What is Gardnerella vaginalis. How does it cause bacterial vaginosis. What are the risk factors for BV. How is bacterial vaginosis diagnosed and treated. What complications can arise from untreated BV.

Understanding Gardnerella Vaginalis and Its Role in Bacterial Vaginosis

Gardnerella vaginalis is an anaerobic bacterium that plays a significant role in the development of bacterial vaginosis (BV), the most common cause of vaginal discharge in women of reproductive age. Named after Hermann L. Gardner, who discovered it in 1955, this microorganism is a normal part of the vaginal flora. However, when it overgrows and becomes the dominant species, it can lead to BV, a condition associated with various health complications.

What is Gardnerella vaginalis?

Gardnerella vaginalis is a non-spore-forming, non-motile coccobacillus that can be found in the vaginal microbiome of many women. It is considered gram-variable, meaning it can appear either gram-positive or gram-negative under microscopic examination. This bacterium can be cultured on specific media, forming small, round, gray colonies on chocolate and Human Blood Tween agar.

How prevalent is Gardnerella vaginalis?

Studies have detected G. vaginalis in up to 50% of women, even in those without symptoms of BV. This high prevalence suggests that Gardnerella may be part of the normal vaginal flora in many women. However, when it comes to bacterial vaginosis, the prevalence varies widely, with estimates ranging from 5% to 70% of women being affected.

The Pathophysiology of Bacterial Vaginosis

Bacterial vaginosis occurs when there is an imbalance in the vaginal microbiome. Normally, the vaginal flora is dominated by Lactobacilli species, which help maintain a healthy vaginal environment. However, when Gardnerella vaginalis and other anaerobic bacteria overgrow, it can lead to BV.

How does Gardnerella vaginalis contribute to BV?

Gardnerella vaginalis is thought to play a key role in initiating the development of BV. It creates a biofilm that adheres to the vaginal epithelium, allowing other opportunistic bacteria to grow. This biofilm formation is believed to be the first step in the progression of BV.

What are the virulence factors of Gardnerella vaginalis?

• Vaginolysin: A pore-forming toxin that specifically affects human cells
• Protease and sialidase enzymes: Contribute to the bacterium’s virulence
• Adherence factors: Allow Gardnerella to compete with Lactobacilli for dominance in the vaginal environment

These virulence factors enable Gardnerella vaginalis to establish itself in the vaginal microbiome and contribute to the symptoms associated with BV.

Risk Factors and Transmission of Gardnerella Vaginalis

While Gardnerella vaginalis is not considered strictly contagious, its role in transmission is not fully understood. Sexual activity appears to play a role in altering the vaginal microbiome, potentially leading to BV.

What factors increase the risk of developing BV?

• Frequent tub baths
• Douching
• Multiple sexual partners
• Use of over-the-counter intravaginal hygiene products
• Increased frequency of sexual intercourse

It’s important to note that BV is more common in African American women compared to Caucasian women, and it primarily affects women of reproductive age.

Diagnosis and Clinical Presentation of Bacterial Vaginosis

Bacterial vaginosis is characterized by specific clinical findings and laboratory tests. Understanding these diagnostic criteria is crucial for proper identification and treatment of the condition.

What are the key diagnostic features of BV?

The presence of clue cells is a hallmark of bacterial vaginosis. These are epithelial cells from the cervix that are covered with rod-shaped bacteria, giving them a distinctive appearance under microscopic examination.

How is BV diagnosed in clinical practice?

Diagnosis of BV typically involves a combination of clinical symptoms and laboratory tests. The Amsel criteria are commonly used, which include:

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

At least three of these criteria must be present for a diagnosis of BV to be made.

Treatment Approaches for Bacterial Vaginosis

Effective treatment of bacterial vaginosis is essential to alleviate symptoms and prevent potential complications. The primary goal of treatment is to restore the normal balance of vaginal flora.

What are the recommended treatments for BV?

The most common treatments for bacterial vaginosis include:

• Metronidazole: Oral or intravaginal formulations
• Clindamycin: Oral or intravaginal formulations
• Tinidazole: An oral alternative to metronidazole

Treatment duration typically ranges from 5 to 7 days, depending on the specific medication and formulation used.

Are there any alternative or complementary treatments for BV?

While antibiotics remain the primary treatment for BV, some research has explored alternative approaches:

• Probiotics: To help restore beneficial vaginal bacteria
• Boric acid suppositories: May help in recurrent cases
• Lifestyle modifications: Such as avoiding douching and using condoms during sexual intercourse

It’s important to note that these alternative treatments should be discussed with a healthcare provider before use.

Complications and Long-term Implications of Untreated BV

Bacterial vaginosis, if left untreated, can lead to various health complications, particularly in pregnant women and those at risk for sexually transmitted infections.

What are the potential complications of untreated BV?

• Increased risk of preterm birth in pregnant women
• Higher susceptibility to sexually transmitted infections, including HIV
• Increased risk of pelvic inflammatory disease
• Possible complications following gynecological surgeries

These potential complications underscore the importance of timely diagnosis and treatment of bacterial vaginosis.

How does BV affect pregnancy outcomes?

Bacterial vaginosis during pregnancy has been associated with an increased risk of preterm birth, low birth weight, and other adverse pregnancy outcomes. For this reason, screening and treatment of BV in pregnant women, especially those with a history of preterm birth, is often recommended.

Prevention Strategies and Maintaining Vaginal Health

While it may not always be possible to prevent bacterial vaginosis, certain strategies can help maintain a healthy vaginal environment and reduce the risk of BV.

What steps can women take to reduce their risk of developing BV?

• Avoid douching and the use of scented vaginal products
• Practice safe sex and limit the number of sexual partners
• Use condoms consistently during sexual intercourse
• Maintain good hygiene practices, but avoid over-cleaning the vaginal area
• Consider probiotic supplements or foods to support vaginal health

It’s important to remember that while these strategies may help, they do not guarantee prevention of BV, as the condition can occur even in women who follow these recommendations.

How can recurrent BV be managed?

For women who experience recurrent episodes of bacterial vaginosis, management strategies may include:

• Extended or suppressive antibiotic therapy
• Regular use of probiotics or vaginal pH-balancing products
• Identification and modification of risk factors
• Consideration of alternative treatments under medical supervision

A healthcare provider should be consulted to develop an individualized management plan for recurrent BV.

The Role of the Interprofessional Team in Managing Gardnerella Infections

Effective management of Gardnerella infections and bacterial vaginosis requires a coordinated effort from various healthcare professionals. An interprofessional approach can improve patient outcomes and ensure comprehensive care.

Who are the key members of the interprofessional team in BV management?

• Primary care physicians
• Obstetricians and gynecologists
• Nurse practitioners and physician assistants
• Pharmacists
• Microbiologists and laboratory technicians
• Sexual health educators

Each member of the team plays a crucial role in diagnosis, treatment, and patient education.

How can care coordination be improved for patients with BV?

Improving care coordination for patients with bacterial vaginosis involves several strategies:

• Clear communication between healthcare providers
• Standardized protocols for diagnosis and treatment
• Patient education on prevention and self-care
• Follow-up appointments to assess treatment efficacy
• Integration of electronic health records for seamless information sharing

By implementing these strategies, healthcare teams can provide more efficient and effective care for patients affected by Gardnerella infections.

Future Directions in Gardnerella Research and BV Management

As our understanding of the vaginal microbiome and the role of Gardnerella vaginalis in bacterial vaginosis continues to evolve, new avenues for research and treatment are emerging.

What are some promising areas of research in BV management?

• Development of more specific and sensitive diagnostic tests
• Exploration of novel antimicrobial agents targeting Gardnerella biofilms
• Investigation of microbiome-based therapies to restore vaginal flora balance
• Research into the potential use of bacteriophages to target Gardnerella
• Studies on the long-term impact of BV on women’s health

These research directions hold promise for improving the diagnosis, treatment, and prevention of bacterial vaginosis in the future.

How might future treatments for BV differ from current approaches?

Future treatments for bacterial vaginosis may focus on more personalized approaches based on individual microbiome profiles. Some potential developments include:

• Targeted probiotics designed to outcompete Gardnerella
• Immunomodulatory therapies to enhance the vaginal immune response
• Biofilm-disrupting agents to improve antibiotic efficacy
• Vaginal microbiome transplantation techniques
• Nanotechnology-based drug delivery systems for improved treatment outcomes

As research progresses, these innovative approaches may offer more effective and long-lasting solutions for managing bacterial vaginosis and maintaining vaginal health.

In conclusion, Gardnerella vaginalis and its role in bacterial vaginosis represent a complex and important area of women’s health. As research continues to uncover the intricacies of the vaginal microbiome and the pathogenesis of BV, we can expect to see advancements in diagnosis, treatment, and prevention strategies. The collaborative efforts of healthcare professionals, researchers, and patients themselves will be crucial in addressing the challenges posed by this common yet often misunderstood condition.

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]

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

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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]

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

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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]

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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]

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

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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]

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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

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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.

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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

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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.

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