Trichomonas vaginalis associated with low birth weight and preterm delivery. The Vaginal Infections and Prematurity Study Group

BACKGROUND

Several studies have suggested that pregnant women infected with Trichomonas vaginalis may be at increased risk of an adverse outcome.

GOAL

To evaluate prospectively the association between T. vaginalis and risk of adverse pregnancy outcome in a large cohort of ethnically diverse women.

STUDY DESIGN

At University-affiliated hospitals and antepartum clinics in five United States cities, 13,816 women (5,241 black, 4,226 Hispanic, and 4,349 white women) were enrolled at mid-gestation, tested for T. vaginalis by culture, and followed up until delivery.

RESULTS

The prevalence of T. vaginalis infection at enrollment was 12.6%. Race-specific prevalence rates were 22.8% for black, 6.6% for Hispanic, and 6.1% for white women. After multivariate analysis, vaginal infection with T. vaginalis at mid-gestation was significantly associated with low birth weight (odds ratio 1.3; 95% confidence interval 1.1 to 1.5), preterm delivery (odds ratio 1.3; 95% confidence interval 1.1 to 1.4), and preterm delivery of a low birth weight infant (odds ratio 1.4; 95% confidence interval 1.1 to 1.6). The attributable risk of T. vaginalis infection associated with low birth weight weight in blacks was 11% compared with 1.6% in Hispanics and 1.5% in whites.

CONCLUSIONS

After considering other recognized risk factors including co-infections, pregnant women infected with T. vaginalis at mid-gestation were statistically significantly more likely to have a low birth weight infant, to deliver preterm, and to have a preterm low birth weight infant. Compared with whites and Hispanics, T. vaginalis infection accounts for a disproportionately larger share of the low birth weight rate in blacks.

Infection withTrichomonas vaginalisIncreases the Risk of HIV‐1 Acquisition

We conducted a prospective study among women in Mombasa, Kenya, to determine whether Trichomonas vaginalis infection was associated with an increased risk of human immunodeficiency virus type 1 (HIV-1) infection. At monthly follow-up visits, laboratory screening for HIV-1 and genital tract infections was conducted. Among 1335 HIV-1-seronegative women monitored for a median of 566 days, there were 806 incident T. vaginalis infections (23.6/100 person-years), and 265 women seroconverted to HIV-1 (7.7/100 person-years). Trichomoniasis was associated with a 1.52-fold (95% confidence interval, 1.04-2.24-fold) increased risk of HIV-1 acquisition after adjustment for potential confounding factors. Treatment and prevention of T. vaginalis infection could reduce HIV-1 risk in women.

The preterm prediction study: significance of vaginal infections. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network

OBJECTIVE

Our purpose was to evaluate the association of bacterial vaginosis, trichomonas vaginitis, and monilial vaginitis with spontaneous preterm birth at < 35 weeks 0 days.

STUDY DESIGN

A total of 2929 women at 10 centers were studied at 24 and 28 weeks' gestation by Gram stain of vaginal smear, wet mount, and 10% potassium hydroxide preparations to detect vaginal infections.

RESULTS

The rates of detected infection at 24 and 28 weeks, respectively, were bacterial vaginosis 23.4% and 19.4%, trichomonas 3.3% and 2.7%, and monilia 21.1% and 19.5%. The occurrence of bacterial vaginosis at 28 weeks was associated with an increased risk of spontaneous preterm birth, odds ratio 1.84 (95% confidence interval 1.15 to 2.95, p < 0.01). Detection of Trichomonas vaginalis (by wet mount) or monilia (by potassium hydroxide preparation) had no significant associations with preterm birth.

CONCLUSION

The presence of bacterial vaginosis at 28 weeks' gestation is associated with an increased risk of spontaneous preterm birth.

Increase in endocervical CD4 lymphocytes among women with nonulcerative sexually transmitted diseases

To assess associations of nonulcerative sexually transmitted diseases (STDs) with human immunodeficiency virus (HIV)-susceptible leukocytes on female genital mucosa, cervicovaginal specimens from 32 HIV-negative STD clinic patients with gonorrhea, chlamydial infection, or trichomoniasis were compared with specimens from 32 clinic patients without these infections. Twenty-eight patients had single infections (15 gonorrhea, 10 chlamydial infection, 3 trichomoniasis), and 4 had dual infections. A saline vaginal wash and saline suspensions of vaginal wall scrapings, ectocervical scrapings, and endocervical brushings were analyzed by flow cytometry. Specimens from the endocervix had the highest proportions of lymphocytes, monocytes, and Langerhans' cells. The median number of endocervical CD4 lymphocytes/10,000 cells was greater among patients with STDs than among those without (476 vs. 245; P < .001). These data suggest that the endocervix may have a particularly important role in heterosexual HIV transmission and that nonulcerative STDs may facilitate HIV transmission by increasing the presence of CD4 lymphocytes at this site.

The effect of treatment of vaginal infections on shedding of human immunodeficiency virus type 1

To assess the effect of treatment of vaginal infections on vaginal shedding of cell-free human immunodeficiency virus type 1 (HIV-1) and HIV-1-infected cells, HIV-1-seropositive women were examined before and after treatment of Candida vulvovaginitis, Trichomonas vaginitis, and bacterial vaginosis. For Candida (n=98), vaginal HIV-1 RNA decreased from 3.36 to 2.86 log(10) copies/swab (P<.001), as did the prevalence of HIV-1 DNA (36% to 17%; odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.5). For Trichomonas vaginitis (n=55), HIV-1 RNA decreased from 3.67 to 3.05 log(10) copies/swab (P<.001), but the prevalence of HIV-1 DNA remained unchanged (22%-25%; OR, 0.8; 95% CI, 0.3-2.2). For bacterial vaginosis (n=73), neither the shedding of HIV-1 RNA (from 3.11 to 2.90 log(10) copies/swab; P=.14) nor the prevalence of DNA (from 21% to 23%; OR, 0.8; 95% CI, 0.3-2.0) changed. Vaginal HIV-1 decreased 3.2- and 4.2-fold after treating Candida and Trichomonas, respectively. These data suggest that HIV-1 transmission intervention strategies that incorporate diagnosis and treatment of these prevalent infections warrant evaluation.

Gynaecological infections as risk determinants of subsequent cervical neoplasia

A longitudinal cohort study was carried out to determine whether gynaecological infections other than human papillomavirus (HPV) are also related to the subsequent increased risk of cervical neoplasia. The study comprised 19114 women attending the organized mass screening in Finland in 1985-1990 with cytologically detected HPV, Actinomyces, herpes simplex, Trichomonas vaginalis, or yeast. The women were followed-up for subsequent preinvasive lesions and invasive cancers until the end of 1994 by linkage to the nation-wide Cancer Registry. Standardized incidence ratios (SIR) with rates for the whole of Finland as reference and 95% confidence intervals (CI) were estimated. Trichomonas vaginalis and HPV were associated with a high relative risk of cervical cancer, SIR 6.4 (CI 3.7-10, preinvasive lesion and invasive cancer combined) and SIR 5.5 (CI 4.2 7.2, preinvasive lesion and invasive cancer combined), respectively. Herpes simplex was rarely detected, but the highest and statistically most significant point estimate was observed (SIR 12, CI 2.4-34, preinvasive lesion and invasive cancer combined). Neither Actinomyces nor yeast was associated with a significantly increased risk of cervical cancer. None of these results could be accounted for by the confounding effect of the other infections. Our results, based on a prospective design, lead us to propose that Trichomonas vaginalis and herpes simplex virus are also predictors for cervical neoplasia.

Effects of bacterial vaginosis and other genital infections on the natural history of human papillomavirus infection in HIV-1-infected and high-risk HIV-1-uninfected women

BACKGROUND

Whether the natural history of human papillomavirus (HPV) infection is affected by bacterial vaginosis (BV) or Trichomonas vaginalis (TV) infection has not been adequately investigated in prospective studies.

METHODS

Human immunodeficiency virus 1 (HIV-1)-infected (n=1763) and high-risk HIV-1-uninfected (n=493) women were assessed semiannually for BV (by Nugent's criteria), TV infection (by wet mount), type-specific HPV (by polymerase chain reaction with MY09/MY11/HMB01 HPV primers), and squamous intraepithelial lesions (SIL) (by cytological examination). Sexual history was obtained from patient report at each visit. Risk factors for prevalent and incident HPV infection and SIL were evaluated by use of multivariate models.

RESULTS

BV was associated with both prevalent and incident HPV infection but not with duration of HPV infection or incidence of SIL. TV infection was associated with incident HPV infection and with decreased duration and lower prevalence of HPV infection. TV infection had no association with development of SIL. Effects of BV and TV infection were similar in HIV-1-infected and high-risk HIV-1-uninfected women. HIV-1 infection and low CD4(+) lymphocyte count were strongly associated with HPV infection and development of SIL.

CONCLUSIONS

BV and TV infection may increase the risk of acquisition (or reactivation) of HPV infection, as is consistent with hypotheses that the local cervicovaginal milieu plays a role in susceptibility to HPV infection. The finding that BV did not affect persistence of HPV infection and that TV infection may shorten the duration of HPV infection helps explain the lack of effect that BV and TV infection have on development of SIL.

Is Trichomonas vaginalis a cause of cervical neoplasia? Results from a combined analysis of 24 studies

BACKGROUND

We conducted this combined analysis of available data from studies with information on this issue to clarify the association between Trichomonas vaginalis infection and cervical neoplasia.

METHODS

We performed MEDLINE searches (1966-1993) using the key words and phrases 'trichomonas vaginitis' and 'neoplasms, cervix' for articles published in English, and searched citations of the articles obtained from MEDLINE: A total of 24 articles (two cohort studies and 22 case-control) were included in this data analysis. In the analysis, the studies were evaluated for heterogeneity using Breslow-Day tests for homogeneity of the odds ratios and of rate ratios. If the odds ratios from studies are heterogeneous, it is not appropriate to combine them using the Mantel-Haenszel method. Also, publication bias was evaluated by assessing the association between the observed effect size and the variance of the effect size using a rank correlation test.

RESULTS

The combined summary relative risk for the two cohort studies was 1.93 (95% confidence interval: 1.22-2.65) indicating an approximate doubling of the risk of cervical neoplasia in the presence of T. vaginalis infection. The attributable risks among exposed subjects and among the source population were 47.4% and 2.1% respectively. Results of the 22 retrospective studies were much less consistent. However, most of them demonstrated a significant positive association.

CONCLUSIONS

This combined analysis suggests that there is an association between T. vaginalis and the risk of cervical neoplasia, but that such infections account for only 2% of cervical neoplasia.

Lack of evidence for cancer due to use of metronidazole

Experimental studies have shown that metronidazole is carcinogenic in rodents and mutagenic in bacteria. In 771 women given metronidazole for the treatment of vaginal trichomoniasis, more cancers developed than had been expected after exclusion of carcinoma of one uterine cervix (observed, 24 cases; expected on the basis of the Connecticut Tumor Registry, 21.7; expected on the basis of the Third National Cancer Survey, 18.4). However, the excess was not statistically significant (P greater than 0.05). The observed and expected numbers of breast-cancer cases were the same, but four lung-cancer cases were observed, whereas 0.6 would have been expected. This finding is confounded by the fact that all four lung cancers developed in women who were smokers. Overall, we observed no appreciable increase in cases of cancer.

Relation of tubal infertility to history of sexually transmitted diseases

We studied the history of sexually transmitted diseases in 283 nulliparous women diagnosed with infertility due to tubal adhesions or occlusion and 3,833 women admitted for delivery at seven collaborating hospitals. The adjusted risks of tubal infertility associated with the history of each sexually transmitted disease were estimated by the odds ratios obtained by multiple logistic regression. Women who reported prior infection with gonorrhea were at a significantly increased risk of tubal infertility (relative odds = 2.4, 95% confidence interval 1.3-4.4). In addition, the risk of tubal infertility was almost twice as high in women who recalled previous trichomoniasis compared with women with no such infection (relative odds = 1.9, 95% confidence interval 1.3-2.8). Furthermore, there was a trend of increasing risk with an increasing number of episodes of gonorrhea or trichomoniasis.

Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies

Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection worldwide. Annually, 7.4 million new infections are estimated in the United States, which is greater than combined new cases of Chlamydia, gonorrhea, and syphilis. Serious adverse reproductive health outcomes including pregnancy complications, pelvic inflammatory disease, and an increased risk of HIV acquisition have been linked to TV infection. There are several sensitive and specific diagnostic tests available, including a newly approved nucleic acid amplification test (NAAT) that utilizes the same instrumentation platform and clinical sample as Chlamydia and gonorrhea tests. In this article, we review TV pathogenicity, adverse reproductive health outcomes, detection, and treatment followed by clinical scenarios for which TV diagnosis may prove useful in obstetrics and gynecology practice.

Interrelationships among human immunodeficiency virus type 1 infection, bacterial vaginosis, trichomoniasis, and the presence of yeasts

Vaginal discharge of mixed etiology occurs frequently, with abnormal vaginal flora being the most common condition. The interrelationships among the disturbance of the vaginal ecology, the presence of yeasts, and infection with Trichomonas vaginalis and human immunodeficiency virus type 1 (HIV-1) were investigated among women presenting to a sexually transmitted diseases service. Analysis was done for 598 women. Although the prevalence of HIV-1 infection increased linearly with increasing Nugent's score (bacterial vaginosis score of Gram stain), the prevalence of T. vaginalis increased suddenly, from 12% in patients with a Nugent's score of < or =3 to 33% in patients with a score of 4, and remained at this level at higher scores. Yeast colonization and vulvovaginal candidiasis were inversely related to Nugent's scores. T. vaginalis might be responsible for the change in normal vaginal flora and may, therefore, be one of the causes of bacterial vaginosis. This could lead to more effective HIV-1 acquisition.

Estimates of the Annual Number and Cost of New HIV Infections Among Women Attributable to Trichomoniasis in the United States

BACKGROUND

Clinical evidence suggests that trichomoniasis facilitates the sexual transmission and acquisition of HIV.

GOAL

The goal of this study was to estimate the annual number and cost of new HIV infections among women in the United States attributable to trichomoniasis.

STUDY

We used a mathematical model of HIV transmission to estimate the probability that a woman with trichomoniasis would acquire HIV as a result of her trichomoniasis-mediated increased susceptibility to HIV infection or as a result of increased HIV infectiousness in a trichomoniasis-infected male partner.

RESULTS

Our results indicate that each year in the United States, an estimated 746 new HIV cases among women can be attributed to the facilitative effects of trichomoniasis on HIV transmission. The lifetime cost of treating these trichomoniasis-attributable HIV infections is approximately $167 million.

CONCLUSIONS

Efforts to prevent trichomoniasis could help prevent HIV transmission and could reduce the economic burden associated with trichomoniasis-attributable HIV cases that occur each year. Because trichomoniasis is so common, however, a substantial number of cases would need to be detected and treated to have a discernible impact on HIV. Future research is needed to examine the cost-effectiveness of trichomoniasis prevention as a tool for HIV prevention.

Trichomonas vaginalis (TV) and human papillomavirus (HPV) infection and the incidence of cervical intraepithelial neoplasia (CIN) grade III

The temporal relationship between cervical infection with Trichomonas vaginalis (TV) or human papillomavirus (HPV) and the incidence rate of cervical intraepithelial neoplasia grade three (CIN III) was examined in a cohort of 43,016 Norwegian women. From 1980 to 1989, a cervico-vaginal infection from TV and HPV was diagnosed cytologically in 988 and 678 women, respectively. During the 181,240 person-years of observation, 440 cases of CIN III/cervical cancer developed. The age-adjusted incidence rates (IR) of CIN III were 225 per 100,000 person-years among women with no cytologic evidence of infection, 459 among women with TV infection, and 729 among women with HPV infection. A multiple regression model yielded a relative rate (RR) of CIN III of 2.1 (95 percent confidence interval [CI] = 1.3-3.4) among women with TV infection and 3.5 (CI = 1.9-6.6) among women with HPV infection, compared with women with neither infection. As CIN can be misclassified as HPV infection, the entry Pap-smears of 10 women with HPV infection who later developed CIN III were re-examined. Excluding the four discordant cases with the corresponding person-years decreased the RR of CIN III to 2.1 (CI = 0.9-4.8). Our report demonstrates the limitations of studies that rely only on cytologic detection of HPV infection. Nevertheless, the results support the hypothesis that HPV is a causal factor for CIN III lesions, and also display an association between TV infection and cervical neoplasia.

Trichomonas vaginalis and cervical cancer. A prospective study in China

The relationship between Trichomonas vaginalis infection and cervical cancer was investigated prospectively in a cohort of 16,797 women aged 25 years or more who were followed from 1974 to 1985 within the framework of a cervical screening program in Jingan, China. Personal interviews were conducted by trained interviewers when the women first entered the screening program. At initial screening, 421 (2.51%) women had a positive cytologic diagnosis of T. vaginalis infection. Ninety-nine incident cases of pathologically confirmed squamous cell carcinoma were identified from the cohort, with a total of 140,018 person-years of observation. T. vaginalis infection was found to contribute to the risk of cervical cancer, as determined by crude estimates and after adjustment for potential confounding effects. In a multiple proportional hazards model, the relative risk for cervical cancer was 3.3 (95% confidence interval: 1.5 to 7.4) among women with T. vaginalis infection. Furthermore, in the multivariate analysis, increased risk of cervical cancer was associated with the following factors: number of extramarital sexual partners of both the subjects and their spouses, cigarette smoking, and irregular menstruation. Having a large number of negative Pap smears was associated with lower risk. This study suggests that there might be an association between T. vaginalis infection and the risk of cervical cancer, but only 4 to 5% of cervical cancer in Chinese women may be attributable to T. vaginalis infection.

Genital warts and cervical neoplasia: an epidemiological study

Cervical carcinoma and cervical intra-epithelial neoplasia (CIN) are likely to be associated with all sexually transmitted diseases (STDs). To help discover which (if any) of the recognised STDs might actually cause these conditions, a key question is whether one particular such association is much stronger than the others. The present study is therefore only of women newly attending an STD clinic, and compares the prevalences of cytological abnormalities of the cervix among 415 women attending with genital warts, 135 with genital herpes, and 458 with trichomoniasis or gonorrhoea. Significantly more genital wart patients (8.1%) than trichomoniasis or gonorrhoea patients (1.9%) showed dyskaryotic changes (adjusted relative risk (RR) = 5.8 with 95% limits 2.5-13.5) at, or a few months before, first attendance, while no excess whatever was seen in women with genital herpes. Moreover, half the women had a subsequent smear (at an average of 3-4 years after first attendance) and, although the diagnosis at first attendance was not related to the onset rate of dyskaryotic changes observed in these subsequent smears, it was related to the onset rate of grade III cervical intra-epithelial neoplasia (CIN III), which was found in 7 previous genital wart patients, in 2 previous trichomonas patients, but in 0 previous genital herpes patients. Thus, our findings suggest that herpes is not directly relevant to dyskaryotic change, but that one or more of the human papilloma viruses that cause genital warts may be.

Risk factors for trichomoniasis among women with human immunodeficiency virus (HIV) infection at a public clinic in Los Angeles County, California: implications for HIV prevention

Persons with human immunodeficiency virus (HIV) infection who subsequently develop an acute sexually transmitted disease have an increased probability of transmitting HIV. Therefore, characterizing such persons can help direct prevention efforts to a group who are likely to be continuing sources of HIV transmission. We assessed the incidence and factors associated with trichomoniasis in a cohort of HIV-infected women receiving care at a public clinic in Los Angeles County, California from 1992 through 1995. Demographic, clinical, and behavioral data were available from medical records and from patient interviews. Trichomonas infection was the most frequently identified sexually transmitted disease and was found in 37 (17.4%) of 212 women representing a crude incidence rate of 14.1 per 100 person-years experience. The crude rate of trichomoniasis was highest in black women (69.0 per 100 person-years), women with a history of trading sex for drugs or money (51.0 per 100 person-years), those using crack or cocaine (35.5 per 100 person-years), women with four or more sex partners (43.0 per 100 person years), and those born in the United States (23.3 per 100 person-years). Among women with severe immunosuppression (CD4+ count < 200), 18.4% (18 of 98) were diagnosed with trichomoniasis. After multivariate analysis using a Cox proportional hazards approach, black race (adjusted rate ratio [RR] = 5.6, 95% confidence interval [CI] = 2.3, 13.3) continued to be strongly associated with Trichomonas infection. Trading sex for money or drugs (adjusted RR = 25.2, 95% CI = 4.3, 148.6) and single marital status (adjusted RR = 3.7, 95% CI = 1.1, 13.0) were independent risk factors for trichomoniasis in nonblack women but not among black women. Data from this study indicate that Trichomonas may be a frequently acquired infection in HIV-positive women. Our findings suggest that HIV-infected women who are black, and nonblack women who trade sex for money or drugs or are unmarried, are at increased risk of trichomoniasis and therefore may be more likely to transmit HIV infection. Local HIV prevention strategies should target such women for intervention efforts.

A randomized treatment trial: single versus 7-day dose of metronidazole for the treatment of Trichomonas vaginalis among HIV-infected women

OBJECTIVE

To determine if the metronidazole (MTZ) 2-gm single dose (recommended) is as effective as the 7-day 500 mg twice a day dose (alternative) for treatment of Trichomonas vaginalis (TV) among HIV+ women.

METHODS

Phase IV randomized clinical trial; HIV+ women with culture confirmed TV were randomized to treatment arm: MTZ 2-gm single dose or MTZ 500 mg twice a day 7-day dose. All women were given 2-gm MTZ doses to deliver to their sex partners. Women were recultured for TV at a test-of-cure (TOC) visit occurring 6-12 days after treatment completion. TV-negative women at TOC were again recultured at a 3-month visit. Repeat TV infection rates were compared between arms.

RESULTS

Two hundred seventy HIV+/TV+ women were enrolled (mean age = 40 years, ±9.4; 92.2% African American). Treatment arms were similar with respect to age, race, CD4 count, viral load, antiretroviral therapy status, site, and loss-to-follow up. Women in the 7-day arm had lower repeat TV infection rates at TOC [8.5% (11 of 130) versus 16.8% (21 of 125) (relative risk: 0.50, 95% confidence interval = 0.25, 1.00; P < 0.05)] and at 3 months [11.0% (8 of 73) versus 24.1% (19 of 79) (relative risk: 0.46, 95% confidence interval = 0.21, 0.98; P = 0.03)] compared with the single-dose arm.

CONCLUSIONS

The 7-day MTZ dose was more effective than the single dose for the treatment of TV among HIV+ women.

Sexually transmitted diseases and tubal pregnancy

The risk of tubal pregnancy associated with seropositivity to Chlamydia trachomatis or following a diagnosis of gonorrhea, genital herpes, trichomoniasis, genital warts, or nonspecific vaginal infection was evaluated in a study of this condition among women who were members of a prepaid health plan. A total of 264 women who had a tubal pregnancy between 1981 and 1986 were interviewed about their history of these sexually transmitted diseases (STDs). Their responses were compared to those of 715 women who were matched by age and county of residence but were otherwise randomly selected from the enrollment files of the health plan. Chlamydia antibody status was known in a sample of 135 cases and 192 controls. Although more cases reported a history of gonorrhea, trichomoniasis, and non-specific vaginal infections than did controls, only a modestly elevated risk for trichomoniasis remained after logistic regression was used to adjust for the effects of age, reference year, race, presence of contraception at reference date, seropositivity to Chlamydia trachomatis, and a history of other STDs. By contrast, among women for whom Chlamydia trachomatis antibody status was assessed, presence of antibody was associated with a two-fold increase in the risk of tubal pregnancy after adjusting for the effects of the previously enumerated variables. These findings confirm the relevance of Chlamydia trachomatis as a risk factor for ectopic pregnancy, and they also underscore the importance of adjustment for the influence of other STDs when evaluating the association between a specific STD and the occurrence of tubal pregnancy.

Impact of oral metronidazole treatment on the vaginal microbiota and correlates of treatment failure

BACKGROUND

Metronidazole is the first-line treatment for bacterial vaginosis, but cure rates are suboptimal and recurrence rates high.

OBJECTIVES

To evaluate the impact of a standard course of oral metronidazole treatment (500 mg twice per day for 7 days) on the vaginal microbiota of Rwandan bacterial vaginosis patients using microscopy and 16S rRNA gene sequencing, and to evaluate correlates of treatment failure.

STUDY DESIGN

HIV-negative, nonpregnant women aged 18-45 years with bacterial vaginosis and/or Trichomonas vaginalis (N=68) were interviewed and sampled before and after metronidazole treatment. They were also screened, and treated if applicable, for other urogenital infections. The vaginal microbiota was assessed by Gram stain Nugent scoring, Illumina 16S rRNA HiSeq sequencing (relative abundances), and BactQuant 16S gene quantitative polymerase chain reaction (estimated concentrations). Only women with a pretreatment Nugent score of 7-10 and a valid posttreatment Nugent score (N=55) were included in metronidazole treatment failure analyses, with treatment failure defined as a posttreatment Nugent score of 4-10.

RESULTS

The bacterial vaginosis cure rate by Nugent scoring was 54.5%. The mean total vaginal bacterial concentration declined from 6.59 to 5.85 log10/μL (P<.001), which was mostly due to a reduction in mean bacterial vaginosis-associated anaerobes concentration (all bacterial vaginosis-associated anaerobe taxa combined) from 6.23 to 4.55 log10/μL (P<.001). However, only 16.4% of women had a bacterial vaginosis anaerobes concentration reduction of more than 50%, and only 3 women had complete eradication. The mean concentration of lactobacilli (all species combined) increased from 4.98 to 5.56 log10/μL (P=.017), with L. iners being the most common species pre- and posttreatment. The mean concentration of pathobionts (defined as Proteobacteria, streptococci, staphylococci, enterococci, and a few others) did not change significantly: from 1.92 log10/μL pretreatment to 2.01 log10/μL posttreatment (P=.939). Pretreatment pathobionts concentration, and having a pretreatment vaginal microbiota type containing more than 50% Gardnerella vaginalis (compared with less than 50%), were associated with increased likelihood of treatment failure, but the latter did not reach statistical significance (P=.044 and P=.084, respectively).

CONCLUSIONS

Metronidazole alone may not cure women with high G. vaginalis relative abundance, potentially due to biofilm presence, and women with high pathobionts concentration. These women may benefit from additional biofilm-disrupting and/or pathobiont-targeting treatments.

Microbial flora of the lower genital tract during pregnancy: relationship to morbidity

Nineteen genera and groups of micro-organisms were isolated from the lower genital tract of 280 women at their first antenatal visit. Chlamydia, viruses, and T-strain mycoplasmas were not sought, and only routine methods of anaerobic culture were used. Growth was recorded as scanty, moderate or heavy. The population studied was grouped according to age, parity, gestational stage at booking, presence and degree of severity of lower genital tract morbidity, past history of vulvovaginitis, and suspicion of lower genital tract morbidity as evidenced by a request for a report on the microbiological findings. The frequency of isolation of the various microbes in health and in disease is given. The grading of Gram-stained smears bore no relation to the isolation rates of lactobacilli, but there was a significant increase (p less than 0-001) in the isolation rates of each of the following: Mycoplasma hominis, Bacteroides spp., Trichomonas vaginalis, Gram-variable cocco-bacilli, and anaerobic streptococci in those patients with smears in which lactobacilli were adjudged to be absent. The isolation of faecal streptococci was increased (p less than 0-001) in women aged more than 34 years. Escherichia coli (p less than 0-05) and anaerobic and microaerophilic streptococci (p less than 0-02) were isolated more frequently from those booking after the 25th week of pregnancy. The incidence of M. hominis (p less than 0-02) and of anaerobic streptococci (p less than 0-05) increased between the first and third trimesters. No significance positive correlations were established between the isolation rates of the various microbes and objective assessment of lower genital tract morbidity or the demonstration of pus cells, but lactobacilli were isolated less frequently (p less than 0-01) from those with morbidity. The isolation of Candida albicans (p less than 0-02), T. vaginalis (p less than 0-05), and M. hominis (p less than 0.05) was increased in patients in whom vulvovaginitis was suspected, and that of T. vaginalis (p less than 0-05) was increased in those with a past history of vulvovaginitis. The study indicates that, other than the pathogens T. vaginalis and C. albicans, only M. Hominis could be suspected, on statistical grounds, of being associated with disease of the lower genital tract during early pregnancy.

New sexually transmitted diseases in HIV-infected patients: markers for ongoing HIV transmission behavior

OBJECTIVE

The objective of this study was to describe the rate of new sexually transmitted diseases (STDs) among HIV-infected patients and to define the behavioral and clinical characteristics of HIV-infected patients who return with a new STD in follow-up.

DESIGN

The study design was a record-based clinical cohort study focusing on patients testing HIV-seropositive in the STD clinics of Baltimore, Maryland from 1993 to 1998.

METHODS

The authors identified those HIV-infected patients later diagnosed with an STD in follow-up and compared their demographic, behavioral, and clinical characteristics with those who were not diagnosed with an STD in follow-up.

RESULTS

Of 796 men and 354 women with HIV infection, 13.9% of men and 11.9% of women were diagnosed with an STD after their initial HIV diagnosis. HIV-infected men returned with a new STD at a rate of 7 cases per 100 person-years; HIV-infected women returned at a rate of 5.6 cases per 100 person-years. In men, multiple sex partners and sex worker contact were associated with a subsequent STD diagnosis (OR = 1.67, p =.037; OR = 1.82, p =.015, respectively). In women, age younger than 30 years was associated with the diagnosis of an STD after the diagnosis of HIV infection (OR = 2.94, p =.0009).

CONCLUSIONS

Patients diagnosed with HIV in an STD clinic setting commonly return with new STDs in follow-up, suggesting continued exposure of HIV to others. More intensive screening and counseling interventions focused on STD prevention in those with HIV infection is a necessary HIV prevention strategy.