Aerobic vaginitis (AV) is an alteration in vaginal bacterial flora that differs from bacterial vaginosis (BV). AV is characterised by an abnormal vaginal microflora accompanied by an increased localised inflammatory reaction and immune response, as opposed to the suppressed immune response that is characteristic of BV. Given the increased local production of interleukin (IL)-1, IL-6 and IL-8 associated with AV during pregnancy, not surprisingly AV is associated with an increased risk of preterm delivery, chorioamnionitis and funisitis of the fetus. There is no consensus on the optimal treatment for AV in pregnant or non-pregnant women, but a broader spectrum drug such as clindamycin is preferred above metronidazole to prevent infection-related preterm birth. The exact role of AV in pregnancy, the potential benefit of screening, and the use of newer local antibiotics, disinfectants, probiotics and immune modulators need further study.Keywords Abnormal vaginal flora, aerobic vaginitis, bacterial vaginosis, chorioamnionitis, intrauterine infection, intrauterine inflammatory syndrome, preterm birth, vaginitis. IntroductionThe prevention of preterm birth remains a major challenge in obstetrics. Whereas over the years much attention has been given to structural deficiencies, such as uterine abnormalities, or a 'weak' or 'insufficient' cervix, during the last decades the importance of ascending infection as a possible cause of preterm birth, preterm rupture of the membranes and intrauterine infection has become increasingly evident. 1The earlier in gestation that preterm labour starts, the higher the likelihood that underlying chorioamnionitis is present. Although the risk of chorioamnionitis in term deliveries is around 1%, this risk increases to more than 45% in preterm deliveries.2 The consequences of intrauterine infection for the fetus is not limited to the complications and sequelae of preterm birth, but is also related to inflammation-induced neurologic injury resulting in intra-or periventricular haemorrhage and cerebral palsy.3 Ascending infection during gestation may also result in maternal complications such as sepsis, septic arthritis and maternal respiratory distress. 4 Definition of aerobic vaginitisAerobic vaginitis (AV) is defined as a disruption of the lactobacillary flora, accompanied by signs of inflammation and the presence of a rather scarce, predominantly aerobic microflora, composed of enteric commensals or pathogens. The concerted and exclusive emphasis on the recognition and diagnosis of bacterial vaginosis (BV) has minimised efforts to describe other abnormal flora types that may cause vaginal disease. By systematically analysing fresh smears of vaginal fluid of symptomatic and asymptomatic women with phase contrast microscopy, another important type of abnormal bacterial flora, in addition to BV, needs to be considered as a potential contributing factor in the pathogenesis of preterm labour. Diagnosis of aerobic vaginitisThe criteria for the microscopic diagnosis of AV are provided in Table...

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Clindamycin and metronidazole are the standard drugs for BV. As other antibiotic and acidifying treatments are progressively being studied, like tinidazole, rifaximin, nitrofuran, dequalinium chloride, vitamin C and lactic acid, more options have become available for switching therapy, combining therapies and long-term prophylactic use to prevent recurrences. Further studies are needed. Also, adjuvant therapy with probiotics may have a significant role in improving efficacy and in preventing recurrences. However, it is unlikely that probiotics will replace antibiotherapy.

The aim of this study is to analyse the association between vaginal microbiota and the histological finding of CIN. From July 2016 until June 2017, we included 110 consecutive patients with abnormal cervical cytology results referred for colposcopy to Riga East Clinical University Hospital Outpatient department in the study group. 118 women without cervical pathology were chosen as controls. Certified colposcopists performed interviews, gynaecological examinations and colposcopies for all participants. Material from the upper vaginal fornix was taken for pH measurement and wet-mount microscopy. Cervical biopsy samples were taken from all subjects in the study group and in case of a visual suspicion for CIN in the control group. Cervical pathology was more often associated with smoking (34.6% vs. 11.0%, p < 0.0001), low education level (47.2% vs. 25.5%, p = 0.001), increased vaginal pH (48.2% vs. 25.4%, p < 0.0001), abnormal vaginal microbiota (50% vs. 31.4%, p = 0.004) and moderate to severe aerobic vaginitis (msAV) (13.6% vs. 5.9%, p = 0.049) compared to controls. The most important independent risk factors associated with CIN2+ were smoking (OR 3.04 (95% CI 1.37–6.76), p = 0.006) and msAV (OR 3.18 (95% CI 1.13–8.93), p = 0.028). Bacterial vaginosis (BV) was found more often in CIN1 patients (8/31, 25.8%, p = 0.009) compared with healthy controls (8/118, 6.8%), or CIN2+ cases (8/79, 10.1%). In the current study msAV and smoking were the most significant factors in the development of CIN in HPV-infected women, especially high grade CIN. We suggest that AV changes are probably more important than the presence of BV in the pathogenesis of CIN and progression to cervix cancer and should not be ignored during the evaluation of the vaginal microbiota.