孕妇阴道感染与乳酸杆菌相关性的研究
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摘要
阴道炎是育龄妇女常见的一种生殖系统感染性疾病。妊娠后，受体内高雌激素水平的影响，阴道内糖原合成增加，前庭腺体和阴道分泌物增加，外阴潮湿，利于细菌的生长繁殖，因而孕妇阴道炎的发病率较高。近年来的研究资料表明，孕期阴道感染，特别是细菌性阴道病，与许多产科并发症有关，包括自然流产、早产、胎膜早破、羊膜腔感染、产后子宫内膜炎等，然而目前临床上尚无理想的药物治疗孕妇阴道感染。乳酸杆菌是正常阴道内的优势菌，通过产酸、产生过氧化氢等作用机制调节阴道微生态平衡，抑制病原微生物生长，从而降低阴道感染的发病率。大量临床资料表明，乳酸杆菌为阴道优势菌时，能够降低孕妇阴道感染的发病率。国内外已有使用不同乳酸杆菌制剂治疗阴道感染的报道，然而，由于目前乳酸杆菌的鉴定困难，许多研究仅仅局限在乳酸杆菌属的水平，关于治疗阴道感染的乳酸杆菌菌种的选择上仍然存在较大争议。
本课题根据孕妇的临床表现和阴道分泌物检查，对孕妇阴道感染的发病率及其与乳酸杆菌的相关性进行了临床调查。同时采用生物化学的方法对孕妇阴道内乳酸杆菌进行鉴定，了解孕妇阴道内乳酸杆菌的分布情况，比较孕妇阴道内四种常见乳酸杆菌产生过氧化氢、降低培养环境PH的能力，初步筛选出适于治疗孕妇阴道感染的乳酸杆菌，实验结果如下：
1、正常孕妇乳酸杆菌的检出率明显高于感染细菌性阴道病的孕妇；与感染白念菌阴道炎的孕妇相比较，相差不显著；
2、孕妇阴道内的优势乳酸杆菌是嗜酸乳酸杆菌和卷曲乳酸杆菌；
3、正常孕妇H_2O_2阳性乳酸杆菌的分离率明显高于感染细菌性阴道病、白念菌阴道炎的孕妇。
4、大多数卷曲乳酸杆菌和嗜酸乳酸杆菌产生H_2O_2，两者降低培养环
境PH的能力较强。
本研究结果表明，HZOZ阳性乳酸杆菌在防御孕妇阴道感染中起着重要
作用。孕妇阴道内的优势氏。阳性乳酸杆菌是卷曲乳酸杆菌和嗜酸乳酸
杆菌，它们在维持阴道微生态平衡、防御阴道感染具有较强的优势，为联
合或单独使用这两种乳酸杆菌防治孕妇阴道感染提供了实验依据。
Vaginosis is one of the most common genital infections among women during childbearing age. During perinatal period, increased level of estrogen stimulate the deposition of glycogen in the vaginal epithelium, the enviroment of the vagina is adapt to the growth of bacteria, so the incidence of vaginal infections is increased in pregnant women. Recently, many studies show that vaginal infections, particularly bacterial vaginosis, is linked to a number of pregnant complications, including spontaneous abortion, preterm delivery ,premature rupture of the membranes , amnionitis, postpartum endometritis, and so on. Lactobacillis are the predominant microorganisms in the vaginal microecosystem of healthy women, they play an important role in the maintenance of the vaginal ecosystem balance, protect the host agaist infection by pathogenic microorganisms. Many properties required to confer this protection have been identified,such as producing hydrogen peroxide ^ producing acid. Lots of clinical studies indicate that
maintennance of lactobacillus-predominant vaginal flora will decrease the incidence of vaginal infections in pregnant women. There are some reports that the instillation of exogenous lactobacilli into the vagina result in decreasing the incidence of vaginal infections.However, in these studies, lactobacilli has usually been identified only to the genus level because of the technical difficulties in the species identification of Lactobacilli. It is uncertainly which lactobacilli species is adapt to cure and protect vaginal infections in pregnant women.
In this study, according to clinical signs and Gram stain of vaginal fluid
smear, we investigate the correlation between lactobacilli and vaginal
infections, such as bacterial vaginosis, vulvovaginal candidiasis. Lactobacilli species are identified by use of biochemical method, acquire the distribution of lactobacillus in the vagina of pregnant women, compare ability of producing H2O2, decreasing the culture enviromment PH among four common lactobacilli species in the vagina of pregnant women. The aim of our study is to select lactobacilli species with beneficial properties for probiotic use in the vaginal tract of pregnant women.
The result and conclusions are as followed:
1 > In the health pregnant women, the presence of lactobacilli is same as the pregnant women infected vulvovaginal candidiasis , but it is obviously higher than that of bacterial vaginosis;
2> The predominant Lactobacillus colonizing in the vagina of pregnant women are L. crispatus and L. acidophilus;
3> The frequency of isolation for HiCh. positive Lactobacilli in vagina of health pregnant women is significantly higher than vaginas of BV> WC.
4> Most clinical isolates of L. crispatus and L. acidophilus produce HiC^ and their ability of decreasing the culture enviromment PH is high.
The study indicates that HaC^-positive Lactobacillus play an important role in prevention from vaginal infections hi pregnant women. As the predominant H2O2 positive Lactobacillus colonizing in the vagina of pregnant women , L. crispatus and L. acidophilus may be have advantages in the maintenance of normal microflora and prevention from vaginal infections in pregnant women. The study provide theorial foundations of that, either or both of these two lactobacillis may be used to prevent and cure vaginal infections in pregnant women in the future.
本课题根据孕妇的临床表现和阴道分泌物检查，对孕妇阴道感染的发病率及其与乳酸杆菌的相关性进行了临床调查。同时采用生物化学的方法对孕妇阴道内乳酸杆菌进行鉴定，了解孕妇阴道内乳酸杆菌的分布情况，比较孕妇阴道内四种常见乳酸杆菌产生过氧化氢、降低培养环境PH的能力，初步筛选出适于治疗孕妇阴道感染的乳酸杆菌，实验结果如下：
1、正常孕妇乳酸杆菌的检出率明显高于感染细菌性阴道病的孕妇；与感染白念菌阴道炎的孕妇相比较，相差不显著；
2、孕妇阴道内的优势乳酸杆菌是嗜酸乳酸杆菌和卷曲乳酸杆菌；
3、正常孕妇H_2O_2阳性乳酸杆菌的分离率明显高于感染细菌性阴道病、白念菌阴道炎的孕妇。
4、大多数卷曲乳酸杆菌和嗜酸乳酸杆菌产生H_2O_2，两者降低培养环
境PH的能力较强。
本研究结果表明，HZOZ阳性乳酸杆菌在防御孕妇阴道感染中起着重要
作用。孕妇阴道内的优势氏。阳性乳酸杆菌是卷曲乳酸杆菌和嗜酸乳酸
杆菌，它们在维持阴道微生态平衡、防御阴道感染具有较强的优势，为联
合或单独使用这两种乳酸杆菌防治孕妇阴道感染提供了实验依据。
Vaginosis is one of the most common genital infections among women during childbearing age. During perinatal period, increased level of estrogen stimulate the deposition of glycogen in the vaginal epithelium, the enviroment of the vagina is adapt to the growth of bacteria, so the incidence of vaginal infections is increased in pregnant women. Recently, many studies show that vaginal infections, particularly bacterial vaginosis, is linked to a number of pregnant complications, including spontaneous abortion, preterm delivery ,premature rupture of the membranes , amnionitis, postpartum endometritis, and so on. Lactobacillis are the predominant microorganisms in the vaginal microecosystem of healthy women, they play an important role in the maintenance of the vaginal ecosystem balance, protect the host agaist infection by pathogenic microorganisms. Many properties required to confer this protection have been identified,such as producing hydrogen peroxide ^ producing acid. Lots of clinical studies indicate that
maintennance of lactobacillus-predominant vaginal flora will decrease the incidence of vaginal infections in pregnant women. There are some reports that the instillation of exogenous lactobacilli into the vagina result in decreasing the incidence of vaginal infections.However, in these studies, lactobacilli has usually been identified only to the genus level because of the technical difficulties in the species identification of Lactobacilli. It is uncertainly which lactobacilli species is adapt to cure and protect vaginal infections in pregnant women.
In this study, according to clinical signs and Gram stain of vaginal fluid
smear, we investigate the correlation between lactobacilli and vaginal
infections, such as bacterial vaginosis, vulvovaginal candidiasis. Lactobacilli species are identified by use of biochemical method, acquire the distribution of lactobacillus in the vagina of pregnant women, compare ability of producing H2O2, decreasing the culture enviromment PH among four common lactobacilli species in the vagina of pregnant women. The aim of our study is to select lactobacilli species with beneficial properties for probiotic use in the vaginal tract of pregnant women.
The result and conclusions are as followed:
1 > In the health pregnant women, the presence of lactobacilli is same as the pregnant women infected vulvovaginal candidiasis , but it is obviously higher than that of bacterial vaginosis;
2> The predominant Lactobacillus colonizing in the vagina of pregnant women are L. crispatus and L. acidophilus;
3> The frequency of isolation for HiCh. positive Lactobacilli in vagina of health pregnant women is significantly higher than vaginas of BV> WC.
4> Most clinical isolates of L. crispatus and L. acidophilus produce HiC^ and their ability of decreasing the culture enviromment PH is high.
The study indicates that HaC^-positive Lactobacillus play an important role in prevention from vaginal infections hi pregnant women. As the predominant H2O2 positive Lactobacillus colonizing in the vagina of pregnant women , L. crispatus and L. acidophilus may be have advantages in the maintenance of normal microflora and prevention from vaginal infections in pregnant women. The study provide theorial foundations of that, either or both of these two lactobacillis may be used to prevent and cure vaginal infections in pregnant women in the future.
引文
1． 杨景云主编．《医用微生态学》．中国医药科技出版社．1996，15-4；
2． 左绪磊主编．《妇产科感染》．人民卫生出版社．2000，2-7；
3． 卞度宏．念珠菌外阴阴道炎发病诱因．实用妇产科杂志．2000；16(4)；172-3；
4. Purohit BC,Joshi KR,RamdeoIN,et al. 1977.The formation of germ tubes by candida albicans ,when grown with staphylococcus pyogenes ,Escherichia coli,Klebsiella pneumoniae,Lactobacillus acidophilus and proters vulgaris Mycopathologia 1977;62:187-9
5. Hillier SL, Krohn MA, Klebanoff SJ, Eschenbach DA. The relationship of hydrogen peroxide-producing lactobacilli to bacterial vaginosis and genital microflora in pregnant women. Obstet Gynecol 1992 Mar;79(3):369-73
6. Lehrer RI. 1969.Antifungal effects of peroxidase systems .J Bacteriol. 1969; 99: 361-5
7. Zdolsek B, Hellberg D, Froman G, Nilsson S, Mardh PA.Vaginal microbiological flora and sexually transmitted diseases in women with recurrent or current vulvovaginal candidiasis. 1995. Infection 1995 Mar-Apr;23(2):81-4
8. Anger P. Joly J.1980.Microbial flora associated with candida albicans vulvoraginitis. Obstet Oyneol, 1980,55:97
9． 徐小丽等．乳酸杆菌对阴道白色念珠菌感染保护作用的实验研究．重庆医学，1998；27(6)：381-2
10. James A.McGregor,MD,CM.2001..妊娠期细菌性阴道病．世界医学杂志 2001, 5 (1) 1-12
11. Ali O. Kilic,1 Sylvia I. Pavlova,2 Sengul Alpay, 1 S. Sirri Kilic,3 and Lin Tao2,*2001.Comparative Study of Vaginal Lactobacillus Phages Isolated from Women in the United States and Turkey: Prevalence, Morphology,
Host Range, and DNA Homology .Clinical and Diagnostic Laboratory Immunology, January 2001, p. 31-39, Vol. 8, No. 1
12. Klebanoff SJ.Control of the microbial flora of the vagina by H_2O_2-generating lactobacilli. J Infect Dis 164:94-100
13. Simoes JA, Aroutcheva A, Heimler I, Shott S, Faro S.2001.Bacteriocin susceptibility of Gardnerella vaginalis and its relationship to biotype, genotype, and metronidazole susceptibility. Am J Obstet Gynecol 2001 Nov; 185(5): 1186-90
14. Catlin,BW. 1992. Gardnerellavaginalis: characteristics, clinical considerations,and controversies. Clin.,Microbiol.Rev,5:213-237
15. Bartlett,L.G.,A,B.Onderdonk,E.Drude,C.Goldstein,M..Anderka, S.Alpert and W.M.McCormack. 1977.Quantitative bacteriology of the vaginal flora. J Infect. Dis. 136:271-277 dissociate
16. Mardh,P,A.and L.V. Soltesz. 1983.In vitro interactions betxeen lactobacilli and other microorganisms occuring in the vaginal flora. Scand. J. Infect. Dis. Suppl.40:47-51
17. Stephen E et。Hydrogen Peroxide-Producing Lactobacilli and Acquisition of VaginalInfections。J Infect Dis 174:1058-1063
18. Wylie JG, Henderson A.1969.dentity and glycogen-fermenting ability of lactobacilli isolated from the vagina of pregnant women, enospecies J Med Microbiol 1969 Aug;2(3):363-6
19. Lachlak N, Ageron E, Zampatti O, Michel G, Grimont PA. 1996.Composition of the Lactobacillus acidophilus complex isolated from vaginal flora. New Microbiol 1996 Apr;19(2): 123-32
20. Reid G, McGroarty JA, Tomeczek L, Bruce AW .Identification and plasmid profiles of Lactobacillus species from the vagina of 100 healthy women. FEMS Immunol Med Microbiol 1996 Aug; 15(1):23-6
21. Giorgi A, Torriani S, Dellaglio F, Bo G, Stola E, Bernuzzi L .Identification
of vaginal lactobacilli from asymptomatic women. 1987.Microbiologica 1987 Oct; 10(4):377-84
22. Pavlova SI, Kilic AO, Kilic SS, So JS, Nader-Macias ME, Simoes JA, Tao L.2002.Genetic diversity of vaginal lactobacilli from women in different countries based on 16S rRNA gene sequences. J Appl Microbiol. 2002;92(3):451-9
23. Vallor AC, Antonio MA, Hawes SE, Hillier SL.2001.Factors associated with acquisition of, or persistent colonization by, vaginal lactobacilli: role of hydrogen peroxide production. J Infect Dis 2001 Dec 1; 184(11): 1431-6
24. May A. D. Antonio, 1 Stephen E. Hawes,3 and Sharon L. Hillier1,2. 1999. The Identification of Vaginal Lactobacillus Species and the Demographic and Microbiologic Characteristics of Women Colonized by These Species. The Journal of Infectious Diseases 1999;180:1950-1956
25. McGroarty JA, Tomeczek L, Pond DG, Reid G, Bruce AW. Hydrogen peroxide production by Lactobacillus species: correlation with susceptibility to the spermicidal compound nonoxynol-9. J Infect Dis 1992; 165:11424.
26. Eschenbach DA, Davick PR, Williams BL, et al. Prevalence of hydrogen peroxideproducing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microbiol 1989; 27:2516.
27. Nagy E, Petterson M, Mardh PA. Antibiosis between bacteria isolated from the vagina of women with and without signs of bacterial vaginosis. APMIS 1991; 99:73944.
28. Hillier SL.Krohn MA.Klebanoff SJ,Eschenbach DA.The relationship of hydrogen peroxide-Producing lactobacilli to bacterial vaginesis and genital microfora in pregnant women. Obstet Gynecol 1992;79:369-73
29. Eschenbach DA.DavickPR. WilliamsBL.et al. 1989.Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis.J Clin Microbiol 1989;27:251-6
30. Stephen E et。Hydrogen Peroxide-Producing Lactobacilli and Acquisition of VaginalInfections. J Infect Dis 174:1058-1063
31. Klebanoff SJ.Control of the microbial flora of the vagina by H_2O_2-generating lactobacilli.J Infect Dis 164:94-100
32. McLean N.W., McGroarty J. A. 1996. Growth inhibition of metronidazole-susceptible and metronidazole-resistant strains of Gardnerella vaginalis by lactobacilli in vitro, Appl. Environ. Microbiol. 62(1996)1089-1092
33. Fontaine E.A., Claydon E., Taylor-Robinson C.1996.Lactobacilli from women with or without bacteial vaginosis and observations on the significance of hydrogen peroxide. Microb. Ecol. Health Dis.9(1996) 135-141
34. Pheifer T.A.,Forsyth P.S.,Durfee M.A.,Pollock H.M., Holmes K.K., Nonspecific vaginitis. Role of Haemophilus vaginalis and treatment with metronidazole, N.Eng. J.Med. 298(1978) 1429-1434
35. Reid G, Soboh F, Bruce AW, Mittelman M.1998.Effect of nutrient composition on the in vitro growth of urogenital lactobacilli and uropathogens. Can J Microbiol 1998 Sep;44(9):866-71
36. Boskey ER, Telsch KM, Whaley KJ, Moench TR, Cone RA. 1999.Acid production by vaginal flora in vitro is consistent with the rate and extent of vaginal acidification. Infect Immun 1999 Oct; 67(10):5170-5
37. Mandar, R., and M. Mikelsar. 1996. Transmission of the mother's microflora to the newborn at birth. Biol. Neonate 69:30-35
38．董德刚等．乳酸杆菌体内外对阴道菌群及PH值生物学影响的研究。中国微生态杂志，1996；8(2)：17-19
39. Melis GB, Ibba MT, Steri B, Kotsonis P, Matta V, Paoletti AM.2000.Role of pH as a regulator of vaginal physiological environment]。Minerva Ginecol. 2000 Apr;52(4): 111-21.
40. G.G. Donders, E. Bosmans, A. Dekeersmaecker, A. Vereecken, B. Van Bulck and B. Spitz, Pathogenesis of abnormal vaginal bacterial flora. Am J Obstet Gynecol 182 (2000), pp. 872-878.
41. D.A. Eschenbach, P.R. Davick, B.L. Williams, S. J. Klebanoff, K. Young-Smith, C.M. Critchlow et al., Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microbiol 27 (1989), pp. 251-256
42. S.E. Hawes, S.L. Hillier, J. Benedetti, C.E. Stevens, L.A. Koutky, P. Wolner-Hassen et al., Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections. J Infect Dis 174 (1996), pp. 1058-1063.
43. S.L. Hillier, M.A. Krohn, S.J. Klebanoff and D.A. Eschenbach, The relationship of hydrogen peroxide-producing lactobacilli to bacterial vaginosis and genital microflora in pregnant women. Obstet Gynecol 79 (1992), pp. 369-373.
44. S.L. Hillier, M.A. Krohn, L.K. Rabe, S.J. Klebanoff and D.A. Eschenbach, The normal vaginal flora, H2O2-producing lactobacilli, and bacterial vaginosis in pregnant women.
2． 左绪磊主编．《妇产科感染》．人民卫生出版社．2000，2-7；
3． 卞度宏．念珠菌外阴阴道炎发病诱因．实用妇产科杂志．2000；16(4)；172-3；
4. Purohit BC,Joshi KR,RamdeoIN,et al. 1977.The formation of germ tubes by candida albicans ,when grown with staphylococcus pyogenes ,Escherichia coli,Klebsiella pneumoniae,Lactobacillus acidophilus and proters vulgaris Mycopathologia 1977;62:187-9
5. Hillier SL, Krohn MA, Klebanoff SJ, Eschenbach DA. The relationship of hydrogen peroxide-producing lactobacilli to bacterial vaginosis and genital microflora in pregnant women. Obstet Gynecol 1992 Mar;79(3):369-73
6. Lehrer RI. 1969.Antifungal effects of peroxidase systems .J Bacteriol. 1969; 99: 361-5
7. Zdolsek B, Hellberg D, Froman G, Nilsson S, Mardh PA.Vaginal microbiological flora and sexually transmitted diseases in women with recurrent or current vulvovaginal candidiasis. 1995. Infection 1995 Mar-Apr;23(2):81-4
8. Anger P. Joly J.1980.Microbial flora associated with candida albicans vulvoraginitis. Obstet Oyneol, 1980,55:97
9． 徐小丽等．乳酸杆菌对阴道白色念珠菌感染保护作用的实验研究．重庆医学，1998；27(6)：381-2
10. James A.McGregor,MD,CM.2001..妊娠期细菌性阴道病．世界医学杂志 2001, 5 (1) 1-12
11. Ali O. Kilic,1 Sylvia I. Pavlova,2 Sengul Alpay, 1 S. Sirri Kilic,3 and Lin Tao2,*2001.Comparative Study of Vaginal Lactobacillus Phages Isolated from Women in the United States and Turkey: Prevalence, Morphology,
Host Range, and DNA Homology .Clinical and Diagnostic Laboratory Immunology, January 2001, p. 31-39, Vol. 8, No. 1
12. Klebanoff SJ.Control of the microbial flora of the vagina by H_2O_2-generating lactobacilli. J Infect Dis 164:94-100
13. Simoes JA, Aroutcheva A, Heimler I, Shott S, Faro S.2001.Bacteriocin susceptibility of Gardnerella vaginalis and its relationship to biotype, genotype, and metronidazole susceptibility. Am J Obstet Gynecol 2001 Nov; 185(5): 1186-90
14. Catlin,BW. 1992. Gardnerellavaginalis: characteristics, clinical considerations,and controversies. Clin.,Microbiol.Rev,5:213-237
15. Bartlett,L.G.,A,B.Onderdonk,E.Drude,C.Goldstein,M..Anderka, S.Alpert and W.M.McCormack. 1977.Quantitative bacteriology of the vaginal flora. J Infect. Dis. 136:271-277 dissociate
16. Mardh,P,A.and L.V. Soltesz. 1983.In vitro interactions betxeen lactobacilli and other microorganisms occuring in the vaginal flora. Scand. J. Infect. Dis. Suppl.40:47-51
17. Stephen E et。Hydrogen Peroxide-Producing Lactobacilli and Acquisition of VaginalInfections。J Infect Dis 174:1058-1063
18. Wylie JG, Henderson A.1969.dentity and glycogen-fermenting ability of lactobacilli isolated from the vagina of pregnant women, enospecies J Med Microbiol 1969 Aug;2(3):363-6
19. Lachlak N, Ageron E, Zampatti O, Michel G, Grimont PA. 1996.Composition of the Lactobacillus acidophilus complex isolated from vaginal flora. New Microbiol 1996 Apr;19(2): 123-32
20. Reid G, McGroarty JA, Tomeczek L, Bruce AW .Identification and plasmid profiles of Lactobacillus species from the vagina of 100 healthy women. FEMS Immunol Med Microbiol 1996 Aug; 15(1):23-6
21. Giorgi A, Torriani S, Dellaglio F, Bo G, Stola E, Bernuzzi L .Identification
of vaginal lactobacilli from asymptomatic women. 1987.Microbiologica 1987 Oct; 10(4):377-84
22. Pavlova SI, Kilic AO, Kilic SS, So JS, Nader-Macias ME, Simoes JA, Tao L.2002.Genetic diversity of vaginal lactobacilli from women in different countries based on 16S rRNA gene sequences. J Appl Microbiol. 2002;92(3):451-9
23. Vallor AC, Antonio MA, Hawes SE, Hillier SL.2001.Factors associated with acquisition of, or persistent colonization by, vaginal lactobacilli: role of hydrogen peroxide production. J Infect Dis 2001 Dec 1; 184(11): 1431-6
24. May A. D. Antonio, 1 Stephen E. Hawes,3 and Sharon L. Hillier1,2. 1999. The Identification of Vaginal Lactobacillus Species and the Demographic and Microbiologic Characteristics of Women Colonized by These Species. The Journal of Infectious Diseases 1999;180:1950-1956
25. McGroarty JA, Tomeczek L, Pond DG, Reid G, Bruce AW. Hydrogen peroxide production by Lactobacillus species: correlation with susceptibility to the spermicidal compound nonoxynol-9. J Infect Dis 1992; 165:11424.
26. Eschenbach DA, Davick PR, Williams BL, et al. Prevalence of hydrogen peroxideproducing Lactobacillus species in normal women and women with bacterial vaginosis. J Clin Microbiol 1989; 27:2516.
27. Nagy E, Petterson M, Mardh PA. Antibiosis between bacteria isolated from the vagina of women with and without signs of bacterial vaginosis. APMIS 1991; 99:73944.
28. Hillier SL.Krohn MA.Klebanoff SJ,Eschenbach DA.The relationship of hydrogen peroxide-Producing lactobacilli to bacterial vaginesis and genital microfora in pregnant women. Obstet Gynecol 1992;79:369-73
29. Eschenbach DA.DavickPR. WilliamsBL.et al. 1989.Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis.J Clin Microbiol 1989;27:251-6
30. Stephen E et。Hydrogen Peroxide-Producing Lactobacilli and Acquisition of VaginalInfections. J Infect Dis 174:1058-1063
31. Klebanoff SJ.Control of the microbial flora of the vagina by H_2O_2-generating lactobacilli.J Infect Dis 164:94-100
32. McLean N.W., McGroarty J. A. 1996. Growth inhibition of metronidazole-susceptible and metronidazole-resistant strains of Gardnerella vaginalis by lactobacilli in vitro, Appl. Environ. Microbiol. 62(1996)1089-1092
33. Fontaine E.A., Claydon E., Taylor-Robinson C.1996.Lactobacilli from women with or without bacteial vaginosis and observations on the significance of hydrogen peroxide. Microb. Ecol. Health Dis.9(1996) 135-141
34. Pheifer T.A.,Forsyth P.S.,Durfee M.A.,Pollock H.M., Holmes K.K., Nonspecific vaginitis. Role of Haemophilus vaginalis and treatment with metronidazole, N.Eng. J.Med. 298(1978) 1429-1434
35. Reid G, Soboh F, Bruce AW, Mittelman M.1998.Effect of nutrient composition on the in vitro growth of urogenital lactobacilli and uropathogens. Can J Microbiol 1998 Sep;44(9):866-71
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