What is Gardnerella vaginalis. How does it cause bacterial vaginosis. What are the risk factors for developing 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 crucial 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.

Is Gardnerella vaginalis always harmful? Not necessarily. Studies have detected G. vaginalis in up to 50% of women without symptoms of BV, suggesting that it may be part of the normal vaginal flora. The problem arises when there’s an imbalance in the vaginal microbiome, allowing Gardnerella to proliferate excessively.

The Prevalence of Gardnerella and Bacterial Vaginosis

Bacterial vaginosis is estimated to occur in 5% to 70% of women, with Gardnerella consistently isolated as a key pathogen. This wide range in prevalence suggests that various factors influence the development of BV, including ethnicity, sexual activity, and hygiene practices.

• BV is more common in African American women compared to Caucasians
• The condition rarely develops in males
• BV primarily affects women of reproductive age

The Pathophysiology of Gardnerella Vaginalis Infection

How does Gardnerella vaginalis cause bacterial vaginosis? The process begins with the formation of a biofilm created by G. vaginalis, which allows other opportunistic bacteria to grow. This biofilm formation is a crucial step in the development of BV.

Gardnerella vaginalis produces a pore-forming toxin called vaginolysin, which specifically targets human cells. This toxin initiates complex signaling cascades that induce target cell lysis, contributing to the virulence of the bacterium. Additionally, Gardnerella exhibits protease and sialidase enzyme activities, further enhancing its ability to colonize the vaginal environment.

Key Virulence Factors of Gardnerella Vaginalis

1. Vaginolysin production
2. Protease and sialidase enzyme activities
3. Ability to adhere to host epithelia
4. Biofilm formation

What makes Gardnerella vaginalis so successful in outcompeting Lactobacilli? Its virulence factors allow it to adhere to host epithelia effectively, giving it an advantage in the competition for dominance in the vaginal environment.

Diagnosing Gardnerella Vaginalis and Bacterial Vaginosis

Diagnosing bacterial vaginosis involves identifying the presence of clue cells, which are epithelial cells of the cervix covered with rod-shaped bacteria. These clue cells are a hallmark of BV and can be observed under a microscope during a vaginal swab examination.

How is Gardnerella vaginalis cultured in a laboratory setting? The bacterium can be grown to form small, round, gray colonies on both chocolate and Human Blood Tween agar. A selective medium for Gardnerella is colistin-oxolinic acid blood sugar.

Microscopic Characteristics of Gardnerella Vaginalis

Gardnerella is a non-spore-forming, non-motile coccobacillus. Interestingly, it 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 microscopic examination. This characteristic can sometimes make identification challenging, requiring additional tests for confirmation.

Risk Factors for Developing Bacterial Vaginosis

While the exact mechanism of BV development is not fully understood, several factors have been identified that may increase the risk of developing this condition. Understanding these risk factors can help in prevention and early intervention.

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

Is bacterial vaginosis considered a sexually transmitted infection? While BV is not classified as an STI, sexual activity can play a role in its development. The spread of Gardnerella between sexual partners may alter the natural balance of bacteria within the vagina, potentially leading to BV.

Treatment Options for Gardnerella Vaginalis and Bacterial Vaginosis

Effective treatment of bacterial vaginosis caused by Gardnerella vaginalis typically involves the use of antibiotics. The most common treatments include:

1. Metronidazole (oral or vaginal gel)
2. Clindamycin (oral or vaginal cream)
3. Tinidazole (oral)

How long does treatment for bacterial vaginosis typically last? Treatment duration can vary depending on the specific antibiotic and its formulation, but it generally ranges from 3 to 7 days. It’s crucial to complete the entire course of antibiotics as prescribed, even if symptoms improve before the treatment is finished.

Alternative and Complementary Treatments

In addition to antibiotics, some women may find relief from BV symptoms through alternative treatments. These may include:

• Probiotics (oral or vaginal)
• Boric acid suppositories
• Tea tree oil (diluted and used topically)
• Apple cider vinegar baths

It’s important to note that while these alternative treatments may provide some relief, they should not replace prescribed antibiotics. Always consult with a healthcare provider before trying any new treatment.

Complications and Health Risks Associated with Untreated Bacterial Vaginosis

If left untreated, bacterial vaginosis can lead to several serious health complications. Understanding these risks emphasizes the importance of prompt diagnosis and treatment.

Increased Risk of Sexually Transmitted Infections

Women with untreated BV have an increased risk of acquiring various sexually transmitted infections, including:

• HIV
• Herpes simplex virus
• Gonorrhea
• Chlamydia

Why does BV increase the risk of STIs? The altered vaginal environment and inflammation associated with BV can make it easier for pathogens to establish an infection.

Pregnancy-Related Complications

Bacterial vaginosis during pregnancy has been associated with several adverse outcomes:

• Preterm birth
• Low birth weight
• Miscarriage
• Postpartum endometritis

How does BV affect pregnancy? The exact mechanisms are not fully understood, but it’s believed that the altered vaginal microbiome and associated inflammation may contribute to these complications.

Pelvic Inflammatory Disease

In some cases, untreated BV can lead to pelvic inflammatory disease (PID), a serious infection of the reproductive organs. PID can cause chronic pelvic pain, infertility, and increase the risk of ectopic pregnancy.

Prevention Strategies for Bacterial Vaginosis

While it’s not always possible to prevent bacterial vaginosis, certain lifestyle changes and habits can help reduce the risk of developing this condition.

Maintaining Vaginal pH Balance

A healthy vaginal environment has a pH between 3.8 and 4.5, which helps prevent the overgrowth of harmful bacteria. To maintain this balance:

• Avoid douching
• Use unscented soaps and hygiene products
• Wear breathable, cotton underwear
• Avoid sitting in wet clothing for extended periods

Safe Sexual Practices

While BV is not considered an STI, sexual activity can influence its development. To reduce risk:

• Use condoms consistently
• Limit the number of sexual partners
• Avoid sharing sex toys, or clean them thoroughly between uses

Probiotic Supplementation

Some studies suggest that probiotics containing Lactobacillus species may help prevent recurrent BV by promoting a healthy vaginal microbiome. These can be taken orally or applied vaginally.

Is probiotic supplementation a guaranteed prevention method for BV? While probiotics show promise, more research is needed to determine their effectiveness in preventing BV. They should be used as a complement to, not a replacement for, other prevention strategies.

The Role of the Interprofessional Team in Managing Gardnerella Infections

Effective management of Gardnerella vaginalis infections and bacterial vaginosis requires a coordinated effort from an interprofessional healthcare team. This approach ensures comprehensive care and improved patient outcomes.

Primary Care Providers

Primary care physicians and nurse practitioners often serve as the first point of contact for women experiencing symptoms of BV. Their responsibilities include:

• Initial assessment and diagnosis
• Prescribing appropriate antibiotic treatment
• Providing patient education on prevention and self-care
• Monitoring treatment response and managing recurrent cases

Obstetricians and Gynecologists

For more complex cases or in pregnant patients, obstetricians and gynecologists play a crucial role:

• Managing BV in high-risk pregnancies
• Addressing recurrent or persistent infections
• Performing additional diagnostic tests when necessary
• Providing specialized care for women with chronic BV

Pharmacists

Pharmacists contribute to BV management by:

• Ensuring appropriate antibiotic selection and dosing
• Educating patients on proper medication use and potential side effects
• Advising on over-the-counter products and probiotics
• Monitoring for drug interactions in patients with multiple medications

Laboratory Technicians

Laboratory professionals play a vital role in the accurate diagnosis of BV:

• Performing microscopic examinations of vaginal swabs
• Conducting pH tests and whiff tests
• Culturing Gardnerella vaginalis when necessary
• Reporting results promptly to healthcare providers

Nursing Staff

Nurses are integral to patient care and education:

• Assisting with sample collection for diagnostic tests
• Providing detailed instructions on medication use and self-care
• Offering emotional support and addressing patient concerns
• Conducting follow-up assessments and coordinating care

How does this interprofessional approach benefit patients with Gardnerella infections? By involving multiple healthcare professionals, patients receive comprehensive care that addresses all aspects of their condition, from accurate diagnosis to effective treatment and ongoing prevention strategies.

Future Directions in Gardnerella Vaginalis Research and Treatment

As our understanding of Gardnerella vaginalis and bacterial vaginosis continues to evolve, researchers are exploring new avenues for diagnosis, treatment, and prevention. These advancements hold promise for improved management of BV and related conditions.

Advanced Diagnostic Techniques

Emerging diagnostic methods aim to provide faster, more accurate identification of BV and the specific bacterial strains involved:

• PCR-based tests for rapid detection of Gardnerella and other BV-associated bacteria
• Metagenomic sequencing to analyze the entire vaginal microbiome
• Point-of-care tests for immediate diagnosis in clinical settings

How will these advanced diagnostics impact BV management? More precise and rapid diagnosis can lead to earlier intervention and more targeted treatment approaches, potentially reducing the risk of complications and recurrence.

Novel Treatment Approaches

Researchers are investigating alternative treatments to address the limitations of current antibiotic therapies:

• Bacteriophage therapy targeting specific BV-associated bacteria
• Vaginal microbiome transplantation to restore a healthy bacterial balance
• Immunomodulatory therapies to enhance the body’s natural defense against BV
• Biofilm-disrupting agents to improve antibiotic efficacy

Personalized Medicine in BV Management

The future of BV treatment may involve tailored approaches based on individual patient factors:

• Genetic testing to identify susceptibility to recurrent BV
• Customized probiotic formulations based on a patient’s specific vaginal microbiome
• Individualized treatment plans considering lifestyle factors and co-existing conditions

What potential benefits does personalized medicine offer for BV patients? By tailoring treatments to individual patient characteristics, healthcare providers may be able to achieve better outcomes, reduce recurrence rates, and minimize side effects.

Preventive Strategies and Vaccines

Ongoing research is exploring new ways to prevent BV and Gardnerella vaginalis overgrowth:

• Development of vaccines targeting key virulence factors of Gardnerella vaginalis
• Creation of novel probiotics specifically designed to outcompete BV-associated bacteria
• Investigation of natural compounds with antimicrobial properties against Gardnerella

These future directions in Gardnerella vaginalis research hold promise for more effective management of bacterial vaginosis. As our understanding of the vaginal microbiome and the role of Gardnerella in BV continues to grow, we can anticipate significant improvements in diagnostic accuracy, treatment efficacy, and prevention strategies. This ongoing research not only aims to reduce the burden of BV on individual patients but also to address the broader public health implications of this common 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.

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References

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

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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]

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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]

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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]

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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]

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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]

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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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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

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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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