Gardnerella, Trichomonas vaginalis, Candida, Chlamydia trachomatis, Mycoplasma hominis and Ureaplasma urealyticum in the genital discharge of symptomatic fertile and asymptomatic infertile women

This study aimed to establish the different prevalence of the microorganisms investigated in the two groups considered: fertile women with symptoms and asymptomatic women with infertility problems. The data from women (n= 952) investigated for two years for quality of genital discharge and the presence of Gardnerella vaginalis, Trichomonas vaginalis, Candida species, Streptococcus agalactiae, Mycoplasma hominis, Ureaplasma urealyiticum and Chlamydia trachomatis were retrospectively analyzed. In the population of fertile women with symptoms the microrganisms most frequently involved are Gardnerella vaginalis (26.6%), Candida species (12.1%) and Streptococcus agalactiae (9.2%). The genital discharges of asymptomatic women with infertility problems are characterized by a prevalence of Gardnerella vaginalis (19.7%), Enterobacteriaceae or Enterococci (12.1%) and Streptococcus agalactiae (8.6%). The reduction of vaginal lactobacilli flora and the presence of an elevated number of polymorphonucleates in the vaginal discharge are important parameters to consider for the evaluation of the health status of the human female urogenital tract. Our results indicate that is important to culture the vaginal discharge for Streptococcus agalactiae and for prevalence of Enterobacteriaceae and Enterococci. Lastly, the reasons for the prevalence of some microorganisms (Gardnerella vaginalis, Enterobacteriaceae and Enterococci, Streptococcus agalactiae) in the population of infertile asymptomatic women need to be better analyzed especially after the recent studies correlating idiopathic infertility with the presence of cervical cytokines in women with an abnormal vaginal flora.

[In vitro inhibitory effect of ajoene on Candida isolates recovered from vaginal discharges]

AIMS

The main purpose of this work was to evaluate the in vitro activity of ajoene of the Candida, obtained from vaginal discharges.

METHODS

For this, 136 samples were analyzed. The yeasts were recovered and identified by conventional mycological methods. The susceptibility to ajoene (at 20, 15, 12.5, 10, 6.25 and 3.125 microg/ml) was performed according to the CLSI M27-A2 document with the EUCAST modifications. The ATCC reference strains 90028 (Candida albicans), 22019 (Candida parapsilosis), and 6258 (Candida krusei) were included in this study. The minimal inhibitory concentration (MIC) was considered as the minimal concentration of ajoena able to inhibit 80% of the fungal growth.

RESULTS

Fifty five yeasts were recovered, 36 (65.4%) of them were causing candidosis and 19 (34.5%) were colonizing. C. albicans was the most frequent (81.8%) of the six isolated species, prevailing on the patients with candidosis (54.5%). The non-albicans species were less frequently isolated (18.2%), and Candida glabrata was the prevailing agent (7.3%) followed by Candida tropicalis (3.6%), C. krusei, C. parapsilosis, Candida guilliermondii and Candida sp. (1.8% each of them). The susceptibility tests to ajoeno showed inhibition of fungal growth in 98.2% of the isolates, showing MIC values 15 microg/ml, and in (one isolate of C. glabrata) (1.8%) this value was >20 microg/ml. The reference strains showed MIC values of 3.125 and 10 microg/ml.

CONCLUSIONS

The results here presented, obtained from a significant number of isolates, mainly C. albicans, demonstrate, once more, the potential of ajoeno as an antifungal agent.

Evaluation of common organisms causing vaginal discharge

BACKGROUND

Vaginal discharge is very common problem among females. Alteration in balance of normal vaginal organisms can cause the overgrowth of the bacteria that creates vaginal discharge. It is common among sexually active women yet there still remain gaps in our knowledge of this infectious disorder.

OBJECTIVE

To evaluate the frequency of bacterial vaginosis (BV), vaginal candidiasis (VC), vaginal trichomoniasis and Group B streptococcus in women complaining of vaginal discharge in our setup.

METHOD

A total of 100 women of reproductive age group with the complaint of vaginal discharge were included in the study. After filling proforma patients were examined by speculum examination and two high vaginal swabs (HVS) were collected aseptically from each patient. One swab was used for making wet mount for clue cells, pus cells and for motility of Trichomonas vaginalis. The other swab was used to check pH and Amine test. The growth was confirmed by Gram staining in each case.

RESULTS

Gardnerrella vaginalis were isolated in 28%, Group B streptococcus in 5% and T. vaginolis in 4% of women.

CONCLUSION

Gardnerella vaginalis causing BV is the most common cause of vaginal discharge in otherwise healthy women of reproductive age group in our setup.

Clinicomicrobiological profile of women with vaginal discharge

One hundred and ten patients presenting with vaginal discharge were investigated for microbiological spectrum of vaginitis and outcome of treatment. Laboratory-documented disorder could be ascertained in 86 patients (78%). Bacterial vaginosis was the commonest aetiology (43.6%), followed by candidiasis (10%), trichomoniasis (9.1%), senile vaginitis (5.4%) and vaginitis of unknown origin (5.4%). Endocervicitis was seen in 13.6% patients and urinary tract infection in 1.8%. Complete relief of symptoms was seen in 77 patients (70%).

[Investigation of the situation of vaginal microflora in healthy women population]

OBJECTIVE

To assess the distribution of vaginal microflora in healthy women and investigate their cognition of lower reproductive tract infection-related knowledge as well as personal hygiene habits and character of behavior in seeking medical treatment.

METHODS

Total of 1660 healthy women who had physical check-ups at the Medical Center of Renji Hospital were selected and received gynecologic examination, as well as routine examination, pH examination and bacterial culture of the vaginal discharge. In addition, 860 of them were randomly selected for questionnaire survey, in which reproductive tract infection -related knowledge and personal hygiene habits as well as behavior in seeking medical treatment were involved.

RESULTS

Among the 1660 censused women, vaginal average pH was 4. 16 +/- 0.21. The positive rate of Candida in vaginal discharge routine examination was 3.86% (64/1660), which was lower than that in aerobes culture 7.71% (128/1660). Candida albicans was the most populous species 78.9% (101/128), followed by 7.8% (10/128) and 7.0% (9/128) for the Candida glabrata and Candida krusei respectively. The most populous species of vaginal microflora were hemolytic streptococcus A (63.80%, 1059/1660), Staphylococcus epidermidis (14.28%, 237/1660), and Enterococcus faecalis (D) group (11.44%, 190/1660). The questionnaire survey showed that 88.4% (760/860) of 860 women took active treatment when feeling unwell, 92.1% (792/860) of them had good hygiene practices, and only 21.2% (182/860) had the habit of vaginal douching. In addition, 50.0% (430/860) of them had the desire to obtain reproductive health knowledge through out-patient consultation.

CONCLUSIONS

Vulvovaginal Candida disease ranks the first in all types of vaginitis, among which, Candida albicans is the most populous species followed by the Candida glabrata and Candida krusei. Hemolytic streptococcus A and Staphylococcus epidermidis are the most common species of vaginal microflora in healthy women. The censused women have high awareness of reproductive health care and pay much attention to common gynecologic diseases such as lower reproductive tract infection. Nevertheless, we should strengthen the public education of reproductive health-related knowledge.

[Microecological investigation of vaginal microflora in women with varying degree gynecologic symptoms in clinics]

OBJECTIVE

To investigate the microecological status of vaginal microflora in the women with different vaginal symptoms.

METHODS

From March 2006 to October 2007, 6982 cases with varying degree vaginal symptoms including pruritus, increaseed leucorrhea, the leucorrhea having unusual smell, in the gynecology outpatient department were studied. The vagina secretions were examined in terms of the pH value, the hydrogen peroxide test, and Gram dyeing inspection of vaginal bacteria and microecology appraisal for colony's density, the multiplicity, the superiority fungus, and the inflammatory response.

RESULTS

Among 6982 patients, normal vaginal microecology was identified in 750 (10.74%, 750/6982); abnormal microecology was found in 6232 (89.26%, 6232/6982); bacterial vaginosis (BV) was detected in 729 (10.44%, 729/6982); vulvovaginal candidiasis (VVC) was in 1527 (21.87%, 1527/6982). Ninety five patients (1.36%, 95/6982) were with both BV and VVC. Abnormal bacteria colonies were found in 1229 (17.60%, 1229/6982), and others were found in 2652 (37.98%, 2652/6982).

CONCLUSIONS

The vaginal microecology in the women with different vaginal symptoms can be either normal or abnormal. Microecology clinical evaluation system can assess the vaginal microecosystem.

Expression of cyclooxygenase-2 in the inflammatory changed porcine uterus

In the present study, the pattern of cyclooxygenase-2 (COX-2) expression in health and inflamed porcine uteri was analyzed using real-time reverse transcriptase-polymerase chain reaction (RT-PCR), Western blot and immunohistochemistry. On day 3 of the estrous cycle, 50 ml of saline or 50 ml of Escherichia coli (E. coli) suspension containing 10(9) colony-forming units/ml, were injected into each uterine horn of the control (n=6) and experimental gilts (n=7), respectively. This latter procedure lead to a moderately (n=3) or severely intense (n=4) acute endometritis after eight days. Expression of both the COX-2 mRNA and protein was increased in the endometrium (ENDO) of animals suffering from the moderate (P < 0.05, P < 0.01, respectively) and severe (P < 0.01) acute endometritis, as compared to the control tissues. Moreover, COX-2 mRNA level and protein content were higher (P < 0.05) in the ENDO of animals with severe than with a moderately acute endometritis. An elevation in the COX-2 gene (P < 0.05) and protein (P < 0.001) expression was also observed in the myometrium (MYO) of animals suffering from severe endometritis, when compared with the levels observed in MYO of both the health and moderate intensely inflamed uteri. However, both the COX-2 mRNA and protein levels were similar in MYO of the control and moderately inflamed organs. The luminal epithelium, some of uterine glands and circular layer of the MYO were more intensely stained for COX-2 in animals with severe endometritis, than in animals with healthy or moderately inflamed uteri. Nonetheless, stronger COX-2 reaction was found in some of the uterine glands in latter group, when compared to that observed in uteri of the control animals. While positive COX-2-labeling was observed in the muscular layer of all arteries supplying the health and inflamed uteri, such staining was exclusively present in the endothelium of some arteries in inflamed organs. Likewise, some arteries in uteri of the animals with severe endometritis displayed immunoreaction stronger than that found in uteri of the animals with moderate inflammation. The present study revealed an up-regulation of COX-2 mRNA and protein in the inflamed porcine uterus, which was directly related to the intensity of the organ inflammation. An increase in the COX-2 expression in the uterus challenged by E. coli-induced inflammation indicates that this enzyme is crucial for elevated prostaglandins production in the inflamed organ.

[Genital discharge in women]

The most frequent cause of genital discharge in women is an infection or colonization with different microorganisms, including sexually transmitted pathogens. Mechanical or chemical irritations are additional causes. Malignant diseases can also cause increased discharge. For this reason, especially postmenopausal and brown, bloody discharges should be differentiated and if necessary, histologically confirmed. Due to the variety of causes, a symptomatic treatment should not be prescribed without prior diagnosis.

[The practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology]

The Dutch College of General Practitioners (NHG) revised their practice guideline on vaginal discharge. From a gynaecological point of view, relocation of cervix problems from this guideline to the NHG guideline 'The STD consultation' is not practical. Moreover, the role of simple, but effective diagnosis with a microscope in the primary-care setting cannot be overemphasized. The reluctance to oral treatment is rather inopportune, because once-only ingestion has the advantage of promoting compliance. As physical examination is not always necessary in a recurrent Candida infection, treatment performed by the patient with imidazole compounds is a possibility that does not always result in abuse or increased resistance.

[Summary of the practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners]

The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.

[The practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]

The revised practice guideline by the Dutch College of General Practitioners (NHG) on vaginal discharge is intended to offer general practitioners a handle for management of vaginal complaints. Most general practitioners experience uncertainties in daily practice with respect to the diagnosis of vaginal discharge. In most cases history taking and physical examination fails to provide sufficient valuable information to arrive at a definite diagnosis. No further (microscopic) investigation is only permissible in a very obvious infection with Candida albicans. A recent onset of complaints of itching accompanied by white odourless discharge means a 70% chance of an infection with C. albicans. If the general practitioner also finds vulvar or vaginal inflammation and a nonhomogeneous fluor during examination the chance of an infection with C. albicans increases to 90%. In all other cases microscopic investigation is inevitable. This does not reflect an inadequacy of the NHG guideline but is a consequence of the limited diagnostic possibilities to arrive at a precise diagnosis.

[Aerobic vaginitis--diagnostic problems and treatment]

The diagnostic criteria and treatment of aerobic vaginitis--AV--have been summarized in this review. An expansion of mixed aerobic microflora, especially Group B Streptococcus--GBS, Escherichia coli--E. coli, Enterococcus spp., and the development of inflammation of the vaginal mucous membrane due to a decreasing amount of Lactobacillus spp., have been observed in women with AV. Disruptions of the vaginal ecosystem during AV cause an increase in pH to >6, a decrease in lactates concentration and an increase in proinflammatory cytokines concentration in vaginal discharge. An optimal treatment scheme for AV, which includes antibacterial agents and simultaneously normalizes the vaginal ecosystem, has not been established until today.

Frequency and antimicrobial susceptibility of aerobic bacterial vaginal isolates

OBJECTIVE

To determine the frequency and antimicrobial susceptibility of aerobic bacterial isolates from high vaginal swab cultures.

DESIGN

Cross-sectional survey.

PLACE AND DURATION OF STUDY

Shifa International Hospital, Islamabad, from January 2003 to February 2004.

PATIENTS AND METHODS

The subjects included 136 symptomatic women attending Obstetrics and Gynecology Out-Patient Department. A proforma was filled to document the demographic details, presenting complaint and examination findings. High vaginal swabs were taken for gram staining, culture and antimicrobial sensitivity testing using standard microbiologic techniques.

RESULTS

Normal flora was isolated in 30% of the cases, followed by Candida spp. (21.3%), Enterococcus spp. (14.7%), E.coli (10.2%), Beta hemolytic Streptococcus spp. (7.3%), Staphylococcus spp. (4.4%), Enterobacter spp. (4.4%), while Streptococcus pyogenes, Staphylococcus epidermidis and Klebsiella spp. were isolated 1.5% each. Enterococcus, Staphylococcus and Streptococcus were mostly sensitive to penicillin and amoxicillin while E.coli and Klebsiella were sensitive to (piperacillin-Tazobactum, Imipenem and vancomycin. Enterococci species showed significant resistance to aminoglycoside antibiotics (68.8% to 81.3%) resistance to vancomycin was 5%.

CONCLUSION

Thirty percent of symptomatic patients had normal flora on culture. Candida spp was the most frequent pathogen isolated. Co-amoxiclav should be used as empiric therapy until culture-sensitivity report is available.

The syndromic management of vaginal discharge using single-dose treatments: a randomized controlled trial in West Africa

OBJECTIVE

To evaluate whether single-dose treatments are as effective as standard therapy in the syndromic management of vaginal discharge.

METHODS

A randomized controlled effectiveness trial compared single-dose tinidazole plus fluconazole (TF) with treatment for 7 days with metronidazole plus 3 days of treatment with vaginal clotrimazole (MC) among 1570 women presenting with vaginal discharge at primary health care institutions in Ghana, Guinea, Mali and Togo. Participants were randomly allocated to one of the two treatments by research nurses or physicians using precoded envelopes. Effectiveness was assessed by symptomatic response on day 14. CLINICAL IDENTIFIER ClinicalTrials.gov NCT00313131.

FINDINGS

The two treatment regimens had similar effectiveness: complete resolution was seen in 66% (TF) and 64% (MC) and partial resolution in 33% (TF) and 34% (MC) of participants (P = 0.26). Effectiveness was similar among subgroups with vulvovaginal candidiasis, Trichomonas vaginalis vaginitis or bacterial vaginosis. The two treatment regimens had a similar effectiveness among human immunodeficiency virus (HIV)-infected (TF: n = 76, 71% complete resolution, 28% partial; MC: n = 83, 72% complete resolution, 25% partial, P = 0.76) and HIV-uninfected women (TF: n = 517, 68% complete, 32% partial; MC: n = 466, 65% complete, 33% partial, P = 0.20). Cervical infections with Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium were uncommon among women not involved in sex work, were associated with bacterial vaginosis or T. vaginalis vaginitis, and did not alter response to treatment with agents active against vaginal infections. Four-fifths of women not relieved by a single dose of TF had a favourable response when MC was administered as second-line treatment.

CONCLUSION

Single-dose TF is as effective as multiple-dose MC in the syndromic management of vaginal discharge, even among women with HIV-infection. Given its low price and easier adherence, TF should be considered as a first-line treatment for vaginal discharge syndrome.

Diagnosis of gonococcal infection in high risk women using a rapid test

OBJECTIVE

To assess the performance and acceptability for patients and health care workers of the NGThermo Biostar (GC OIA) to diagnose gonococcal infection compared with culture using modified Thayer Martin medium.

METHODS

This study involved 326 high-risk women presenting with vaginal discharge or referral by sexual partner with urethral discharge at a sexually transmitted infections (STI) clinic in Manaus, Brazil. Endocervical swabs collected from the women were tested with both the NG Biostar and modified Thayer Martin culture as the reference standard test. Clinic staff were trained to perform the NG Biostar on site and the culture was performed in the laboratory of the clinic.

RESULTS

The prevalence of gonococcal infection as measured by the reference standard was 15% (50/326) overall. Among asymptomatic participants, the prevalence of infection was 17.7% (25/141) and among symptomatic women it was 13.5% (25/185) (p = 0.3). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the NG Biostar test, with 95% confidence intervals (CI), were 60% (46.4% to 73.6%), 89.9% (86.2% to 93.6%), 55.6% (42.4% to 68.8%), and 92.6% (89.5% to 95.7%), respectively; 98.8% of study participants were willing to wait approximately 1 hour in the clinic for test results.

CONCLUSION

Syndromic management protocols for treatment of STI in developing countries require refinement because, as currently described, they lead to over-treatment of cervical infection. A rapid test done during patients' initial presentation and leading to immediate treatment if positive would help improve the accuracy of diagnosis and could also be used to screen asymptomatic women. Even though the NG Biostar had a low sensitivity and PPV, which is less than ideal, it could still improve the rates of treatment over the gold standard test that requires return visits for patients to receive results and to benefit from treatment. Cost-effectiveness studies using rapid point-of-care tests for Neisseria gonorrhoeae infection compared to the syndromic approach should be carried out to assess their value in STI diagnosis and treatment in developing nations.

Concurrent pathological and bacteriological findings in the urogenital organs and mammary glands of sows culled because of chronic vulvovaginal discharge and swine urogenital disease (SUGD): a case study

The urogenital organs and mammary glands of sows, culled because of excessive vulval discharge, milking problems, and urogenital infections (swine urogenital disease, SUGD) in their history (n=1070 sows) were examined. The culled sows were assigned to three groups according to parity: parity 1 (n=356); 2-6 (n=354); and >6 (n=360). Necropsy findings associated with these groups were analysed separately. Bacteriological examination of vulval discharges was performed. Escherichia coli and a large number of Gram-positive and Gram-negative organisms were found in all samples of vulval discharge. Except ovarian degeneration and oedematous endometrium, older sows had more (P<0.05) pathological changes in the oviduct, ovaries, and uteri than younger (parity 1) sows. More (P<0.05) parity 1 sows had hyperaemic and congested vaginal walls and haemorrhages into the vaginal lumen than sows of higher parity, which suffered more (P<0.05) from accumulation of purulent material in the vaginal lumen, fibrinopurulent exudate adherent to the wall of the vagina, multifocal vaginal erosions and ulcerations, and purulent, mucopurulent or purulohaemorrhagic exudate in the vagina or on the cervix. Except acute pyelonephritis, mucosal hyperaemia, and congestion of the urinary bladder, more (P<0.05) sows of higher parity had pathological changes in their urinary organs. More (P<0.05) parity 1 sows had acute or chronic purulent exudative mastitis than sows of higher parity, which had more (P<0.05) mammary gland abscessation, mammary gland cysts, and fibrous mastitis. All parity 2-6 and >6 sows had mammary gland and bladder changes, parity >6 sows had changes in the kidney, and renal pelvis, and parity 1 sows had mammary gland changes. Most parity 1 sows had bladder, kidney, and renal pelvis alterations and most parity 2-6 animals had pathological kidney and renal pelvis changes.

Best practice in primary care pathology: review 4

This fourth best practice review examines four series of common primary care questions in laboratory medicine are examined in this review: (1) safety monitoring for three common drugs; (2) use of prostate-specific antigen; (3) investigation of vaginal discharge; and (4) investigation of subfertility. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of the guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most of them are consensus based rather than evidence based. They will be updated periodically to take account of new information.