Who's There? Changing concepts of vaginal microbiota

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2 Who's There? Changing concepts of vaginal microbiota Healthy vaginal ecosystem: H 2 O 2 -producing lactobacilli E.J. Baron, Ph.D., D(ABMM), F(AAM), F(IDSA) Prof. Emerita Pathology, Stanford University Executive Director of Technical Support, Cepheid

3 Trichomonas Candida Mycoplasma/ Ureaplasma Lesions: Herpes simplex Human papilloma virus (HPV) Trepon. pallidum (Syphilis) Molluscum contagiosum Chlamydia Gonorrheae Bacterial vaginosis (BV)

4 Etiologies of vaginal infections 30.2 Percent of women Before NAAT for Trich (25% asymptomatic) 0 Trich Mixed/ STD Yeast BV Normal From a major U.S. Ob/Gyn department.

5 Trichomonas vaginalis 1. Protozoan; flagellate 2. High incidence (50%) in some populations 3. Carried by males/females (25% asymptomatic) 4. Assoc. with preterm labor 5.Lab diagnosis: NAAT best test (Hologic); culture next; or VP Affirm Wet preparation only 50% sensitive

6 Ct Trich % Ng Age of patient

7 STIs in USA (NAATs best test) Estimated 2.8 million new cases in ,000 new cases in 2011

8 Good or bad vaginal gram stain?

9 Vaginal Lactobacilli vs. HIV or STD Acquisition of: Absence of Lactobacilli HIV 2.5 GC 1.7 C. trachomatis 1.8 T. vaginalis 1.4 Candida 0.6 BV 1.3 Hillier, S.L. Communication

10 The adherence of Trichomonas vaginalis to host ectocervical cells is influenced by lactobacilli Phukan et al Sex. Trans. Infect.

11 Gram stain for BV Intermediate Normal

12 Gram stain for BV BV

13 Bacterial Concentration Lacto G. vag Anaer Hillier, S.L. Communication ph

14 BV vaginal mucosal ecosystem Looks like a biofilm

15 Gardnerella coated epithelium Fluorescent probe stained Gardnerella vaginalis Conclusion: BV is a biofilm disease

16 BV increases Risks: Preterm delivery First trimester miscarriage in women undergoing in vitro fertilization Amniotic fluid infections Chorioamnionitis Postpartum and postabortal endometritis Postabortal pelvic inflammatory disease (PID) In nonpregnant women, BV increases risk of post-hysterectomy infections and PID Risk of acquiring Neisseria gonorrhoeae

17 BV increases Risks: Among HIV-infected women, the quantity of HIV shed in vaginal secretions from those with BV was increased nearly 6-fold relative to those without BV BV probably enhances women s likelihood of sexual acquisition of HIV

18 BV vs. HIV Prevalence Country # HIV in BV+ HIV in BV- Odds Ratio Thailand % 11% 2.7 Uganda % 17% 1.9 Malawi % 20% 2.0 US % 0.9% 3.8 Hillier, S.L. Communication Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies. Atashili J, Poole C, Ndumbe PM, Adimora AA, Smith JS. AIDS Jul 31;22(12):

19 Risk of sexually transmitted infection within 24 months for different categorizations of bacterial vaginosis Allsworth & Pierper AJOG

20 Normal Vaginal Microbes (Culture based) Lactobacilli 95% Streptococci 38% Ureaplasma 80% Enterics 25% Staphylococci 66% Pigmenters 25% Prevotella spp. Peptostrept. 52% 42% Mycoplasma 14%

21 MICROBES ASSOCIATED WITH BV By Traditional Methods Prevotella bivia; P. disiens Prevotella corporis; Bacteroides levii Mobiluncus spp. Peptostreptococcus tetradius; P. anaerobius viridans streptococci Gardnerella vaginalis Mycoplasma hominis Ureaplasma urealyticum

22 Molecular Methods Used to Study Vaginal Microbiota Marrazzo et al Sex. Trans. Dis.

23 FISH test of vaginal discharge from woman with BV Green=Prevotella/Porphyromonas Red=Atopobium/Eggerthella

24 What s normal via PCR? Lactobacillus crispatus Lactobacillus jensenii Gardnerella vaginalis (up to 70% of normal women) What s associated with BV via PCR? Atopobium vaginae Prevotella species Mobiluncus species Mycoplasma hominis Ureaplasma urealyticum BVAB1, 2, 3 (Clostridiales) Lactobacillus iners Megasphaera type 2 Sneathia Leptotrichia Eggerthella Dialister Slackia

25 New organisms recognized with PCR Atopobium vaginae Peptoniphilus sp. Sneathia sanguinegens Leptotrichia amnionii Anaerococcus sp. Lactobacillus iners Pseudoramibacter sp. Aerococcus sp. Dialister sp. Actinobacteridae sp. Megasphaera sp. BVAB (Clostridium group)

26 Molecular methods to describe the spectrum and dynamics of the vaginal microbiota Fredricks. Anaerobe 2011.

27 Normal Vaginal Microbes Molecular based The Human Vaginal Bacterial Biota and Bacterial Vaginosis. Srinivasan and Fredricks. Interdisc. Perspect. Infect. Dis. 2008:1-22. Lactobacillus crispatus Lactobacillus iners Gardnerella vaginalis

28 BV Vaginal Microbes Molecular based Gardnerella vaginalis Prevotella Lactobacillus iners Atopobium vaginae Leptotrichia Megasphaera Prevotella Porphyromonas Clostridial Clostridial - unnamed BVAB

29 Molecular methods to describe the spectrum and dynamics of the vaginal microbiota Fredricks. Anaerobe 2011.

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31 What happened? 1. Transmission of a specific bacterial pathogen 2. Transmission of a phage that attacks the protective lactobacilli 3. Use of vaginal lubricants that disrupt the normal ecosystem

32 Extravaginal Reservoirs of Vaginal Bacteria as Risk Factors for Incident Bacterial Vaginosis Marrazzo et al J. Infect. Dis. Gardnerella in oral cavities of cases vs controls

33 Flora changes with advent of sexual activity Mitchell et al Obstet. Gyn.

34 Relationships via cultures Relationships via molecular methods (genomic studies)