Doctors often prescribe tests and various research methods, while not always plainly explaining their results. Either the girl decided to do the analysis herself, and there was no one to explain the results to. If you have a similar situation with femoflor 16, this article will help you sort out incomprehensible columns and rows.
This best method diagnosis of bacterial diseases of the vaginal flora. Femoflor 16 quickly and qualitatively determines the components of the biocenosis of the urogenital tract in a woman, finds bacteria that disrupt the normal vital activity of the flora and the functioning of the adequate functioning of the vagina.
Why is the efficiency of the method better?
Femoflor 16 has long lived up to its expectations and surpassed other research methods.
This analysis is done in real time, then the doctor and the patient can get the result in a few hours. In comparison, sowing on the flora of the vagina is carried out for about a week. This time is necessary for the growth of pathogenic flora and the detection of colonies of microorganisms.
Femoflor 16 is produced by PCR (polymerase chain reaction), which is particularly sensitive and specific.
The polymerase chain reaction method is carried out faster and better due to its principle of action and the presence of microorganisms. The polymerase chain reaction contains antigens to certain microorganisms, viruses and other bacteria, which will be laid down by bacteriologists and virologists. In this analysis, the antigens of 16 bacteria are laid, the list of which is indicated below. This analysis, in a scraping taken from the vagina, looks for the native DNA of the target organism. Even the smallest number of bacteria, down to 1, will not be able to hide from the polymerase chain reaction. The analysis will quickly determine the amount of bacteria contained. Therefore, it is distinguished by quality and specificity, unlike other methods, which require a minimum content, much more than 1 microorganism, to determine the presence, and not just the quantity.
The analysis is taken without special training. The only rule for proper preparation for analysis so that it shows the correct value is personal hygiene. Before going to the doctor, it is necessary to carry out a toilet of the external genitalia, since the accumulation of the natural skin folds of the external labia overnight can lead to false results and incorrect counting of the number of opportunistic and pathogenic microorganisms.
It is not recommended to carry out the analysis during menstruation. Since blood is the best habitat and breeding opportunities for pathogenic flora, it simply attracts bad rods and cocci.
Femoflor 16 is an excellent method for determining the effectiveness of the treatment.
Indications for analysis
Deciphering the analysis of Femoflor 16
Femoflor 16 - decoding in women, the norm - all this is done in the laboratory and according to a special table.
Decryption includes the following indicators:
- Whether the material for analysis was collected correctly and qualitatively;
- total weight bacterial microorganisms;
- The presence and quantitative composition of the normal population of the vagina;
- Quantitative composition of conditionally pathogenic microorganisms;
- The presence and number of pathogenic flora in the test material.
Determining the quality of material sampling is determined by the composition of epithelial cells in the smear. Normally, if the flora is taken correctly, epithelial cells should be at least 10,000 cells. Then the smear is collected correctly and in the required quantity.
The total number of bacterial microorganisms should also have its own norm. The lower limit of the total number of bacteria is 1,000,000 rods and possibly cocci. This figure should be within these limits if the preparation of the woman for the smear is done correctly.
The normal flora of the vagina should be represented by lactobacilli. They are the ruling population. Under normal conditions, lactophilic rods should quantitatively far exceed the rest of the microorganisms that inhabit the internal environment of the vagina. They can range from the total number of bacteria up to 90%.
Opportunistic flora should be in the smear, and is always present there, but should have its own boundaries. Active growth and increased numbers can provoke the same disease as pathogenic microorganisms. When diagnosing bacterial vaginosis, the number of anaerobic organisms is always increased relative to the norm.
Pathogenic microorganisms should be absent altogether. They can be found even with the relative complete well-being of the organism. Then they can either become a regulator of the disease when the immune system is weakened, or provoke malignant neoplasms.
Femoflor 16 was named for a reason. This test includes the presence of antibodies to the native DNA of 16 microorganisms that can colonize the vaginal environment. The data obtained are collected in a table that indicates the bacteria found, their quantitative and qualitative composition, the normal value of the numbers of these microorganisms in a healthy internal environment of the vagina.
The table includes the following names of microorganisms:
- Lactobacillus spp.
- Streptococcus spp.
- Enterobacterium spp.
- Staphylococcus spp.
- Gardnerella vaginalis + Prevotella bivia + Porphyromonas spp.
- Eubacterium spp.
- Leptotrichia spp. + Sneathia spp. + Fusobacterium spp.
- Clostridium spp. + Lachnobacterium spp.
- Megasphaera spp. + Dialister spp. + Veillonella spp.
- Corinebacterium spp. + Mobiluncus spp.
- Peptostreptococcus spp.
- Mycoplasma genitalium
- Atopobium vaginae
- Candida spp.
- Ureaplasma spp.
- Mycoplasma hominis
The meaning of the results obtained
Spp - means that the quantitative value is indicated not for a single microorganism, but for 1 group - a colony of bacteria.
After computer analysis of the received data, these indicators are presented in a special table. Typically, the results are sent to the patient's email address or are with the doctor in electronic or printed form.
The next group is called mycoplasma, which includes 2 microorganisms: Mycoplasma hominis and the Ureaplasma group (urealyticum + parvum). The mushrooms of the Genus Candida complete the table of results.
The results are convenient in that the numerical values written in the first column are calculated in logarithms - the ratio of bacteria inoculated to the total mass of the smear taken.
And the last column indicates not just the norms in numbers, but how much the results obtained exceed or underestimate the required numbers. That is, a woman does not need to compare her numbers with normal ones, but you can simply look at the last column and immediately see the norm or pathology.
The effectiveness of this analysis was not long in coming, and at present it is the first of its kind.
0I. Obligate anaerobic bacteria microflora of the vagina (resident microflora) includes all microorganisms that are constantly part of the normal microflora of the vagina.
A. Gram-positive obligate anaerobic bacteria:Lactobacilli (Doderlein bacteria): L. fermentum, L. Crispatus, L. Jensenii, L. Gasseri etc. The concentration in the vaginal discharge material - 10 7 -10 9 CFU / g. They form milk
Application 7. __________________ 651
acid and other organic acids that maintain a low pH of the vaginal environment. Lactobacilli have a high adhesive ability to the surface of epithelial cells (adhesion - lipoteichoic acid), preventing adhesion to epitheliocyte receptors of other microbes (the phenomenon of colonization resistance). They produce bacteriocins and bacteriocin-like substances that also inhibit bacterial growth.
Immunostimulatory effect of lactobacilli: activation of macrophages, an increase in the level of phagocytes and immunoglobulins. Muramyl dipeptide of the cell wall of lactobacilli has immunostimulating properties.
Bifidobacteria (B. bifidum, B. breve, B. adolescentis, B. langum). The concentration in the vaginal discharge material is 10 3 -10 7 CFU / g.
Properties of bifidobacteria: ability to produce acids; adhesion to vaginal epitheliocytes; natural antibiotic resistance; synthesis of bacteriocins, lysozyme, alcohols (maintaining colonization resistance), amino acids and vitamins.
Peptostreptococci (P cocci). Part of the Doderlein flora. The amount in the vaginal discharge is 10 3 -10 4 CFU / g. More common P.asaccharoliticus, less often P. magnus, P. prevotii And P. tet-radius. These microorganisms are often found in septic abortions, tubal-ovarian abscesses, endrometritis, bacterial vaginosis.
Clostridia- mobile G + rods, form spores. With bacterial vaginosis, the frequency of their release increases.
Propionbacteria - polymorphic G + non-spore-forming rods. They belong to the group of diphtheroidomorphic bacteria. Catalase positive. Typical representative - P. acnes. Their number is 10 4 CFU/g of the material under study. Support colonization resistance of the vagina and have immunostimulatory properties.
Mobilejuncus - mobile, non-spore-forming microorganisms. There are 2 types of bacteria: M. curtisii subsp. curtsii, M. curtisii subsp.holmesii and M. mulieris. With bacterial vaginosis, their number increases significantly.
652 Practical gynecology
Mobiluncus properties: adhesion to vaginal epitheliocytes; synthesis of mucinase and neuraminidase (an increase in their activity leads to the development of infection in the cervix, rupture of membranes and premature birth).
B. Gram-negative obligate anaerobic bacteria make up 10 3 -10 4 CFU/g of vaginal discharge. Some of them have pathogenic properties: as part of the cell wall, they contain lipopolysaccharide, which triggers the inflammatory process; capable of forming a capsule; produce aggression enzymes (hyaluronidase, collagenase, fibrinolysin, heparinase, sialidase); secrete succinic acid, which inhibits the migration of neutrophils; produce immunoglobulin protease.
Bacteroids - G - non-spore-forming, polymorphic rods, immobile or peritrichous. The most common is B. urealyticus. Bacteroides of the "fragilis" group (B.fragilis, B. vulgaris, B. avatus, B. distasonis, B. uniformis, B. sassae, B. multiacidus) are detected in 9-13% of healthy women. Normally, the level of bacteroids is 10 3 -10 4 CFU/g of the test material.
Prevotella - non-spore-forming, polymorphic rods. The most frequently distinguished P. bivia And P. disiens, less often - P. intermedia, P. melaninogenica And P. loechii. Quantity - 10 4 CFU/g of the test material.
Porphyromonas- G "non-spore-forming, polymorphic sticks. Typical representative - P. asaccharolitica. Quantity - 10 3 CFU / g.
Fusobacteria - non-spore-forming rods. Peritrichs. Concentration - 10 3 CFU/g of the test material. Frequent Representative - F. nucleatum. Able to produce hemagglutinins and hemolysins, leukotoxin, platelet aggregation factors.
Waylonelles - Mr. cocci. Motionless, do not form a dispute. Quantity - 10 3 CFU/g of the test material.
II. Facultative anaerobic bacteria:
Gardnerella- pleomorphic G "or gram-variable sticks. Capsules and spores do not form. Quantity - 10 6 CFU / g of the material under study. The only type of bacteria - G. vaginalis. Properties: adhesion on the surface of the vaginal
Application 7. Normal microflora of the vagina 653
epitheliocytes; synthesis of mucolytic enzymes, hemolysin, leukotoxic factor, succinate, inhibiting leukocyte chemotaxis and phagocytosis.
Corynebacterium - acid-resistant polymorphic bacteria. Dispute does not form. Cell morphology depends on the growth phase of bacteria: during the exponential growth phase, irregular straight or slightly curved rods are present, with sharp ends or club-shaped swellings at the ends; in the stationary phase - short rods, often coccoid. In the vagina of a healthy woman, they are found in the amount of 10 4 -10 5 CFU / g. Most common C. minutissimus, C. equi, C. aquaticum, And C. xerosis.
Mycoplasmas belong to the department Tenericutes and the class Mol-licutes. This class contains one order Mycoplasmatales, which is divided into 3 families. The Mycoplasmataceae family contains mycoplasmas that are pathogenic to humans and animals. The genus Mycoplasma includes about 70 species. The genus Ureaplasma contains 3 species, pathogenic for humans is only Ureaplasma urealyticum. He has a cell wall. Normally, U. urealyticum is excreted in 6-7% of women in the amount of 10 4 -10 5 CFU / g, M. hominis in 2-15% of women in an amount up to 10 3 CFU / g of the test material. With bacterial vaginosis, the level of M. hominis increases.
U. urealyticum has proteolytic activity against Ig A, which favors their rapid colonization of the vaginal epithelium. Ureaplasmas take part in the occurrence of urethritis, mycoplasmas - pyelonephritis and salpingitis. M. hominis and U. urealyticum can equally cause infertility in men, premature miscarriages, chorionamnionitis, postpartum fevers, pathological neonatal conditions - fetal malnutrition, premature rupture of the membranes.
Staphylococci. Most common S. epidermidis(quantity - 10 3 -10 4 CFU/g of the studied material). S. aureus usually colonize the vagina transiently (5% of cases) and produce TSST-1 toxin, which causes toxic shock syndrome. TSST-1 is able to stimulate T cells, TNF, induce the cytokine IL-1.
654 Practical gynecology
Streptococci. Normally, 3 groups are distinguished in the vagina: 1) streptococci of the viridans group (“green” or a-, y- hemolytic Streptococcus spp); 2) streptococci of serological group B (S. agalacticae) capable of causing serious illness respiratory organs, meningitis, septicemia; 3) streptococci of serological group D (enterococci).
Enterococci- normal representatives of the gastrointestinal tract, urogenital tract and human skin. However, they may cause inflammatory processes urinary system. Viridescent streptococci are the cause of postoperative complications.
Enterobacteria- G "sticks. Most common Escherichia coli. Enterobacteria (E. coli, Proteus sp., Klebsiella sp.), as well as Pseudomonas aeruginosa can cause urogenital diseases.
Yeast-like fungi of the genus Candida- may be present in the vagina of healthy women. The most common is Candida albicans (up to 30%) in the amount of 104 CFU/g of the test material. Properties of C. albicans: adhesion to vaginal epitheliocytes; synthesis of glycotoxin (changes the geometry of cells and their chemotactic ability, produces superoxide anion, absorbs and digests bacteria) and antineisseria (a factor that inhibits the reproduction and colonization of the vagina by N. Gonorrhoeae).
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Stone tools and techniques for their manufacture
Sometimes the Olduvai stone industry is called the chipped pebble culture, or pebble, but this is not entirely correct, because. in addition to pebbles, other stone raw materials were also used. It should be noted that the traditions of making products by rough pebble upholstery exist in some regions, for example, in South and Southeast Asia, throughout the entire Paleolithic era.
Upholstery is a technique for chipping a number of fairly large fragments from the original core, or blank. Chips, as a rule, are located along its perimeter and directed towards the center, thereby forming a rib. If one side of the object is processed with upholstery, then the upholstery is called one-sided, and the object is called monoface, if the upholstery extends to both surfaces, it is called double-sided, and the object - biface. The technique of one-sided and two-sided padding is especially characteristic of the early archaeological epochs, although it is present throughout the Stone Age. The upholstery technique was widely used in the manufacture nuclei, choppers,hand axes.
The Olduvai era is characterized by three main groups of tools: polyhedrons, choppers, and flake tools.
1. Polyhedra are roughly worked, rounded stones with many facets obtained as a result of upholstery. Among polyhedra, discoids, spheroids, and cuboids stand out. It is assumed that they were percussion instruments and served to process plant and animal food.
Olduvai era tools:
1 - chopper; 2, 3 - chopping; 4, 5, 8 - tools on flakes; 6, 7 - disc-shaped nuclei
2. Choppers and choppers- the most characteristic tools of the era. These are massive tools made, as a rule, of pebbles, in which the end or edge forming the blade has been hewn and sharpened by several successive blows. When processing the blade on one side, the product is called a chopper, in cases where the blade is chipped on both sides, it is called chopping.
The rest of the surface of the tool is not processed and is comfortable to hold in the hand; the blade is massive and uneven, has cutting and chopping functions. These tools could be used for butchering animal carcasses and processing plant materials.
3. Flake tools were made in several stages. Original natural piece rock a certain definite form was given, i.e. the nucleus, or core, was made. From such cores, short and massive chips were obtained by directed blows, which are called flakes.
Then the flakes were subjected to special processing, the purpose of which was the formation of blades and working edges. One of the common types of such secondary stone processing is called retouching in archeology: it is a system of small and tiny chips that give the product the desired shape and working qualities.
Flake tools are represented by side-scrapers, flakes with serrated and notched edges, and rough points. In addition, scrapers and incisors are extremely rare, but these types become widespread only in the Upper Paleolithic. All Olduvai tools are characterized by shape instability. Flake tools could be used in various labor operations - cutting, scraping, piercing, etc.
It should be noted that already at the initial stage of the manufacture of tools, they are represented by a whole range of products that can provide people with a variety of plant and animal food, simple clothing and satisfy other needs, including the manufacture of other tools. The main technique in their manufacture is upholstery, and retouching is used only to decorate some details. The sizes of products usually do not exceed 8-10 cm, but occasionally larger ones are also found.
Often, the tools themselves have a sort of random shape, but the methods of processing the blades and working edges are quite stable and make it possible to distinguish certain groups of items presented on different sites. Their artificial origin is not in doubt among experts. Numerous tools are found in the cultural layers of the Olduvai sites, as well as tools from later Stone Age eras, which indicates their deliberate manufacture.
The monuments of the developed Olduvai testify that the oldest and longest (at least 1.5 million years) era of human history was characterized by a very slow progress in the technology of making tools. By the end of the Olduvian, no major changes were observed in the shape of the products and their assortment, only their slight enlargement can be noted.
The article presents current data on bacterial vaginosis, the main cause of various infectious and inflammatory complications in obstetric and gynecological practice. Questions of clinical symptomatology, diagnostics and treatment are reflected. The most promising include vaccination of women (Solkotrikhovak vaccine) as monotherapy or in combination with interferon inducers.
Bacterial vaginosis (BV) is a polymicrobial non-inflammatory vaginal syndrome that occurs due to a dramatic imbalance in the vaginal microflora caused by the replacement of the dominant microorganisms of the genus Lactobacillus by an association of different bacteria. To date, the nature of violations of the vaginal microflora in bacterial vaginosis and the spectrum of microorganisms involved in the development of this disease have been studied quite well. It is very important to understand that bacterial vaginosis is a change not only in the qualitative, but also in the quantitative ratio of the vaginal microflora, which is characterized by a sharp decrease or absence of lactobacilli producing H 2 O 2 with a simultaneous increase in the colonization of Gardnerella vaginalis, gram-negative anaerobic bacteria - Mobiluncus spp. , Prevotella spp., Bacteroides spp., Fusobacterium spp., Peptostreptococcus spp., as well as Mycoplasma hominis and Ureaplasma urealyticum, the appearance of fungi of the genus Candida in a low titer.
Anaerobic imbalance is exacerbated by Atopobium vaginae and Leptotrihia spp., which are associated with the most severe, recurrent forms of bacterial vaninosis. The composition of a huge number of bacteria of the pathological vaginal biotope also includes facultative anaerobic representatives of the intestinal group (Escherichia coli, Klebsiella pneumonii, Enterococcus fecalis, Enterococcus faecium, Staphylococcus spp., Streptococcus spp. and others), as well as atypical coccal forms of lactobacilli. Against the background of a sharp decrease or absence of Lactobacillus spp. dysbiosis of the vaginal microbiota is characterized by a high degree of colonization (10 6 -10 10 cfu / ml) of various groups of bacteria that create an alkaline environment of the vagina (table 1).
Table 1
The degree of contamination of the vaginal discharge by various types of microorganismshealthy women of reproductive age and women with bacterial vaginosis
Microorganism | Quantity (cfu/ml) |
|
healthy women | women with BV |
|
Microaerophilic bacteria: | ||
Lactobacillus spp. | ||
G. vaginalis | ||
Obligate anaerobic Gram-positive bacteria: |
||
Lactobacillus spp. | ||
Bifidobacterium spp. | ||
Clostridium spp. | ||
Propionibacterium spp. | ||
Mobiluncus spp. | 10 10 or more |
|
Peptostreptococcus spp. | 10 5 or more |
|
Obligate anaerobic Gram-negative bacteria: |
||
Bacteroides spp. | 10 5 or more |
|
Prevotella spp. | 10 5 or more |
|
Porphyromonas spp. | ||
Fusobacterium spp. | 10 4 or more |
|
Veilonella spp. | ||
Facultative anaerobic Gram-positive bacteria: |
||
Corynebacterium spp. | ||
Staphylococcus spp. | ||
Streptococcus spp. | ||
Enterobacteriaceae | ||
M. hominis | 10 4 or more |
|
U. urealyticum | 10 4 or more |
|
M. fermentas | ||
Yeast-like fungi of the genusCandida | ||
The ability of lactobacilli to form lactic acid in the process of glycogen destruction determines the pH of the vaginal contents in the range of 3.8-4.5 and prevents the reproduction of acidophilus bacteria. In addition to the protective, the vaginal microflora performs enzymatic, vitamin-forming, immunostimulating functions, and therefore it is considered as an indicator of the state of the vagina.
The impact on the body of a woman of various external or internal factors leads not only to a decrease in colonization resistance in the vagina and the appearance of transient microflora, but also to the active introduction of opportunistic microorganisms into the mucous membrane of the vagina, urinary tract, cervical canal and upper divisions reproductive system. This happens especially easily against the background of inhibition of leukocyte function, which develops under the influence of specific catabolites, which are produced by anaerobic bacteria, Gardnerella vaginalis, Mobiluncus, Atopobium vaginae and others.
The most significant factors contributing to the formation of bacterial vaginosis include sexually transmitted infections. Chronic chlamydial, trichomonas infection, as well as gonorrhea can have a "mask" in the form of persistent bacterial vaginosis, which requires additional, special methods for examining women. At the same time, vaginal dysbiosis also develops in women who use various contraceptives (hormonal, IUDs or spermicides), who have malformations of the vagina and uterus, and anatomical deformities of the external genital organs after childbirth. The gaping entrance to the vagina with the descent of the walls is an important condition for the disruption of the microbiota and the colonization of the intestinal microflora. Of great importance are endocrine (hypothyroidism, diabetes mellitus), gynecological and extragenital diseases of women, as well as frequent tonsillitis, acute respiratory infections and pathology. gastrointestinal tract. Probably, this somatic pathology leads to immune shifts, which are reflected in the dysbiosis of the vaginal microflora. Violation of local immunity is of great importance. Associated with bacterial vaginosis are mycoplasmas and ureaplasmas, which are able to cleave secretory immunoglobulin A, one of the main “defenders” of the mucosa. Inhibition of the functional activity of leukocytes caused by anaerobic flora, a decrease in the level of lysozyme, lysine, opsonins are typical disorders of local immunity in bacterial vaginosis.
Bacterial vaginosis is a disease that affects women at any age, from childhood to menopause. Clinically, in typical situations, it is characterized by profuse leucorrhea with an unpleasant odor (especially after intercourse or menstruation). With prolonged flow, the leucorrhea is sticky, yellowish-greenish in color or foamy. Often the main complaint is itching, burning in the vagina, pain during intercourse, dysuric disorders. In 25% of cases, the symptoms are practically not expressed. This is an asymptomatic course of bacterial vaginosis, but it does not remove the possibility of developing complications - urethritis, cervicitis, endometritis and salpingoophort, and during pregnancy - isthmic-cervical insufficiency, threat of interruption, chorionamnionitis.
According to the severity of clinical manifestations, there are three degrees of bacterial vaginosis (Mavzyutov R. A. et al.):
1 degree — compensated, which is characterized by the complete absence of microflora in the test material with unchanged epitheliocytes. The specified condition of the vaginal mucosa is not considered pathological, but the absence of lactobacilli flora indicates the fundamental possibility of settling an empty ecological niche with microorganisms entering from the external genital organs and the subsequent formation of BV. The described forms can be observed under microscopy as a result of "excessive" preparation of the patient for a visit to the doctor or after intensive chemotherapy with broad-spectrum antibacterial drugs.
2 degree - subcompensated, characterized by a quantitative decrease in lactobacilli, commensurate with an increase in the number of concomitant gram-variable polymorphic bacterial flora, and the appearance of single (1-5) "key" cells in the field of view with relatively moderate leukocytosis (15-25 in the field of view). "Key" cells can be represented both by epithelial cells covered with bacterial flora on the outside, and containing bacteria intracellularly due to the nonspecific implementation of phagocytosis functions by epithelial cells.
3 degree - decompensated, which is clinically pronounced in accordance with the symptoms of BV and microscopically characterized by the complete absence of lactobacilli, when the entire field of view is filled with "key" cells. In this case, the bacterial flora can be represented by a wide variety of microorganisms, in the absence of lactobacilli, both in monoculture and in various morpho- and species combinations.
In the diagnosis of bacterial vaginosis, the main criteria are R. Amsel. These include:
- pathological nature of vaginal discharge,
- vaginal discharge pH more than 4.5,
- positive amine test (“fishy” smell when mixing vaginal discharge with 10% KOH),
- identification of "key" cells by microscopy of unstained smears.
In addition, the assessment of the ratio of the number of leukocytes and epithelial cells in the vaginal smear is of great importance. The predominance of epithelial cells is characteristic, the number of which is 2-3 times more than leukocytes.
The formation of "key" cells occurs in case of increased colonization of G. vaginalis And Mobiluncus spp. followed by their adhesion to the cells of the vaginal squamous epithelium. "Key" cells are intact or lytically altered cells torn away from the epithelial lining, covered with bacteria in the form of a cloud or veil with a concentration along the periphery. In the most severe clinically pronounced cases, bacteria also fill the intercellular space.
The most reliable diagnostic method is microscopy of vaginal smears stained by Gram's method, when "key" cells are easy to differentiate from "false key" ones. The sensitivity of the microscopic method is 93%, the specificity is 70%. The microscopic method allows you to evaluate the morphological features, the ratio of individual components of the vaginal microflora, to obtain information about the state of the vaginal mucosa and the degree of leukocyte reaction. The quantitative criterion for the detection of "key" cells remains debatable. The generally recognized fact of the prevalence of bacteria of the genus Lactobacillus in the norm allows us to use it as the main criterion for the norm or pathology in the study of vaginal fluid. This is supported by the impossibility of excessive development of the accompanying flora, and, consequently, the presence of "key" cells with the preserved quantitative level of lactobacilli.
Currently, there is no doubt that a bacteriological study with an assessment of the ratio of the number of typical lactobacilli to the rest of the components of the microbial flora of the vagina is the main one among laboratory diagnostic tests. But it is not always possible to fulfill it. The developed method for quantitative assessment of vaginal biota by real-time PCR inspires great hope with comparative analysis specific representatives of normo- and conditionally pathogenic microflora and the total number of microorganisms in the vagina. Identification of the imbalance of microflora in this case and the possibility of assessing the degree of its severity make it possible to determine dysbiosis on early stages development (the method was developed by the staff of the DNA-Technology Research and Production Fund and is called Femoflor).
Basic principles of BV treatment:
1. Antimicrobial therapy aimed at suppressing the anaerobic flora, locally or systemically.
2. Creation of optimal physiological conditions for the environment of the vagina.
3. Restoration of normal or as close to normal microbiocenosis of the vagina as possible.
4. Carrying out immunocorrective therapy.
Given the local nature of the lesions in BV, it is considered optimal to carry out local therapeutic measures.
According to CDC international recommendations, the following schemes are effective for the treatment of BV: oral metronidazole 500 mg 2 times or clindamycin 300 mg 3 times a day for 7 days in combination with intravaginal administration of clindamycin cream 2%-5 g 1 time daily for 3- 7 days, or according to the same scheme of clindamycin in suppositories 100 mg, or metronidazole-gel 0.75% -5.0 g 2 times a day for 5 days.
Perhaps the combined use of Trichopol preparations - 1 vaginal tablet 500 mg once and 250 mg of the drug orally 2 times a day. As a rule, in mild cases (compensated or asymptomatic BV), treatment is limited only to local agents, in the rest, a combined administration (oral and intravaginal) is advisable.
When prescribing metronidazole, the following should be considered:
- Metronidazole is contraindicated in the first trimester of pregnancy and during breastfeeding.
- In the II trimester, the use of vaginal suppositories is acceptable.
- In the III trimester, you can prescribe the drug inside.
When BV is combined with candidiasis, combined agents should be used intravaginally - Klion D, neopenotran, terzhinan or iodine-containing drugs in combination with fluconazole. With the isolation of Atopobium vaginae and a recurrent course, it is generally recognized the need to use clindamycin preparations orally and locally, Leptotrix (in the amount of 10 4 or more CFU / ml) is sensitive to amoxicillin, which is administered orally at a daily dose of 2.0 for 7 days with the aim of general sanitation of the mucosa vagina.
To restore the microbiocenosis of the vagina at the II stage of treatment, eubiotic preparations are prescribed - floradofilus, lactogin orally or ecoflor locally. They are the most adapted and effective for these purposes.
In menopausal women, at the second stage of treatment, estrogens are used - estriol locally (Ovestin from Organon).
One of the new and effective ways treatment for bacterial vaginosis is L-ascorbic acid (Vaginorm-C ® , 250 mg vaginal tablets). Vaginorm-S ® reduces the pH of the vagina, inhibits the growth of bacteria and helps restore and maintain normal pH and vaginal flora (Lactobacillus acidophilus, Lactobacillus gasseri). With a decrease in the pH of the vagina for several days, a pronounced suppression of the growth of aerobic bacteria occurs, as well as the restoration of normal flora. The advantage is the gradual dissolution of the tablet, which contributes to the prolonged action of the drug and prevents irritation of the mucosa. Vaginorm-S ® is used intravaginally for 6 days once a day in the evening. Studies conducted by Eiko Peterson, 2004 showed that the use of Vaginorm-S ® leads to the normalization of the vaginal flora and the effectiveness of its use was 86%. Vaginorm-S ® can be used during pregnancy and lactation.
Despite the proposed variety of treatment methods, relapses of bacterial vaginosis are the main problem of this pathology. Conventional methods of treatment in these cases are ineffective. Certainly promising should be the vaccination of women in the form of monotherapy or in combination with interferon inducers (genferon, viferon, epigen spray, lavomax, cycloferon, and others) used after the main course of treatment. The Solkotrikhovac vaccine can be used as an absolutely independent method for the prevention of recurrence of bacterial vaginosis. It was created on the basis of 8 strains of atypical coccal forms of lactobacilli, which are commonly found in BV. The vaccine activates the production of antibodies to various vaginal microflora, including Trichomonas, stimulates the synthesis of immunoglobulin A and, according to our data, significantly increases the production of all classes of immunoglobulins, increases macrophage and phagocytic activity. With severe symptoms of bacterial vaginosis, vaccination is carried out only in combination with etiotropic therapy; with compensated or subcompensated dysbiosis, monotherapy with Solkotrikhovak is sufficient. The vaccine is very effective in cases of a combination of bacterial vaginosis and chronic cervicitis, whatever it is caused by, which is probably due to increased production of secretory Ig A and, according to our data, lysozyme. The vaccine is well tolerated, rarely develops a local reaction (redness, swelling) and, in isolated cases, a general one (fever, headache, chills). With the development of such a reaction, the administration of the drug should be discontinued ( allergic reactions when using Solkotrichovak are not described). Contraindications for vaccination are acute infectious diseases, tuberculosis, leukemia, decompensated kidney and heart diseases. The treatment course consists of three intramuscular injections of the drug with an interval of 2 weeks and revaccination with a single injection after 1 and then every 2 years. The effectiveness of the treatment can be traced already after the second injection at the beginning of therapy, and the stability of the therapeutic and preventive effect is guaranteed after the main basic course. It should be emphasized that vaccination with Solcotrikhovac, restoring the vaginal microflora, prevents recurrence of bacterial vaginosis in 80% of patients.
Thus, bacterial vaginosis as the main cause of various infectious and inflammatory complications in obstetric and gynecological practice, including sepsis, can be eliminated using the available methods of therapy. Vaccination of women is one of the most important methods of treatment and prevention.
L.I. Maltsev,
doctor of medical sciences, professor, head. Department of Obstetrics and GynecologyI
Kazan State Medical Academy
Gardnerellosis (bacterial vaginosis) - symptoms, treatment
Gardnerellosis (bacterial vaginosis)) - a disease caused by gardnerella (Gardnerella vaginalis), which is characterized by a high concentration of obligate anaerobic microorganisms, as well as a low content of lactobacilli in the human body.
Gardnerellosis is characterized by excessive reproduction of anaerobic and facultative bacteria, which changes the vaginal microflora. The disease belongs to sexually transmitted diseases (venereal diseases). The disease affects about 20% of women of childbearing age. Often, women infected with gardnerella are found mycoplasma, peptococcus, peptostreptococcus and bacteroid.
Infection occurs more often in sexually active women who do not use barrier methods of contraception. Often the disease is detected in patients suffering from chlamydial or gonorrheal cervicitis. Infection of a pregnant woman can lead to intrauterine infection of the fetus.
The incubation period is from 3 to 10 days, after which symptoms of the disease appear. Often there are mixed infections. Gardnerellosis can affect both women and men. Although the disease is less common in men, they can be carriers of the infection.
In men, the infection causes gardnerella urethritis in which the patient complains of grayish discharge, itching and burning during urination. In women, urethritis is also accompanied by inflammation of the vagina and cervix. The reason for the unpleasant "fishy" odor is the amines formed during the metabolism of gardnerella.
Because causes of gardenerellosis are not fully understood, have been allocated three main variants of vaginal microbiocenosis:
Option 1 - normal microflora, in which lactobacilli predominate
Option 2 - normal microflora with a small amount of lactobacilli changes dramatically due to the appearance of bacteria characteristic of gardnerellosis
Option 3 - there is a complete replacement of lactobacilli with obligate anaerobic microorganisms, which leads to a complete change in the microbiocenosis of the vagina
Hormonal factors can also lead to an imbalance in the microflora of the vagina. The entry of exogenous bacteria into the vagina leads to increased reproduction of endogenous microorganisms.
Gardnerellosis is a disease that requires treatment. If left unattended, serious complications can arise. Not only the microflora of the vagina will change dramatically, but diseases of the pelvic organs may also occur (both in women and men):
Inflammatory diseases of the pelvic organs
- infertility
- urethral syndrome
- cervical intraepithelial neoplasia
- Bartholinitis and abscesses of the Bartholin gland
- chronic prostatitis
- non-gonococcal urethritis
- balanitis, balanoposthitis
Gardnerella (Gardnerella vaginalis) is the causative agent of a bacterial infection - gardnerellosis, an inflammatory disease of the genitourinary tract.
Clinical picture of gardnerellosis
Gardnerellosis can occur without any signs, but in most cases there are:
Profuse, creamy, greyish-white discharge that sticks to the walls of the vagina
- the presence of an unpleasant (fishy) odor resulting from the breakdown of amines, which are produced by anaerobic bacteria
- inflammation of the vagina
- vulvovaginal irritation (itching and burning)
- Discomfort during intercourse
In pregnant women, gardnerellosis can cause:
Inflammatory diseases of the reproductive system and urinary tract with frequent relapses
- abnormal uterine bleeding
- premature rupture of membranes during childbirth
- postpartum endometritis
- complications after operations on the pelvic organs and caesarean section
- chorionamnionitis
- pneumonia in a newborn
- low birth weight
In women with gardnerellosis, infection of the membranes of the placenta is common. However, the risk of having a low birth weight baby can be reduced by timely treatment of the mother.
Persistent changes in the microflora of the vagina lead to serious complications, significantly increasing the risk of diseases of the pelvic organs.
Diagnosis of gardnerellosis
The following laboratory tests are used to diagnose gardnerellosis:
- measurement of the pH of the vaginal discharge
- amino test
- Gram-stained smear microscopy method
- identification of key cells
The following criteria indicate the presence of infection:
- detection of key cells (in native preparations, squamous epithelial cells are detected, on which gardnerella are attached)
- homogenous vaginal discharge with a fishy odor
- vaginal pH > 4.5.
- amine test (the presence of gardnerella is indicated by a fishy smell that appears when one or two drops of secretions are added to 5-10% hydroxide)
The diagnosis can only be established if at least three criteria are confirmed, since the presence of key cells does not yet indicate the presence of the disease.
There are 4 categories depending on the number of morphotypes of microorganisms:
1+ (1 in sight)
2+ (1-5 in sight)
3+ (6-30 in sight)
4+ (>30 per field of view)
With gardnerellosis, the number of morphotypes of lactobacilli in the smear is reduced (1+ or 2+), and the number of gardnerella and anaerobes is increased (3+ or 4+).
It is not recommended to isolate a pure culture of Gardnerella vaginalis, because in more than half of healthy women the level of these microbes in the vaginal secretion is quite high.
Treatment of gardnerellosis
Treatment of gardnerellosis begins with antibiotic therapy. It should be borne in mind that gardnerella is resistant to tetracyclines, sulfonamides, aminoglycosides and cephalosporins, but sensitive to ampicillin and clindamycin.
Further treatment of gardnerellosis is the use of local eubiotics to restore the biocenosis of the vagina. For this purpose, microbial preparations are used that have antagonistic activity against opportunistic microorganisms and are freeze-dried biomass of live cultures, which is produced from strains of bifidus and lactobacilli. different types.
The effectiveness of treatment is determined by a number of factors:
- dynamics of clinical symptoms
- normalization of laboratory parameters
- disappearance of subjective sensations
A week after completion of therapy, the first laboratory examination is carried out, and a second one - after 4-6 weeks.
Treatment of gardnerellosis approach number 2
Treatment of gardnerellosis includes topical preparations (vaginal tablets and suppositories) and oral administration (tablets or capsules).
Preparations for topical treatment include (international names are given first, then commercial names are listed in brackets):
Metronidazole, 0.75% gel (Metrogil, Flagyl, Klion-D 100). The drug is injected into the vagina 2 times a day for 5 days.
Clindamycin 2% cream (Dalacin). The drug is injected into the vagina 1 time per day (at night) for 7 days.
Oral preparations include (international names listed first, followed by trade names in parentheses):
Metronidazole (Klion, Metronidazole, Medazol, Metrogil, Trichopolum, Flagyl, Efloran). The drug is taken 500 mg orally 2 times a day for 7 days. Metronidazole is absolutely incompatible with alcohol!
Clindamycin (Dalacin, Climycin, Clindamycin). The drug is taken 300 mg orally 2 times a day for 7 days.
Side effects of local treatment are less than with systemic treatment. However, given the role of gardnerellosis in the development of inflammation of the appendages and female infertility, now more and more preference is given to drugs for oral administration.
In some cases, treatment is prescribed that complements antibiotic therapy (immunotherapy, restorative drugs, physiotherapy, etc.).
Treatment of gardnerellosis in pregnant women
Treatment of gardnerellosis during pregnancy should be carried out under the supervision of a gynecologist. Self-treatment is unacceptable. Clindamycin (both topically and orally) is contraindicated during pregnancy.
In the first trimester of pregnancy, metronidazole is also contraindicated. With exacerbation of gardnerellosis in the first trimester of pregnancy, ampicillin is prescribed. In the II and III trimesters, metronidazole is prescribed, which is more effective than ampicillin.
Research Institute of Physical and Chemical Medicine of the Ministry of Health of the Russian Federation Research and Production Company "LITECH" Moscow State University named after M.V. Lomonosov Russian Medical Academy of Postgraduate Education
L.V. Kudryavtseva, E.N. Ilyina, V.M. Govorun, V.I.Minaev, S.V.Zaitseva, E.V.Lipova, E.A.Batkaev
Introduction normocenosis Bacterial vaginosis Laboratory diagnostics of vaginal microecology disorders Preliminary diagnosis of BV microscopic examination Bacteriological method Basic culture media recipes Indicator Recipes Culture media recipes for determining carbohydrate fermentation Gas-liquid chromatography method Method of gene diagnostics Practical recommendations Principles of treatment Bibliography
|
INTRODUCTION |
Various human organs and cavities with their inherent microflora represent a single ecological system - microbiocenosis. Microbiocenoses have arisen in places of contact of the human body with the environment - the skin, the mucous membrane of the gastrointestinal tract, the vagina and are in a state of dynamic equilibrium with changing environmental conditions. The microbiocenosis of various human organs and cavities is a very sensitive indicator system that is able to respond with qualitative and quantitative changes to any physiological and pathological changes in the state of the macroorganism and prevent the invasion of pathogenic microorganisms.
The vagina with its inherent microflora form a single ecosystem in which the vaginal environment controls the microflora, and the microflora, in turn, affects the vaginal environment.
The normal microflora of the vagina is divided into obligate (resident, indigenous), facultative and transient.
The obligate microflora includes microorganisms that are constantly part of the normal microflora of the vagina (non-pathogenic, conditionally pathogenic). Participating in the metabolism of the host organism, they prevent the penetration of pathogenic bacteria into the vaginal biotope. Representatives of the facultative microflora are quite often, but not always, found in healthy women. Transient microflora includes non-pathogenic, opportunistic and pathogenic microorganisms accidentally introduced into the genital tract from the environment. In the normal state of the microecology of the vaginal tract, these microorganisms, as a rule, are not capable of a long stay in it and do not cause the development of a pathological process. In the event of a violation of the microecology of the genital tract, which can occur when a woman's body is exposed to various adverse external influences - in extreme conditions, stressful situations, in cases of a decrease in the immune status, with hormonal disorders, therapeutic measures, conditions are created and maintained that lead to a decrease in colonization resistance during vagina in relation to the settlement of its pathogenic and opportunistic microorganisms. As a result of this, the introduction of transient microflora or the additional introduction of opportunistic microorganisms - representatives of the normal microflora of the vagina into the mucous membrane of its wall may occur, followed by translocation to the urinary tract, cervical canal and other organs and tissues.
Antibiotic therapy, which is successfully used for the prevention and treatment of infectious diseases, at the same time can lead to a violation of the microecology of the vagina and colon or contribute to an increase in the degree of already existing violations of the microecology.
Hormonal and chemotherapy, long-term use of intrauterine devices, radiation therapy, surgical interventions, and toxic environmental factors can have a damaging effect on the normal microflora of the vagina.
Infectious and inflammatory diseases of the female genital organs occupy a special place in the structure of general morbidity. Their significance is primarily due to the fact that these diseases affect organs and tissues related to the reproductive system, and therefore they can have a direct impact on reproductive function.
According to numerous epidemiological studies among infectious and inflammatory diseases of the female genital organs, all greater value acquire inflammatory processes, the etiological agent of which are opportunistic bacteria and fungi ( U. urealyticum, Bacteroides spp., Corynebacterium spp., Candida spp.. etc.), which are an integral part of the normal microflora. The absence of a specific picture of inflammation, a sluggish and often asymptomatic course complicate the diagnosis of these diseases, which can contribute to the chronicity of the process and the development of complications. The detection of certain types of these microorganisms in the composition of the vaginal microflora does not allow to give an objective assessment of the state of microcenosis and resolve the issue of the need for etiotropic therapy. Only quantitative studies that determine the ratio of certain types of microorganisms, as well as the study of their biological properties, fully characterize vaginal microcenosis.
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NORMOCENOSIS |
The vaginal microflora is strictly individual and can even undergo changes in the normal state in various phases of the menstrual cycle. In addition, the concept of the norm may be different for different age groups, ethnic groups and even geographical areas. In this regard, variants of the normal microbiocenosis (normocenosis) of the vagina are possible.
The microecology of the vagina is largely due to its embryonic origin and histomorphological structure. The vagina is covered with stratified non-keratinizing squamous epithelium, which does not contain glands. The dividing cells of the basal layer of the epithelium mature as they move towards the lumen of the vagina. The processes of physiological maturation of epitheliocytes, their desquamation and the thickness of the surface layer are subject to cyclic changes in response to the action of sex hormones.
The epithelium of the vagina, performing a protective function, ensures its resistance to the effects of pathogenic agents (bacteria, viruses, fungi). An important indicator of the resistance of the vaginal epithelium is the amount of glycogen, which is contained mainly in the surface cells. Since these cells are constantly shedding and undergoing cytolysis, glycogen is released, providing a nutrient substrate for normal microflora. Glycogen also promotes tissue regeneration, is an important carbohydrate component of the body, which is involved in the production of immune bodies. The amount of glycogen in the cells of the vaginal epithelium varies in the same woman throughout life, and also depending on the phase of the menstrual cycle. A relationship has been established between the content of glycogen in the upper layers of the epithelium, vaginal transudate and hormonal function of the ovaries. The maximum accumulation of glycogen occurs at the time of ovulation.
Thus, the possible hormonal changes during the menstrual cycle and the life of a woman (puberty, menopause, pregnancy) determine the intensity of enzymatic processes in the vagina and affect the state of its microflora.
The composition of the vaginal microflora, both qualitative and quantitative, can be influenced by the national characteristics of the toilet of the genital organs, the degree of sexual activity, as well as all kinds of methods of contraception.
It should be noted that in addition to the endocrine system and interactions at the level of bacteria - representatives of the normoflora of the vaginal biotope (certain types of microorganisms are able to dominate others and the products of their metabolism can serve as factors limiting the total population of bacteria that are part of the normal microflora (vagina), the microbiocenosis of the vagina is affected nervous and immune systems that act as a whole.A violation in one of these links invariably leads to certain shifts in the coordinated function of the entire complex, resulting in a violation of the microecology of the vagina, which can further lead to the development of inflammatory processes in the genital tract.
Normally, the vagina in newborn girls is sterile in the first hours of life. By the end of the first day after birth, it is colonized by aerobic and facultative anaerobic microorganisms. After a few days, glycogen accumulates in the vaginal epithelium, which is an ideal growth substrate for lactobacilli, and lactobacilli begin to predominate in the vaginal microflora of newborn girls. Ovarian hormones, stimulating the receptor activity of the vaginal epithelium, also contribute to the active adhesion of lactobacilli on the surface of the vaginal epithelium. Lactobacilli, in turn, break down glycogen to form lactic acid. This leads to a shift in the pH of the vaginal contents to the acidic side (up to 3.8-4.5) and limits the growth and reproduction of microorganisms that are sensitive to an acidic environment. During this period, the vaginal microflora in newborn girls is similar to the microflora of the vagina of healthy adult women.
Three weeks after birth, girls are completely metabolized maternal estrogens. The epithelium becomes thin. The content of glycogen in it decreases. This leads to a decrease in the amount of normal microflora, primarily lactobacilli, as well as a decrease in the level of organic acids produced by these bacteria. As a result of a decrease in the level of organic acids, the pH of the vaginal environment increases from 3.8-4.5 to 7.0. Strictly anaerobic bacteria begin to dominate in the microflora.
Starting from the second month of life and throughout the pubertal period until the activation of ovarian function, there is a decrease in the total number of microorganisms in the vagina in girls compared with the neonatal period.
In the pubertal period, from the moment of activation of the ovarian function, “own”, endogenous estrogens appear in the body of girls. Under the influence of these estrogens, glycogen accumulates in the cells of the vaginal epithelium and the so-called “estrogen-stimulated epithelium” is formed. On the surface of vaginal epitheliocytes, the number of receptor sites for adhesion of lactobacilli increases. The thickness of the epithelial layer increases. From this point on, lactobacilli again become the dominant microorganisms in the vagina and subsequently retain this position throughout the entire reproductive period in women. The metabolism of lactobacilli contributes to a stable shift in the pH of the vaginal environment to the acid side up to 3.8-4.5. In the vaginal environment, the redox potential increases, and this all creates unfavorable conditions for the growth and reproduction of strictly anaerobic microorganisms.
In healthy women of reproductive age, estrogens act on the vaginal epithelium during the follicular or proliferative phase of the menstrual cycle, and progesterone during the luteal or secretory phase. In this regard, the frequency of inoculation and the number of strictly anaerobic and most aerobic representatives of normal microflora are higher in the proliferative phase than in the secretory one. Therefore, the most information about the quantitative and qualitative composition of the vaginal microflora can be obtained on days 2-14 of the menstrual cycle. The smallest number of microorganisms in the vagina is determined during menstruation. The level of lactoflora remains constant.
Morphofunctional, physiological and biochemical changes in the genital tract during pregnancy lead to the fact that the vaginal microflora becomes more homogeneous. During pregnancy, the concentration of glycogen in the vagina in women increases. Favorable conditions are created for the vital activity of lactobacilli, the amount of which in the vagina of pregnant women significantly exceeds those in the vagina of non-pregnant women. At the same time, the numbers of bacteroids and other non-spore-forming strict anaerobes, as well as aerobic gram-positive cocci and gram-negative rod-shaped bacteria, are reduced. These changes reach a peak in the third trimester of pregnancy, which subsequently reduces the likelihood of contamination of the fetus by opportunistic microorganisms during its passage through the birth canal.
During childbirth, the primary contamination of the child's body, normally sterile before birth, with vaginal microflora occurs. The composition of the vaginal microflora of the woman in labor subsequently determines the composition of the microflora of the conjunctiva, gastric aspirate, skin, which are identical to the microflora of the mother's birth canal, and the risk of developing an infectious process in newborns is directly dependent on the degree of contamination of the amniotic fluid. The vaginal microflora of the woman in labor also plays an important role in the formation of normal intestinal microflora in newborns.
Thus, the state of the microflora of the mother's vagina has a significant impact on the formation of the intestinal microbiocenosis of the child and on the nature of the course of the neonatal period.
After childbirth, significant changes occur in the microflora of the vagina - both qualitative and quantitative. These changes may be associated with a significant decrease in estrogen levels, especially in the third trimester of pregnancy, the possibility of trauma to the vagina and its contamination with intestinal microflora during childbirth. In the postpartum period, the number of non-spore-forming gram-negative strict anaerobes increases significantly - Bacteroides spp.. and gram-negative facultative anaerobic bacteria - E.coli and there is a decrease in the levels of lacto- and bifidobacteria. Violations of the normal vaginal microflora in the postpartum period can contribute to the development of infectious complications in the uterus and appendages. Changes in the microflora in parturient women are transient, and by the 6th week of the postpartum period, the vaginal microflora is restored to normal.
With the onset of menopause, the levels of estrogens and, accordingly, glycogen in the genital tract are significantly reduced. The number of lacto- and bifidobacteria decreases. During this period, in women, the pH of the vaginal environment acquires neutral values. The qualitative composition of the microflora becomes scarce. The overall level of bacteria decreases. Among the microorganisms detected in the vagina, obligate anaerobic bacteria predominate.
The normal microflora of the vagina in healthy women of reproductive age is characterized by a wide variety of bacterial species, the vital activity of which largely depends on their ability to adhere to the cells of the vaginal epithelium and the possibility of competition among themselves for habitats and food. The vaginal microflora of healthy women of reproductive age includes a wide range of microaerophiles, facultative and obligate anaerobes (Table 1).
Table 1 Species composition of the vaginal microflora of healthy women of reproductive age.
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Types of microorganisms |
Release frequency (%) |
Ability to cause disease |
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Microaerophilic bacteria: |
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Lactobacillus spp. L.fermentum L.crispatus L.jensenii L.gasseri L.acidophilus L.plantarum L.brevis L.delbruckii L.salivarius |
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G. vaginalis |
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Lactobacillus spp. |
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Bifidobacterium spp. B.bifidum B.breve B.adolescentis B.longum |
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Clostridium spp. |
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Propionibacterium spp. p.acnes |
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Mobiluncus spp. |
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Peptostreptococcus spp. P.asaccharoliticus P.magnus P.prevotii P.tetradius |
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Bacteroides spp. B.utealyticum B.fragilis B.vulgatus B.ovatus B.distasonis B.uniformis B.caccae B.multiacidus |
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Prevotella spp. P.bivia P.disiens |
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Porphyromonas spp. P.asaccharolitica |
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Fusobacterium spp. F. nucleatum |
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Veilonella spp. |
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Corynebacterium spp. С.aquatum C.minutissium C.equi C.xerosis C.bovis C.enzymicum C.kutsheri |
Causative agents of opportunistic infections |
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Staphylococcus spp. S.epidermidis S.saprophyticus |
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Streptococcus spp. S.viridans E.fecalis E.faecium S.agalactiae |
Respiratory diseases, meningitis, neonatal senticemia |
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Enterobacteriaceae |
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E.coli Enterobacter spp. Klebsiella spp. Proteus spp. P. aerugenosa |
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M. hominis |
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U. urealyticum |
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M. fermentans |
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Yeast-like fungi of the genus Candida: |
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C.albicans C.tropicalis Torulopsis glabrata |
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Most often, microaerophilic, producing H 2 O 2 (71-100%), less often anaerobic (5-30%) gram-positive rods are isolated - representatives of the genus Lactobacillus. Among the representatives of obligate anaerobes with a high frequency (30-90%), a group is found Peptostreptococcus, which includes all members of the genus previously known as Peptococcus (with the exception of P.niger) and all Gram-positive anaerobic cocci previously identified as Gaffkya anaerobia. Gram-positive rods, strict anaerobes Bifidobacterium spp.. detected in healthy women with a frequency of 12%, Clostridium spp.. - in 10-25% of cases, respectively. In rare cases (0-5%), species are found in the vaginal discharge Mobiluncus. Typical representatives of the normal microflora of the genital tract in women are Propionibacterium spp. (P. acnes), which can be isolated with a frequency of up to 25%. Gram-negative strictly anaerobic rod-shaped bacteria such as Bacteroidides spp.. (b. urealyticum, B. fragilis, B. vulgatus, B. ovatus, B. distasonis, B. uniformis, B. coccae, B. multiacidus), are detected in 9-13% of women, Fusobacterium spp.. in 14-40%, Porphyromonas spp. 31% Prevotella spp. present in the vagina in women in 60% of cases. Significant space is given Pr. bivia And Pr. disiens- unique microorganisms of the female genital tract, the role of which is equated with the role of B. fragilis in the intestine. B. fragilis isolated from the genital tract of healthy women, according to various sources, in 5-12% of cases.
Microaerophiles in the vagina of healthy women, in addition to lactobacilli, are represented by G. vaginalis. According to various authors G. vaginalis occurs in 6-60% of cases.
Among facultative anaerobic microorganisms, catalase-positive, coagulase-negative S.epidermidis, and novobiocin-resistant S.saprophyticus (62%), Streptococcus spp.(streptococci of the viridans group - "green", alpha (or gamma), hemolytic, serological group B streptococci (Str. agalactie) and serological group D streptococci (enterococci)), non-pathogenic corynebacteria ( C. minutissium,C. equi(new name Rhodococcus equi), C. aquaticum, C. xerosis) are present in 30-40%. E. coli, according to various sources, are isolated from 5-30% of women. Other enterobacteria ( Klebsiella spp.., Citrobacter spp., Enterobacter spp..) occur in less than 10% of healthy women. Normocenosis is characterized by the presence of genital mycoplasmas - M. hominis And U. urealyticum, which occur in 2-15% of sexually active women, while M. fermentas rarely defined.
Yeast-like fungi of the genus Candida: C. albicans, C. tropicalis And Torulopsis glabrata(previously candida glabrata) are detected in the vagina of healthy women in 15-20% of cases. candida albicans- the most characteristic type, determined in 80-90% of women whose vagina is colonized by fungi of the genus Candida.
Vaginal discharge normally contains 10 8 -10 12 CFU / ml of microorganisms, while facultative anaerobic bacteria are 10 3 -10 5 CFU / ml, anaerobic - 10 5 -10 9 CFU / ml (Table 2).
table 2. The degree of contamination of the vaginal discharge by various types of microorganisms in healthy women of reproductive age
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Microorganism |
Quantity (cfu/ml) |
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Microaerophilic bacteria: Lactobacillus spp. G.vaginalis |
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Obligate anaerobic Gram-positive bacteria: Lactobacillus spp.Bifidobacterium spp. Clostridium spp. Propionibacterium spp. Mobiluncus spp.Peptostreptococcus spp. |
10 7 -10 9 10 3 -10 7 up to 10 4 up to 10 4 up to 10 4 10 3 -10 4 |
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Obligate anaerobic Gram-negative bacteria: Bacteroides spp.Prevotella spp. Porphyromonas spp. Fusobacterium spp. Veilonella spp. |
10 3 -10 4 up to 10 4 up to 10 3 up to 10 3 up to 10 3 |
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Facultative anaerobic Gram-positive bacteria: Corynebacterium spp.Staphylococcus spp. Streptococcus spp. Enterobacteriaceae |
10 4 -10 5 10 3 -10 4 10 4 -10 5 10 3 -10 4 |
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M.hominis U.urealyticum M.fermentas |
10 3 10 3 to 10 3 |
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Yeast-like fungi of the genus Candida |
Against the background of all species diversity, the leading place in the vaginal microcenosis is occupied by microaerophilic lactobacilli, the number of which can reach 10 9 CFU / ml. By colonizing the vaginal mucosa, lactobacilli participate in the formation of an ecological barrier and thereby ensure the resistance of the vaginal biotope. The protective properties of lactobacilli are implemented in different ways: due to antagonistic activity, the ability to produce lysozyme, hydrogen peroxide and adhesive properties. However, the main mechanism providing colonization resistance of the vaginal biotope is the ability of lactobacilli to acid formation. Lactic acid is a metabolic product of lactobacilli. It is formed during the destruction of the glycogen of the vaginal epithelium by lactobacilli and determines the acidic pH of the vaginal contents, which is normally 3.8-4.5. Lactobacilli produce lactic acid in quantities sufficient to create a pronounced acidic environment in the vaginal discharge and, thereby, prevent the growth of acidophobic bacteria.
Thus, the determining factor in the state of vaginal microcenosis is lactoflora, its concentration and combination of properties.
Bifidobacteria, being part of the microcenosis of the vagina, like bacteria of the genus Lactobacillus, belong to the Doderlein flora. In healthy women of reproductive age, they are detected with a lower frequency, at concentrations of 10 3 -10 7 CFU / ml. Like lactobacilli, they are acid-producing microorganisms and are involved in maintaining low pH values in the vagina. Bifidobacteria adhere to the surface of vaginal epithelial cells, are able to produce bacteriocins, lysozyme, alcohols, which also ensures their participation in the creation and maintenance of colonization resistance in the vagina against opportunistic and pathogenic microorganisms. Bifidobacteria synthesize amino acids and vitamins, which are actively used by the host organism in its metabolism.
Peptostreptococci are the third constituent of the Doderlein flora. The number of anaerobic cocci in the vaginal discharge is 10 3 -10 4 CFU / ml. Although peptostreptococci are part of the normal flora of the female genital tract, they are often found in septic abortions, tubal-ovarian abscesses, endometritis, and other severe infections of the female genital organs. In association with other anaerobic bacteria, peptostreptococci are isolated in a large number of cases in bacterial vaginosis.
Propionobacteria are commensals of the human body. Due to the organic acids produced by them, these bacteria can participate in maintaining the colonization resistance of the vagina. They have immunostimulating properties. They are allocated in quantities not exceeding the norm of 10 4 CFU / ml.
Normally, the quantitative level of porphyromonas, veillonella and fusobacteria does not exceed 10 3 CFU/ml, and bacteroids and prevotella - 10 4 CFU/ml, respectively. .
The pathogenic properties of strictly anaerobic Gram-negative bacteria are associated with their enzymatic systems. So u B. fragilis hyaluronidase, collagenase, fibrinolysin, immunoglobulin proteases, heparinase and sialidase were identified. B. fragilis have other pathogenicity factors, for example, capsular polysaccharide. In addition, bacteroids of the "fragilis" group are capable of producing catalase, which allows them to resist the action of H 2 O 2 produced by lactobacilli. Various proteases and collagenases have been found in bacteria of the genus Porphyromonas. Proteases and fibrinolysin were also found in various kinds kind Prevotella. Fusobacterium necrophorum have the ability to synthesize hemolysin and platelet aggregation factors.
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