines
5. Patient-centered approach, involving women in decision-making about their care
6. Collaboration with public health departments for community education and screening programs

By working together, the interprofessional team can provide comprehensive care that addresses the multifaceted nature of Gardnerella infections and bacterial vaginosis, ultimately improving patient outcomes and quality of life.

Gardnerella – StatPearls – NCBI Bookshelf

Norah Kairys; Manish Garg.

Author Information and Affiliations

Last Update: August 1, 2022.

Continuing Education Activity

Gardnerella vaginalis is an anaerobic bacterium that is the causative agent in bacterial vaginosis (BV). This bacteria normally is part of the vaginal flora and any overgrowth can cause BV which is the most common cause of vaginal discharge. This activity reviews the evaluation and treatment of Gardnerella and explains the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the epidemiology of Gardnerella infection.

• Identify the typical patient history in those with Gardnerella infection.

• Review the use of antibiotics in the treatment of Gardnerella infection.

• Outline the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients affected by Gardnerella infection.

Access free multiple choice questions on this topic.

Introduction

Gardnerella vaginalis is an anaerobic bacterium that resides in the normal vaginal flora.[1] Normally, vaginal flora is predominated by the Lactobacilli species, but when organisms such as Gardnerella begin to overgrow and become the dominant species, this leads to bacterial vaginosis (BV).[1]
Gardnerella was named after Hermann L. Gardner, who discovered the bacterium in 1955.[1] The bacteria are thought to be sexually transmitted between partners and can create a biofilm that progresses into BV.[1] BV is the most common cause of vaginal discharge.[1] Of clinical consequence, BV is associated with preterm birth and increased risk for acquisition of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs).[1]

Etiology

Although Gardnerella is not considered to be contagious, the role of transmissibility is yet to be completely understood. [2] The spread of this bacteria among individuals through sexual intercourse may alter the natural balance of bacteria within the vagina, and this imbalance can even lead to the development of BV.[2] Typically, BV is caused by a decrease in the number of normal hydrogen peroxide-producing Lactobacilli with an overgrowth of anaerobic bacteria such as G. vaginalis.[2]

Historically, bacterial vaginosis was called G. vaginitis because it was believed that this bacterium caused the condition.[1] However, the newer name helps to highlight the fact that a variety of bacteria that naturally live in the vaginal canal may grow in excess and it is specifically this imbalance that causes this condition.

Factors that may play a role in the development of bacterial vaginosis include frequent tub baths, douching, multiple sex partners, use of over the counter intravaginal hygiene products and increased frequency of sexual intercourse.

Epidemiology

Studies have detected G. vaginalis in up to 50% of women even without symptoms of BV.[3] Thus it has been presumed that Gardnerella may be part of the normal vaginal flora.[3] Additionally, BV is the most common vaginal infection found in women of reproductive age and is estimated to occur in 5% to 70% of women.[3][4] Gardnerella has consistently been isolated as a key pathogen in BV, suggesting a high overall prevalence of Gardnerella in this population.[3]

BV is most common in African American women compared to Caucasians. The condition rarely develops n males. BV is a condition seen in women of reproductive age.

Pathophysiology

Although uncertain, it is thought that most BV infections start with a biofilm created by G. vaginalis which then allows other opportunistic bacteria to grow.[5] Bacterial vaginosis is characterized by the presence of clue cells, which are epithelial cells of the cervix that are covered with rod-shaped bacteria.[6]

G. vaginalis itself produces a pore-forming toxin, vaginolysin, that can only affect human cells. [6] Vaginolysin is a cholesterol-dependent cytolysin that initiates complex signaling cascades that induce target cell lysis and allow for Gardnerella’s virulence.[6] Additionally, protease and sialidase enzyme activities typically accompany this bacterium.[6] Gardnerella has the necessary virulence factors to adhere to host epithelia, which allows it to compete with Lactobacilli for dominance in the vaginal environment successfully.[6] The symptoms of BV are thought to be caused by an increase in normally dormant vaginal anaerobes that create symbiotic relationships with Gardnerella.[6]

Histopathology

Gardnerella is a non-spore-forming, non-motile Coccobacillus.[2] The bacterium can be grown to form small round gray colonies on both chocolate and Human Blood Tween agar.[7] A selective medium for Gardnerella is colistin-oxolinic acid blood sugar.[7]
Gardnerella has a thin gram-positive cell wall but is considered to be gram-variable because it can appear either gram-positive or gram-negative under the microscope due to the varying visibility of this thin cell wall. [7]

History and Physical

Women colonized with G. vaginalis are typically asymptomatic unless they have bacterial vaginosis.[8] Most women with BV present with a complaint of malodorous vaginal discharge, which often becomes more pronounced after sexual intercourse. A diagnosis of BV is suggested by a higher than normal vaginal pH (greater than 4.5), the presence of clue cells on a wet-mount slide, and a positive whiff test.[8] A drop of sodium chloride solution is placed on the wet-mount slide containing some of the swab specimens, and the slide is examined under the microscope for visualization of the characteristic clue cells.[9] The whiff test is performed by adding a small amount of potassium hydroxide (KOH) to the microscopic slide containing the vaginal discharge and is considered to be positive if a characteristic fishy-scent is revealed.[9] Typically, two of these positive tests, as well as the presence of the characteristic discharge, is enough to confirm the diagnosis of BV. [8] If no discharge is present, then all of these criteria are needed to make the diagnosis.[8]

Evaluation

Before the identification of the rapid identification method, the only way to isolate Gardnerella was by growing cultures on selective agar medium.[10] With the advent of the rapid identification method in 1982 (a micro-method based on starch and raffinose fermentation and hippurate hydrolysis), 91.4% of the strains of Gardnerella were able to be isolated without the need for culture and Gram stain.[10]

Occasionally a Gram stain of the vaginal fluid is still done to examine the predominant strain of bacteria to make a microbiological diagnosis of BV. This technique, referred to as Nugent criteria, has a sensitivity and specificity of 89% and 83%, respectively.[10]

Treatment / Management

Asymptomatic Gardnerella colonization does not need to be treated. It has even been reported that up to 30% of cases of BV may even resolve on its own without treatment. [1] However, if a patient is bothered by the symptoms of BV, or is pregnant, it should be treated with either oral or vaginal clindamycin or metronidazole.[1][11]Unfortunately, it has been shown that recurrence may occur in up to 80% of women after treatment.[1][12] If a patient presents with recurrent symptoms, a second course of antibiotics is typically prescribed.[1] A 2009 Cochrane review found tentative but insufficient evidence to support the use of probiotics as treatment or prevention of BV.[13]

Differential Diagnosis

A proper pelvic exam can help to narrow down the differntial diagnosis and exclude other similarly presenting diseases such as herpes simplex virus.[1] Speculum exam can look for cervicitis and a wet mount of the vaginal discharge can determine if there is candidiasis or trichomoniasis.[1] Additional cervical swab cultures can be sent for chlamydia and gonorrhea.[14] 

Prognosis

Most uncomplicated cases of bacterial vaginosis resolve with treatment. However, recurrences are not uncommon. Over time, BV is a risk factor for acquiring HIV. Over the past decade, there have been multiple reports of resistant strains that do not resolve with conventional treatment.

Complications

BV can lead to the following:

• Increased risk for endometritis and salpingitis

• Increased risk of post-surgery infections

• Adverse outcomes in pregnancy including premature labor, premature rupture of membranes and postpartum endometritis.

• Pelvic inflammatory disease

• Neonatal meningitis

Pearls and Other Issues

Untreated BV can lead to increased risk of pregnancy complications and STIs, including HIV.[14] Data also suggest an association between BV and both tubal factor infertility and pelvic inflammatory disease.[15] During pregnancy, BV has been associated with an increased risk of premature birth and miscarriage.[15] It also has been shown to increase the risk of chorioamnionitis, premature rupture of membranes and postpartum endometritis. [15]

Enhancing Healthcare Team Outcomes

Gardnerella is a common genital infection that is often encountered by the emergency department physician, nurse practitioner, internist, and the gynecologist.  Asymptomatic Gardnerella colonization does not need to be treated as nearly 30% of cases resolve spontaneously. All symptomatic patients need treatment but despite treatment, recurrences are common. 

Untreated BV can lead to increased risk of pregnancy complications and STIs, including HIV.[14] Data also suggest an association between BV and both tubal factor infertility and pelvic inflammatory disease.[15]

These patients need to be followed by the nurse practitioner until all symptoms have disappeared.

Even though BV is not a sexually transmitted infection, the nurse practitioner should educate the patient on the importance of safe sex measures, avoidance of multiple sex partners and use of barrier protection.

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Clue cells. Image courtesy S Bhimji MD

References

1.

Hartmann AA. [Gardnerella vaginalis infection. Clinical aspects, diagnosis and therapy]. Urologe A. 1987 Sep;26(5):252-5. [PubMed: 3318083]

2.

Schwebke JR, Muzny CA, Josey WE. Role of Gardnerella vaginalis in the pathogenesis of bacterial vaginosis: a conceptual model. J Infect Dis. 2014 Aug 01;210(3):338-43. [PubMed: 24511102]

3.

Kenyon CR, Osbak K. Recent progress in understanding the epidemiology of bacterial vaginosis. Curr Opin Obstet Gynecol. 2014 Dec;26(6):448-54. [PubMed: 25304606]

4.

Janulaitiene M, Paliulyte V, Grinceviciene S, Zakareviciene J, Vladisauskiene A, Marcinkute A, Pleckaityte M. Prevalence and distribution of Gardnerella vaginalis subgroups in women with and without bacterial vaginosis. BMC Infect Dis. 2017 Jun 05;17(1):394. [PMC free article: PMC5460423] [PubMed: 28583109]

5.

Machado A, Cerca N. Influence of Biofilm Formation by Gardnerella vaginalis and Other Anaerobes on Bacterial Vaginosis. J Infect Dis. 2015 Dec 15;212(12):1856-61. [PubMed: 26080369]

6.

Baruah FK, Sharma A, Das C, Hazarika NK, Hussain JH. Role of Gardnerella vaginalis as an etiological agent of bacterial vaginosis. Iran J Microbiol. 2014 Dec;6(6):409-14. [PMC free article: PMC4411427] [PubMed: 25926959]

7.

Hardy L, Jespers V, Dahchour N, Mwambarangwe L, Musengamana V, Vaneechoutte M, Crucitti T. Unravelling the Bacterial Vaginosis-Associated Biofilm: A Multiplex Gardnerella vaginalis and Atopobium vaginae Fluorescence In Situ Hybridization Assay Using Peptide Nucleic Acid Probes. PLoS One. 2015;10(8):e0136658. [PMC free article: PMC4548953] [PubMed: 26305575]

8.

Hartmann AA, Elsner P. [Gardnerella vaginalis infection–another sexually transmitted disease]. Hautarzt. 1984 Oct;35(10):512-6. [PubMed: 6389437]

9.

Elsner P, Hartmann AA, Wecker I. [Detection of Gardnerella vaginalis in the pathogen spectrum of sexually transmissible diseases in vulvovaginitis]. Z Hautkr. 1985 Nov 01;60(21):1655-62. [PubMed: 3907172]

10.

Catlin BW. Gardnerella vaginalis: characteristics, clinical considerations, and controversies. Clin Microbiol Rev. 1992 Jul;5(3):213-37. [PMC free article: PMC358241] [PubMed: 1498765]

11.

Menard JP. Antibacterial treatment of bacterial vaginosis: current and emerging therapies. Int J Womens Health. 2011;3:295-305. [PMC free article: PMC3181210] [PubMed: 21976983]

12.

Tosun I, Alpay Karaoğlu S, Ciftçi H, Buruk CK, Aydin F, Kiliç AO, Ertürk M. [Biotypes and antibiotic resistance patterns of Gardnerella vaginalis strains isolated from healthy women and women with bacterial vaginosis]. Mikrobiyol Bul. 2007 Jan;41(1):21-7. [PubMed: 17427549]

13.

Nagaraja P. Antibiotic resistance of Gardnerella vaginalis in recurrent bacterial vaginosis. Indian J Med Microbiol. 2008 Apr-Jun;26(2):155-7. [PubMed: 18445953]

14.

Elsner P, Hartmann AA, Wecker I. Gardnerella vaginalis is associated with other sexually transmittable microorganisms in the male urethra. Zentralbl Bakteriol Mikrobiol Hyg A. 1988 Jul;269(1):56-63. [PubMed: 3140532]

15.

Kasprowicz A, Białecka A. [Gardnerella vaginalis in infections of reproductive organs]. Med Dosw Mikrobiol. 1993;45(2):199-203. [PubMed: 8309297]

Disclosure: Norah Kairys declares no relevant financial relationships with ineligible companies.

Disclosure: Manish Garg declares no relevant financial relationships with ineligible companies.

Gardnerella – StatPearls – NCBI Bookshelf

Norah Kairys; Manish Garg.

Author Information and Affiliations

Last Update: August 1, 2022.

Continuing Education Activity

Gardnerella vaginalis is an anaerobic bacterium that is the causative agent in bacterial vaginosis (BV). This bacteria normally is part of the vaginal flora and any overgrowth can cause BV which is the most common cause of vaginal discharge. This activity reviews the evaluation and treatment of Gardnerella and explains the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the epidemiology of Gardnerella infection.

• Identify the typical patient history in those with Gardnerella infection.

• Review the use of antibiotics in the treatment of Gardnerella infection.

• Outline the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients affected by Gardnerella infection.

Access free multiple choice questions on this topic.

Introduction

Gardnerella vaginalis is an anaerobic bacterium that resides in the normal vaginal flora.[1] Normally, vaginal flora is predominated by the Lactobacilli species, but when organisms such as Gardnerella begin to overgrow and become the dominant species, this leads to bacterial vaginosis (BV). [1]
Gardnerella was named after Hermann L. Gardner, who discovered the bacterium in 1955.[1] The bacteria are thought to be sexually transmitted between partners and can create a biofilm that progresses into BV.[1] BV is the most common cause of vaginal discharge.[1] Of clinical consequence, BV is associated with preterm birth and increased risk for acquisition of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs).[1]

Etiology

Although Gardnerella is not considered to be contagious, the role of transmissibility is yet to be completely understood.[2] The spread of this bacteria among individuals through sexual intercourse may alter the natural balance of bacteria within the vagina, and this imbalance can even lead to the development of BV.[2] Typically, BV is caused by a decrease in the number of normal hydrogen peroxide-producing Lactobacilli with an overgrowth of anaerobic bacteria such as G. vaginalis.[2]

Historically, bacterial vaginosis was called G. vaginitis because it was believed that this bacterium caused the condition.[1] However, the newer name helps to highlight the fact that a variety of bacteria that naturally live in the vaginal canal may grow in excess and it is specifically this imbalance that causes this condition.

Factors that may play a role in the development of bacterial vaginosis include frequent tub baths, douching, multiple sex partners, use of over the counter intravaginal hygiene products and increased frequency of sexual intercourse.

Epidemiology

Studies have detected G. vaginalis in up to 50% of women even without symptoms of BV.[3] Thus it has been presumed that Gardnerella may be part of the normal vaginal flora.[3] Additionally, BV is the most common vaginal infection found in women of reproductive age and is estimated to occur in 5% to 70% of women.[3][4] Gardnerella has consistently been isolated as a key pathogen in BV, suggesting a high overall prevalence of Gardnerella in this population. [3]

BV is most common in African American women compared to Caucasians. The condition rarely develops n males. BV is a condition seen in women of reproductive age.

Pathophysiology

Although uncertain, it is thought that most BV infections start with a biofilm created by G. vaginalis which then allows other opportunistic bacteria to grow.[5] Bacterial vaginosis is characterized by the presence of clue cells, which are epithelial cells of the cervix that are covered with rod-shaped bacteria.[6]

G. vaginalis itself produces a pore-forming toxin, vaginolysin, that can only affect human cells.[6] Vaginolysin is a cholesterol-dependent cytolysin that initiates complex signaling cascades that induce target cell lysis and allow for Gardnerella’s virulence.[6] Additionally, protease and sialidase enzyme activities typically accompany this bacterium.[6] Gardnerella has the necessary virulence factors to adhere to host epithelia, which allows it to compete with Lactobacilli for dominance in the vaginal environment successfully. [6] The symptoms of BV are thought to be caused by an increase in normally dormant vaginal anaerobes that create symbiotic relationships with Gardnerella.[6]

Histopathology

Gardnerella is a non-spore-forming, non-motile Coccobacillus.[2] The bacterium can be grown to form small round gray colonies on both chocolate and Human Blood Tween agar.[7] A selective medium for Gardnerella is colistin-oxolinic acid blood sugar.[7]
Gardnerella has a thin gram-positive cell wall but is considered to be gram-variable because it can appear either gram-positive or gram-negative under the microscope due to the varying visibility of this thin cell wall.[7]

History and Physical

Women colonized with G. vaginalis are typically asymptomatic unless they have bacterial vaginosis.[8] Most women with BV present with a complaint of malodorous vaginal discharge, which often becomes more pronounced after sexual intercourse. A diagnosis of BV is suggested by a higher than normal vaginal pH (greater than 4. 5), the presence of clue cells on a wet-mount slide, and a positive whiff test.[8] A drop of sodium chloride solution is placed on the wet-mount slide containing some of the swab specimens, and the slide is examined under the microscope for visualization of the characteristic clue cells.[9] The whiff test is performed by adding a small amount of potassium hydroxide (KOH) to the microscopic slide containing the vaginal discharge and is considered to be positive if a characteristic fishy-scent is revealed.[9] Typically, two of these positive tests, as well as the presence of the characteristic discharge, is enough to confirm the diagnosis of BV.[8] If no discharge is present, then all of these criteria are needed to make the diagnosis.[8]

Evaluation

Before the identification of the rapid identification method, the only way to isolate Gardnerella was by growing cultures on selective agar medium.[10] With the advent of the rapid identification method in 1982 (a micro-method based on starch and raffinose fermentation and hippurate hydrolysis), 91. 4% of the strains of Gardnerella were able to be isolated without the need for culture and Gram stain.[10]

Occasionally a Gram stain of the vaginal fluid is still done to examine the predominant strain of bacteria to make a microbiological diagnosis of BV. This technique, referred to as Nugent criteria, has a sensitivity and specificity of 89% and 83%, respectively.[10]

Treatment / Management

Asymptomatic Gardnerella colonization does not need to be treated. It has even been reported that up to 30% of cases of BV may even resolve on its own without treatment.[1] However, if a patient is bothered by the symptoms of BV, or is pregnant, it should be treated with either oral or vaginal clindamycin or metronidazole.[1][11]Unfortunately, it has been shown that recurrence may occur in up to 80% of women after treatment.[1][12] If a patient presents with recurrent symptoms, a second course of antibiotics is typically prescribed.[1] A 2009 Cochrane review found tentative but insufficient evidence to support the use of probiotics as treatment or prevention of BV. [13]

Differential Diagnosis

A proper pelvic exam can help to narrow down the differntial diagnosis and exclude other similarly presenting diseases such as herpes simplex virus.[1] Speculum exam can look for cervicitis and a wet mount of the vaginal discharge can determine if there is candidiasis or trichomoniasis.[1] Additional cervical swab cultures can be sent for chlamydia and gonorrhea.[14] 

Prognosis

Most uncomplicated cases of bacterial vaginosis resolve with treatment. However, recurrences are not uncommon. Over time, BV is a risk factor for acquiring HIV. Over the past decade, there have been multiple reports of resistant strains that do not resolve with conventional treatment.

Complications

BV can lead to the following:

• Increased risk for endometritis and salpingitis

• Increased risk of post-surgery infections

• Adverse outcomes in pregnancy including premature labor, premature rupture of membranes and postpartum endometritis.

• Pelvic inflammatory disease

• Neonatal meningitis

Pearls and Other Issues

Untreated BV can lead to increased risk of pregnancy complications and STIs, including HIV.[14] Data also suggest an association between BV and both tubal factor infertility and pelvic inflammatory disease.[15] During pregnancy, BV has been associated with an increased risk of premature birth and miscarriage.[15] It also has been shown to increase the risk of chorioamnionitis, premature rupture of membranes and postpartum endometritis.[15]

Enhancing Healthcare Team Outcomes

Gardnerella is a common genital infection that is often encountered by the emergency department physician, nurse practitioner, internist, and the gynecologist.  Asymptomatic Gardnerella colonization does not need to be treated as nearly 30% of cases resolve spontaneously. All symptomatic patients need treatment but despite treatment, recurrences are common. 

Untreated BV can lead to increased risk of pregnancy complications and STIs, including HIV. [14] Data also suggest an association between BV and both tubal factor infertility and pelvic inflammatory disease.[15]

These patients need to be followed by the nurse practitioner until all symptoms have disappeared.

Even though BV is not a sexually transmitted infection, the nurse practitioner should educate the patient on the importance of safe sex measures, avoidance of multiple sex partners and use of barrier protection.

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

Figure

Clue cells. Image courtesy S Bhimji MD

References

1.

Hartmann AA. [Gardnerella vaginalis infection. Clinical aspects, diagnosis and therapy]. Urologe A. 1987 Sep;26(5):252-5. [PubMed: 3318083]

2.

Schwebke JR, Muzny CA, Josey WE. Role of Gardnerella vaginalis in the pathogenesis of bacterial vaginosis: a conceptual model. J Infect Dis. 2014 Aug 01;210(3):338-43. [PubMed: 24511102]

3.

Kenyon CR, Osbak K. Recent progress in understanding the epidemiology of bacterial vaginosis. Curr Opin Obstet Gynecol. 2014 Dec;26(6):448-54. [PubMed: 25304606]

4.

Janulaitiene M, Paliulyte V, Grinceviciene S, Zakareviciene J, Vladisauskiene A, Marcinkute A, Pleckaityte M. Prevalence and distribution of Gardnerella vaginalis subgroups in women with and without bacterial vaginosis. BMC Infect Dis. 2017 Jun 05;17(1):394. [PMC free article: PMC5460423] [PubMed: 28583109]

5.

Machado A, Cerca N. Influence of Biofilm Formation by Gardnerella vaginalis and Other Anaerobes on Bacterial Vaginosis. J Infect Dis. 2015 Dec 15;212(12):1856-61. [PubMed: 26080369]

6.

Baruah FK, Sharma A, Das C, Hazarika NK, Hussain JH. Role of Gardnerella vaginalis as an etiological agent of bacterial vaginosis. Iran J Microbiol. 2014 Dec;6(6):409-14. [PMC free article: PMC4411427] [PubMed: 25926959]

7.

Hardy L, Jespers V, Dahchour N, Mwambarangwe L, Musengamana V, Vaneechoutte M, Crucitti T. Unravelling the Bacterial Vaginosis-Associated Biofilm: A Multiplex Gardnerella vaginalis and Atopobium vaginae Fluorescence In Situ Hybridization Assay Using Peptide Nucleic Acid Probes. PLoS One. 2015;10(8):e0136658. [PMC free article: PMC4548953] [PubMed: 26305575]

8.

Hartmann AA, Elsner P. [Gardnerella vaginalis infection–another sexually transmitted disease]. Hautarzt. 1984 Oct;35(10):512-6. [PubMed: 6389437]

9.

Elsner P, Hartmann AA, Wecker I. [Detection of Gardnerella vaginalis in the pathogen spectrum of sexually transmissible diseases in vulvovaginitis]. Z Hautkr. 1985 Nov 01;60(21):1655-62. [PubMed: 3907172]

10.

Catlin BW. Gardnerella vaginalis: characteristics, clinical considerations, and controversies. Clin Microbiol Rev. 1992 Jul;5(3):213-37. [PMC free article: PMC358241] [PubMed: 1498765]

11.

Menard JP. Antibacterial treatment of bacterial vaginosis: current and emerging therapies. Int J Womens Health. 2011;3:295-305. [PMC free article: PMC3181210] [PubMed: 21976983]

12.

Tosun I, Alpay Karaoğlu S, Ciftçi H, Buruk CK, Aydin F, Kiliç AO, Ertürk M. [Biotypes and antibiotic resistance patterns of Gardnerella vaginalis strains isolated from healthy women and women with bacterial vaginosis]. Mikrobiyol Bul. 2007 Jan;41(1):21-7. [PubMed: 17427549]

13.

Nagaraja P. Antibiotic resistance of Gardnerella vaginalis in recurrent bacterial vaginosis. Indian J Med Microbiol. 2008 Apr-Jun;26(2):155-7. [PubMed: 18445953]

14.

Elsner P, Hartmann AA, Wecker I. Gardnerella vaginalis is associated with other sexually transmittable microorganisms in the male urethra. Zentralbl Bakteriol Mikrobiol Hyg A. 1988 Jul;269(1):56-63. [PubMed: 3140532]

15.

Kasprowicz A, Białecka A. [Gardnerella vaginalis in infections of reproductive organs]. Med Dosw Mikrobiol. 1993;45(2):199-203. [PubMed: 8309297]

Disclosure: Norah Kairys declares no relevant financial relationships with ineligible companies.

Disclosure: Manish Garg declares no relevant financial relationships with ineligible companies.

Bacterial vaginosis (gardnerellosis)

Gynecology

Bacterial vaginosis is a vaginal dysbacteriosis, a condition in which the correct ratio of microorganisms that normally live in the vagina is disturbed. Especially unpleasant is the situation in which the proportion of lactic bacteria decreases and other microflora grows. Gardnerella also belongs to this “other”, therefore bacterial vaginosis is sometimes called gardnerellosis. Bacterial vaginosis (gardnerellosis)
It should be said right away that bacterial vaginosis is not an infection: it is not transmitted from person to person in any way, and this condition does not require the treatment of your partner. There are also no external signs of inflammation: there is neither redness of the mucous membranes, nor swelling and bleeding. And so this condition is called “vaginosis” and not “vaginitis.” Normally, the vagina maintains an acidic, oxygen-rich environment that is favorable for the reproduction of lactic acid bacteria. When environmental conditions change – a decrease in oxygen and alkalization, lactic bacteria are replaced by those for whom these conditions are favorable: gardnerella and other bacteria that live in an alkaline environment and do not use oxygen.

Bacterial vaginosis can be caused by:

• wearing tight-fitting synthetic underwear, tight-fitting synthetic trousers, i.e. creation of obstacles for the penetration of oxygen;
• abuse of panty liners and tampons for the same reason;
• long-term use of antibiotics that are harmful to lactic acid bacteria;
• malnutrition – a lack of fermented milk products in the diet, which are a source of lactic acid bacteria for the body;
• chronic bowel disease and other conditions causing general dysbacteriosis;

Bacterial vaginosis is usually manifested by vaginal discharge – whitish-gray, homogeneous, sticky, with a sharp unpleasant “fishy” odor. There is no point in conducting a PCR study for gardnerellosis. The diagnosis is made on the basis of complaints, features of the discharge and the results of bacterioscopy. With bacterial vaginosis, a characteristic change in the vaginal flora occurs: the predominance of “small” lactic bacteria over the normal bacterium and the presence of the so-called. “key” cells (epithelial cells covered with a “small” stick), characteristic only and precisely for bacterial vaginosis. More precisely, the nature of vaginosis is determined using bacteriological culture, in which the quantitative ratio of lactic bacteria, gardnerella and other bacteria is determined. This method is especially useful for monitoring the effectiveness of the treatment.

The first stage of such treatment is to suppress the excess amount of “bad” bacteria, and the second is to populate the vacated niche with “good” ones. For this, drugs are first used against anaerobic (oxygen-free) bacteria: mainly locally in the form of suppositories and gels, but sometimes systemically, by ingestion. Only the woman is treated, because, we repeat: vaginosis is not an infection and is not sexually transmitted.

The second stage is the colonization of the vagina with lactic acid bacteria. A diet with a high content of them (biokefirs, yogurts, sauerkraut), preparations of lactic bacteria (lactobacterin, acylact, Narine) inside and locally – various suppositories, gels is prescribed. The appointment of lactic acid bacteria preparations is possible only after repeated tests and the conviction that the patient does not have vaginal candidiasis (fungal colpitis or “thrush”), which often develops during the treatment of vaginosis and then progresses well in an acidic environment, together with lactic acid bacteria.

In parallel, you should be examined for intestinal dysbacteriosis and, if necessary, correct it. Dysbacteriosis rarely develops in isolation and “from scratch”; as a rule, this is a process common to the body, which has its own causes and predisposing factors. If these are not eliminated, it will either remain or arise again, giving the impression of “wrong treatment”.

So, lovely women:

• if you suddenly have a slight discharge, accompanied by a sharp unpleasant odor, do not rush to accuse your partner of cheating or sin on “an infection in the pool”;

• refuse for a while from pads “for every day”, which mask problems, giving them time to progress, and also violate the oxygen regime.

• go to the gynecologist and examine the smear results;

• if you are diagnosed with bacterial vaginosis, follow the indicated instructions, enrich your diet with lactic acid products.

• during treatment, sexual activity is possible; it is necessary to protect yourself when taking drugs inside (since they are contraindicated in pregnancy). Any method of protection, but if you use oral contraceptives, remember that their effectiveness is reduced while taking antibiotics.

• after treatment, you need to take a second smear and follow the measures to prevent relapse.

Dear Men:

• If you suspect that your partner has some gynecological disorders, force her not to self-medicate and not to delay contacting a qualified specialist of our “LeVita” Clinic.

• If your partner has been diagnosed with bacterial vaginosis (gardnerellosis), know that this condition is not infectious, it is not transmitted in any way, including sexually. However, this does not prevent you from undergoing an examination too – other diseases may be detected in parallel.

• You do not need to be treated for gardnerellosis. However, there are cases when, along with gardnerellosis, a real infection is already detected. But then both partners need to be treated, according to all the rules for the treatment of STDs: simultaneously, with the same drugs, protected by a condom, until positive treatment results (control smears) are obtained.

• sexual life during the treatment of vaginosis is possible without restrictions.

Gardnerellosis (bacterial vaginosis) treatment consultation in St. Petersburg at the clinic ID-CLINIC

Gardnerellosis (bacterial vaginosis) treatment consultation in St. Petersburg at the ID-CLINIC clinic

• Medical appointments

• Syphilidologist
• INFECTIONIST
• Dermatologist
• Therapist
• Cardiologist
• Oncologist
• Endocrinologist
• Neurologist
• Medical certificates
• Ultrasound diagnostics – Ultrasound
• Functional diagnostics
• Urologist
• Venereologist
• Parasitologist
• Mammologist
• All services

• Diagnosis

• Gynecology
• Dermatovenereology
• Cardiology
• Neurology
• Oncology
• Therapy
• Urology
• Endocrinology
• Infectology

• Treatment

• A
• B
• to
• G
• D
• E
• Yo
• F ​​
• W
• and
• Y
• K
• L
• M
• H
• O
• P
• R
• C
• T
• W
• F ​​
• X
• C
• H
• W
• W
• E
• Yu
• I

COVID

Full range of medical care for viral infection COVID

CHECK-UP

Full range of complex medical diagnostics

Tests

take tests at affordable prices

Drugs 9000 3

specialized pharmacy

online

specialist consultation

DISCOUNTS

Only profitable offers for you!

St. Petersburg, Ivana Chernykh st., 25A

Mon.-Sat. from 9:00 – 20:00, sun. from 10:00 – 18:00

• home
• •
• Treatment
• •
• G
• •

• Gardnerellosis (bacterial vaginosis)

EXPERT ASSISTANCE

• herpes viruses
• human papillomavirus
• viral hepatitis
• mycobacteriosis
• HIV infection
• intrauterine, parasitic and other infectious diseases

Bacterial vaginosis is the most common gynecological problem in women. This term is understood as a violation of the microflora of the vagina with a predominance of opportunistic bacteria. Since the main role in the development of the disease is played by the microorganisms Gardnerella vaginalis, the disease is often called gardnerellosis. However, bacterial vaginosis is a broader concept that includes all types of vaginal dysbiosis.

Normal vaginal flora

More than 95% of vaginal microorganisms are lactobacilli – Dederlein’s rods. They maintain the correct level of acidity in the vagina, prevent the growth of anaerobic flora. Opportunistic microorganisms are a small part of the microflora, they cannot actively multiply and do not cause problems. If this balance is disturbed, the woman suffers from the symptoms of bacterial vaginosis.

Causes of gardnerellosis

The disease is not transmitted sexually. Its development requires a combination of several provoking factors:
● long-term antibiotic therapy, insertion of antimicrobial suppositories into the vagina
● violation of the rules of intimate hygiene
● wearing synthetic underwear
● use of scented personal care products
● Abuse of douching without medical indications
● reduced immunity, chronic somatic diseases

How to recognize gardnerellosis

The hallmark of bacterial vaginosis is abundant gray vaginal discharge with a typical fish odor. At the same time, there is a burning sensation and itching in the intimate area, discomfort during urination. Penetrating sexual intercourse causes discomfort and soreness in a woman. The disease can occur in acute or chronic form. Chronic gardnerellosis is distinguished by an erased clinical picture, periodically causing exacerbations.

Make an appointment

St. Petersburg, Ivan Chernykh st., 25A

Mon-Sat 09.00-20.00, Sun 10.00-18.00

By clicking on the “Sign up” button you agree to the processing of personal data

Online consultation

Convenient way,

at your convenience

By clicking on the “Sign up” button you agree to the processing of personal data

Complications of bacterial vaginosis

In addition to discomfort, untreated gardnerellosis can bring many problems:
● increases the risk of contracting sexually transmitted infections and exacerbates their course
● complicated by bacterial or fungal vulvovaginitis
● promotes the transfer of infection to the overlying parts of the reproductive system – the cervix and body of the uterus, fallopian tubes, ovaries
● in pregnant women, it can provoke miscarriage, premature birth, impaired intrauterine development of the fetus

Which doctor to contact

Vaginal discomfort and discharge – indications for a consultation with a gynecologist. It is recommended not to delay a visit to a specialist in order to identify the disease at an early stage and avoid serious consequences. An ID-Clinic gynecologist conducts a face-to-face appointment: finds out complaints and the history of the development of the disease, examines the patient on the chair, and takes biomaterial for analysis. The doctor also consults online – gives general recommendations, selects a diagnostic plan, adjusts the treatment.

Criteria for diagnosis of gardnerellosis

● Thick grayish-white discharge that evenly covers the vaginal mucosa
● increased acidity in the vagina over 4.5
● Pungent smell of rotten fish during pathognomonic examination with 10% potassium hydroxide
● microscopy of “key cells” in the examination of the vaginal smear

Treatment of gardnerellosis

Therapy is carried out in all acute forms of the disease and in asymptomatic bacterial vaginosis, if a woman is prescribed invasive manipulations, gynecological operations. Effective treatment of the problem is carried out in 2 stages:
● topical antibacterial therapy – vaginal suppositories and tablets
● restoration of vaginal microflora – suppositories with lactobacilli, vaginal probiotics

Make an appointment with a doctor

Consultation with an ID-Clinic gynecologist is available by appointment. To choose a convenient time, leave a request in the online form and wait for a call from our administrator.

Cost of clinic services

Inspection

Get service

Analyzes

Get service

Other clinic services

Online consultation with a gynecologist

• SmirnovaUlyana Sergeevna

  Gynecologist,
  Sexologist

  Make an appointment

• GolovanovaVeronika Anatolyevna

  Gynecologist,
  Mammologist,
  Oncogynecologist,
  Gynecologist-Endocrinologist,
  Ultrasound Doctor,
  PhD

  Make an appointment

• Elena Vertiletskaya

  Gynecologist,
  Gynecologist-endocrinologist,
  Doctor of the highest category

  Make an appointment

All specialists

Read reviews

Promotions and special offers

Stories and reviews of our patients

Sergey Vyacheslavovich

The reception was wonderful, about K. Yu. Krotov. I can say that he is a good doctor, tactful, correct. I was diagnosed with the initial stage of cancer, the doctor examined me, looked at the tests and said that I had no cancer, no stage, thus saving me from an unnecessary diagnosis. Now I am undergoing correct treatment for a different diagnosis.

Specialist:
Krotov Kirill Yurievich

User NaPopravku

Wonderful clinic professionally, qualitatively, doctor virologist Svetlana Alexandrovna Zvontsova sensitive Doctor professional attentive approach to the patient!! We will be treated in the clinic.

Specialist:
Zvontsova Svetlana Alexandrovna

Anonymous

Attentive doctor. Pleasant atmosphere at the reception, worries about the patient and is delicate. don’t be ashamed of your problem. Appointments are all given and helped in solving my problem, explained everything. I recommend. Very good doctor!

Specialist:
Ulitko Tatyana Vladimirovna

Prodoctors

My mother was in the oncological dispensary at the 5th department, Krotov was her attending physician. I would like to express my gratitude to the doctor for the competent medical care of my mother and the moral support he gave her during her long stay in the hospital. Mom believes that she was lucky with the doctor in charge, and I share this opinion, since I personally also talked several times with Kirill Yuryevich, inquired about the mother’s condition. He is a great professional and a great person.

Specialist:
Krotov Kirill Yurievich

The doctor is wonderful. Good girl. I have been with him for four months. Pulled me out of the world. Thanks to him endlessly.

Specialist:
Savchenko Mikhail Andreevich

User (On the Correction)

I am doing a Medical pedicure with Dr. Bortuleva V.V. – I recommend this doctor / previously put BS-plates in a course – the procedure is effective! In the ID-clinic doctors are of a high category and the Clinic is equipped with high-quality equipment.

Specialist:
Bortuleva Victoria Valerievna

Prodoctorov

I have been here before, but today I brought my mother and at the same time donated blood for antibodies to covid-19. I don’t have the best veins, but the nurse is amazing. Fast, painless! Mom was at the appointment with the infectious disease specialist Savchenko M.A. The doctors are knowledgeable, the administrators are polite, the environment is beautiful.

User (NaPopravku)

Registered for vaccination against coronavirus Sputnik Light. Everything went well, hosted by Efimov Georgy Aleksandrovich. I liked everything, the doctor was very attentive, measured the pressure, temperature, got vaccinated, I endured it easily. And, perhaps, I will also sign up for the next vaccination in this medical center.

Specialist:
Efimov Georgy Alexandrovich

User (SberHealth)

Anna Borisovna attentive, polite, competent and professional doctor. Pleasant to talk to, calm. My treatment is long-term and I think everything is going well. This is not the first time I have come. I wish Anna Borisovna good luck.

Specialist:
Balandina Anna Borisovna

Dmitry

I have a good impression of Dr.