Amine content of vaginal fluid from untreated and treated patients with nonspecific vaginitis.

We examined the vaginal washings from patients with nonspecific vaginitis (NSV) to seek biochemical markers and possible explanations for the signs and symptoms of this syndrome. Seven amines were identified including methylamine, isobutylamine, putrescine, cadaverine, histamine, tyramine, and phenethylamine. These amines may contribute to the symptoms of NSV and may contribute to the elevated pH of the vaginal discharge. They may also be partly responsible for the "fishy" odor that is characteristic of vaginal discharges from these patients. Among the seven amines, putrescine and cadaverine were the most abundant and were present in all vaginal discharges from each of ten patients before treatment. These amines are produced in vitro during growth of mixed vaginal bacteria in chemically defined medium, presumably by decarboxylation of the corresponding amino acids. We hypothesize the anaerobic vaginal organisms, previously shown to be quantitatively increased in NSV, are responsible for the amine production, because metronidazole inhibited the production of amines by vaginal bacteria in vitro, and Haemophilus vaginalis did not produce amines. H. vaginalis did release high concentrations of pyruvic acid and of amino acids during growth in peptone-starch-dextrose medium, whereas, other vaginal flora consumed both pyruvic acid and amino acids in the same medium during growth. These findings suggest that a symbiotic relationship may exist between H. vaginalis and other vaginal flora in patients with NSV.     

Ineffectiveness of erythromycin for treatment of Haemophilus vaginalis-associated vaginitis: possible relationship to acidity of vaginal secretions.

To assess the efficacy of oral erythromycin in the treatment of nonspecific vaginitis (NSV), conducted a nonrandom, unblinded pilot study among 17 women with symptoms and signs of NSV. At the completion of treatment, 10 of 13 patients had persistent symptoms, 9 of 13 had persistent abnormal discharge, and 11 of 13 had persistently positive cultures for Haemophilus vaginalis. Ten patients with persistent or relapsing NSV and four who did not complete erythromycin treatment were retreated with oral metronidazole, and 14 of 14 showed clinical improvement and eradication of H. vaginalis. The susceptibility of 27 clinical isolates of H. vaginalis to erythromycin was determined at pH 5.5, 6.0, 6.5, and 7.0. The minimal inhibitory concentration of erythromycin for H. vaginalis was approximately 10-fold higher at pH 5.5 than at pH 7.0. Erythromycin is not effective for the treatment of H. vaginalis-associated NSV; this may be partly attributable to the reduced activity of this drug in acidic vaginal secretions.     

Identifying vaginitis in general practice

Clinicians conducted a study of 154 women who presented themselves at a health center of the University of Wales College of Medicine with symptoms of vaginitis. A nurse examined the vagina with a speculum to note the appearance of the cervix, the color and amount of discharge, and the presence of odor and inquired about soreness during the examination. The nurse took 3 endocervical swabs and 2 high vaginal swabs. Upon microscopic examination, any vaginal discharge with epithelial cells stippled with small coccobacilli indicated a possible Gardnerella vaginalis infection. Laboratory personnel identified G. vaginalis either alone or in combination with other organisms in 53% of the women. Those with G. vaginalis alone or in combination with anaerobes reported more symptoms than those women who had negative cultures. In addition, women with G. vaginalis alone and those G. vaginalis in combination with other organisms had more discharge, described as yellow and runny, than those with negative cultures. 77% of the women infected with G. vaginalis had a high cheese or fishy odor. 75% of the women with G. vaginalis came to the health center between 2-4 weeks or even longer after they 1st noticed symptoms. On the other hand, women who were infected with C. albicans presented to the health center within a week of the start of the symptoms. Clinicians had previously treated erroneously many of the women with G. vaginalis with an antifungal agent. These women should be treated with metronidazole or, if a yeast infection is also present, with an antifungal agent and metronidazole. All women who present themselves to a nurse or physician with vaginal symptoms should have a history taken, an examination, and vaginal discharge samples taken and evaluated in the laboratory.     

In vitro susceptibility of Gardnerella vaginalis and Bacteroides organisms, associated with nonspecific vaginitis, to sulfonamide preparations.

Recent reports suggest that anaerobic Bacteroides organisms are frequently found with Gardnerella vaginalis in nonspecific vaginitis. Specimens taken from 96 women with vaginal discharge were tested simultaneously for these organisms. G. vaginalis was found in 73% of the specimens, Bacteroides was found in 53%, and both organisms were found in 47%. Sulfonamides have been widely used in the successful treatment of vaginitis. Paradoxically, G. vaginalis is reported to be resistant, and it has been suggested that it could be the vehicle of the drugs which effects the cure. Little is known of the susceptibility of vaginal anaerobes to the sulfonamides. G. vaginalis and Bacteroides isolates were therefore tested in vitro against the individual excipients of sulfonamide tablets, and minimal inhibitory concentration tests were also performed against the three active drugs. The excipients had no effect on G. vaginalis, but Bacteroides strains were susceptible to the urea component. All strains of both organisms were susceptible to at least two of the three sulfonamides at high concentrations.     

BACTERIAL VAGINOSIS

SUMMARY Bacterial vaginosis (BV) is an alteration of the vaginal flora, where the normally predominant lactobacilli are replaced by a cocktail of organisms including Gardnerella vaginalis and anaerobes. It presents with a grey, homogenous, offensive vaginal discharge that has a raised pH. However, around half the women with this condition are asymptomatic. Diagnosis is best made by microscopic examination of a Gram-stained smear of vaginal secretions. Treatment is with metronidazole or clindamycin. The indications for treatment of asymptomatic BV are not clear, but women should probably be treated before any invasive gynaecological procedure, including intrauterine contraceptive device (IUCD) insertion. BV during pregnancy is associated with preterm labour, although a causal effect is not proven; studies are in progress to determine whether treatment of BV will improve the outcome of these pregnancies.     

200例产后妇女阴道微生态状况分析

目的探讨产后女性阴道微生态状况。方法选择本院产后门诊复查的产后妇女200例及来本院妇科体检的健康妇女40例,采集阴道分泌物,测定pH值,并用革兰氏染色涂片后采用Nugent评分进行阴道微生态学评价及比较。结果200例产后妇女阴道pH值为（4．66±0．25）;微生态正常者9例,占4．5％;阴道微生态失调191例,占95．5％;乳杆菌检出率14．5％。40例健康妇女阴道pH值为（4．25±0．35）;阴道微生态正常者31例,占77．5％;阴道微生态失调9例,占22．5％;乳杆菌检查率82．5％。差异有统计学意义。结论产后妇女阴道微生态发生改变,表现为pH升高,微生态失调比例明显升高,应引起关注。     

Cervico-vaginal pathogens and contraception: microbiological observations

The authors relate the results about 172 vaginal and cervical swabs, in women with or without oral/local (IUD) contraception, with or without vaginosis/vaginitis. Gardnerella vaginalis was always prevalent; the authors observed an high correlation between cervical IUD and vaginal Gardnerella, more than IUD and cervical Chlamydia trachomatis. Bacterial associations in Gardnerella vaginalis (Mobiluncus, obligate anaerobes) are related; incidence of Candida and Trichomonas vaginalis are reported; correlation between these microbial agents and contraception are discussed.     

The microbiology of bacteriuria in men: a 5-year study at a Veterans' Affairs hospital

Bacteriuria and urinary tract infection occur relatively frequently in older men, but data regarding the causative microorganisms are limited. We retrospectively identified all positive cultures of urine specimens (n = 4943) obtained over a 5-year period at our institution. We determined the frequency of causative microorganisms and grouped these by Gram type, setting of patient care, and method of urine specimen collection. We also assessed the performance characteristics of the Gram-stained smear of uncentrifuged urine. Among our patients, Gram-positive cocci (GPC) were isolated as often as Gram-negative rods (GNR). Escherichia coli was the single or predominant isolate in only 14% of cases, and Enterococcus was the single most commonly identified genus (22.5%). The Gram stain was accurate in predicting the culture results (positive likelihood ratio, 7.0 for GPC and 8.1 for GNR). We conclude that the microorganisms causing bacteriuria in older male veterans are substantially different from those found in women, and the Gram-stained smear provides useful information on the causative organisms.     

Bacterial vaginosis: etiology, association with preterm labor, diagnosis, and management

Bacterial vaginosis is a polymicrobial condition (anaerobes, Gardnerella vaginalis) that is associated with symptomatic vaginal discharge. Bacterial vaginosis can be reliably diagnosed through clinical indicators such as clue cells on wet preparation of vaginal discharge, an increased pH of vaginal discharge, a fishy, amine odor emitted when a sample of vaginal discharge is placed in potassium hydroxide, and cultures that isolate G. vaginalis. The vaginal discharge is often heavy and foul smelling, and usually resolves when treated with metronidazole, 500 mg twice a day for seven days. It is unclear whether bacterial vaginosis is caused by G. vaginalis or whether G. vaginalis is simply associated with the condition and its development is related to other factors. More importantly, the association of bacterial vaginosis with preterm labor (whether merely a risk factor or a causal factor) needs to be clarified, and the question of whether treatment of bacterial vaginosis in pregnancy will improve fetal outcome by decreasing prematurity needs to be addressed.     

Performance of a rapid yeast test in detecting Candida spp. in the vagina

We compared the performance of a rapid vaginal yeast assay (Savvycheck) with that of microscopic examination of a Gram-stained smear and culture of vaginal discharge in detecting Candida spp. Two hundred thirty-one women with vaginal symptoms were studied prospectively. Vaginal specimens obtained from all participants were studied by the Savvycheck rapid yeast test, microscopic evaluation of Gram-stained vaginal smears, and yeast culture. Savvycheck rapid yeast test was positive in 79% of women with positive cultures and in 3.6% of women with negative cultures. The Savvycheck test detected yeasts in 93% of subjects with positive Gram stain and in 5.5% of subjects with negative Gram stain. The Savvycheck rapid yeast test showed 93% sensitivity, 95% specificity, and a 97% negative predictive value compared with the Gram stain. It revealed 79% sensitivity, 96% specificity, and an 87% negative predictive value compared with culture. The Savvycheck rapid yeast test can be used in the busy office instead of microscopy as a point-of-care tool for diagnosing vulvovaginal candidiasis. It can also reduce the need for yeast cultures in patients with vaginitis.     

Increased sensitivity of Trichomonas vaginalis isolation from vaginal secretions by subsequent blind passage of preliminary negative cultures

Trichomonas vaginalis is a vaginal protozoon causing the most prevalent nonviral sexually transmitted disease. Culture is considered as the most reliable and gold standard among conventional diagnostic methods in the detection of T. vaginalis. In the present study, the diagnostic effect of subsequent blind culturing of vaginal secretion samples in Diamond's complete medium at every 48 h was investigated in 93 women. Vaginal secretion samples were examined by wet mount and inoculated into Diamond's complete medium. All tubes were subcultured to a new culture tube blindly 5 times at 48-h interval and checked microscopically everyday for the presence of T. vaginalis trophozoites. Three of 93 women were found to be positive both by wet mount and standard culture methods. Five more positive results were detected with subsequent blind culturing among 90 negative results. This system appears to be a useful method for the detection of T. vaginalis.     

Microbiology of vaginal discharge in general practice

Three groups of women were examined by culture for Gardnerella vaginalis and Candida. Group I consisted of 427 women, who complained spontaneously of vaginal discharge, group II of 311 women who did not complain of vaginal discharge until questioned prior to gynaecological examination, and group III of 100 women who denied vaginal discharge. Groups I and II also had cultures made for Trichomonas vaginalis and Neisseria gonorrhoica. In group I with spontaneous complaints the one-year prevalence rate of vaginal discharge was 3.4%. Candida, Trichomonas vaginalis and Neisseria gonorrhoica were cultured in 24%, 8% and 1% respectively. Gardnerella vaginalis was cultured in half of the women in all groups. A characteristic discharge or a positive microscopic finding was related to high concentration of Gardnerella vaginalis. A characteristic discharge even without spontaneous complaints of vaginal discharge was related to a high prevalence of Gardnerella vaginalis. Women complaining from discharge had higher concentrations of Gardnerella vaginalis than non-complaining. This leads to the conclusion that clinical disease may not be present unless concentrations of Gardnerella vaginalis have risen above some minimum level. The Gardnerella vaginalis syndrome defined by positive culture, clinical finding and microscopy was found in 20% of symptomatic women.     

Differentiation of Enterobacteriaceae, Pseudomonas aeruginosa, and Bacteroides and Haemophilus species in gram-stained direct smears.

The accuracy of examination of the Gram-stained direct smear to classify presumptively Gram-negative rods into three morphotype groups, that is, (a) Enteric bacteria, (b) Pseudomonas, and (c) Bacteroides or Haemophilus, was evaluated. Randomly selected clinical strains (4-9) each of Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Ps. aeruginosa, B. fragilis, and H. influenzae were used to produce peritonitis or subcutaneous abscesses in mice. A Gram-stained direct smear was prepared from exudate collected from each animal. The direct smears were examined to classify bacteria observed into one of the three morphotype groups. The percent accuracy was 82, 56, and 95, respectively, and 76 overall. The assumption was made that classification was based primarily on differences in length and width of the organisms. To test this hypothesis, we prepared scanning electron photomicrographs from each specimen of exudate and measured the lengths and widths of bacteria. Examination of the Gram-stained direct smear was more accurate for classification of enteric bacteria, H. influenzae, or B. fragilis. Electron microscopy was more accurate for classification of Ps. aeruginosa. The higher length-width radio should be helpful in recognizing Ps. aeruginosa in direct smears.     

Tioconazole 2% cream in the treatment of Trichomonas vaginalis or mixed vaginal infections

Twenty patients with documented T. vaginalis infections, six of whom were simultaneously infected with C. albicans and one with G. vaginalis, were treated topically (intravaginally) once daily with 5 g of 2% tioconazole vaginal cream (Trosyd, Pfizer) for 3 consecutive days in an open, non-comparative study. At the first follow-up visit (about 7 days post-treatment), 95% (19/20) of the patients were cured; 95% (18/19) of patients remained cured with respect to the baseline infection at the long-term follow-up (2 months post-treatment) visit, and one patient had a reinfection or relapse with T. vaginalis. Only one patient reported a side-effect, a mild vaginal burning which disappeared with continued treatment. It was concluded that tioconazole 2% vaginal cream is safe and effective for the treatment of T. vaginalis and mixed vaginal infections.     

HPV感染及高级别CIN患者阴道微生态研究

目的分析人乳头瘤病毒16、18(HPV16、18)宫颈感染及高级别宫颈上皮内瘤变(CIN)患者阴道微生态特征。方法以3例湿疣样变或CIN1级HPV16和/或18感染患者为低级别CIN组,以5例高级别CIN病变HPV16和/或18感染患者为高级别CIN组,以3例HPV阴性阴道炎患者为对照组,采用16S rRNA基因扩增技术分析各研究组患者阴道微生物菌群组成,采用分层聚类法分析并比较各研究组阴道微生物菌群分布特征。结果高级别CIN组阴道微生物细菌种类多样性及复杂性较低级别CIN组、对照组更为明显;从对照组、低级别CIN组至高级别CIN组,卷曲乳杆菌和穹隆乳杆菌丰度呈下降趋势,惰性乳杆菌丰度呈增加趋势;定植菌犬布鲁氏菌丰度呈下降趋势,致病菌戴阿李斯特琥珀酸纤毛杆菌、阴道加德纳菌和短普雷沃菌丰度呈上升趋势。结论高级别CIN患者阴道菌种结构复杂性、多样性明显。阴道乳杆菌种类和丰度对阴道健康起重要作用,惰性乳杆菌则具有相反作用。犬布鲁氏菌、戴阿李斯特琥珀酸纤毛杆菌、阴道加德纳菌和短普雷沃菌长期存在于阴道,与HPV持续感染、进展至高级别CIN病变密切相关。     

Early detection of lower respiratory tract infection: the value of the gram-stained sputum smear.

In some clinical laboratories the routine examination of sputum includes a Gram-stained smear. Of specimens examined in this study the Gram-stained smear was found to be useful, but fallible in predicting bacterial culture results. Smear results requested urgently by clinicians should be relayed with caution. However, the predictive negative value of the Gram stain was encouraging.     

Diagnostic value of clinical examination, direct microscopy, and culture in the Gardnerella vaginalis syndrome

In a general practice 467 women aged 15-49 years with vaginal discharge were consecutively examined in order to compare the diagnostic value in the Gardnerella vaginalis syndrome of the clinical examination, direct microscopy of the vaginal secretion, and culture. We found significant correlations between all relevant combinations of the diagnostic methods. The predictive value of a positive test for the clinical examination, the microscopy, and the clinical examination combined with microscopy, respectively, was 0.75, 0.89 and 0.90, whereas the predictive values of the negative test were 0.59, 0.72 and 0.61, respectively. Because even small numbers of Gardnerella vaginalis may yield growth on selective culture media, the clinical examination and the microscopy are often negative despite positive culture. To avoid overtreatment of a benign condition we therefore conclude that the presence of a characteristic clinical picture and positive microscopy constitute a safe basis for the diagnosis of the Gardnerella vaginalis syndrome, and that the diagnosis should be based on this combination or on the fulfilment of three of the following four criteria: 1) characteristic vaginal secretion; 2) vaginal pH greater than 4.5; 3) positive potassium hydroxide test or characteristic herring-brine smell, and 4) clue cells at microscopy. With the present methods culture for Gardnerella vaginalis should not routinely be performed, until the value of quantitated methods has been proved. Coexistence of other microorganisms rendered the diagnosis difficult. We recommend to treat the most predominant infection first.     

革兰染色法在诊断细菌性阴道病中的应用

目的:探讨革兰染色法在诊断细菌性阴道病中的价值。方法:以Amsel法为标准,分别用阴道加德纳菌培养法和G染色法检测60例细菌性阴道病患者和60例正常对照。结果:G染色细菌积分的灵敏度为90.0%,特异性为96.7%,阳性预示值为96.4%,阴性预示值为93.5%;阴道加德纳菌培养法的灵敏度只有41.7%,特异性为88.3%,阳性预示值为78.1%,阴性预示值为60.2%。结论:革兰染色法可以客观、准确、简便的诊断细菌性阴道病。     

念珠菌乳胶免疫层析法的性能评价

目的评价念珠菌乳胶免疫层析法检测试剂盒(以下简称念试剂)检测阴道分泌物中念珠菌的性能和种属特异性。方法采用涂片/革兰染色法和念试剂检测354例怀疑为念珠菌阴道炎妇女阴道分泌物和9种属22种阴道常见感染微生物,并与涂片/革兰染色法半定量比较,评价念试剂的临床标本检测性能及种属特异性。结果与涂片/革兰染色法相比,念试剂的灵敏度为93.81%,特异度为99.10%,准确性97.31%,阳性预期值为98.14%,阴性预期值为96.90%;与涂片/革兰染色法半定量相比,该念试剂检测阴道分泌物中的念珠菌在标本中念珠菌浓度较低时仍然具有较高的特异度、可接受的灵敏性;在种属特异度评价,6种念珠菌阳性,其他16种阴道常见感染微生物均为阴性。结论念试剂检测阴道分泌物中念珠菌具有较高的临床和种属特异度、灵敏度、阳性预测值和阴性预测值。     

Vaginitis/vaginosis

Vaginitis/vaginosis is an extremely common medical problem. Most cases are caused by yeast (predominantly Candida albicans), the protozoan Trichomonas vaginalis, or a specific mixture of bacteria (bacterial vaginosis). The prevalence of each of these varies with the patient population. The clinical signs used in differentiating among these and the associated bacterial flora are shown in Table 3. Because vaginitis/vaginosis cannot be adequately diagnosed solely on the basis of symptoms or physical examination, some laboratory methods are required. Yeast vaginitis is diagnosed by microscopic detection of budding yeast or pseudohyphae in vaginal secretions. The most sensitive method for detection of Trichomonas vaginalis is culture, but microscopic methods are more commonly used. Wet-mount examination for motile trichomonads is the least sensitive microscopic method. The sensitivity is increased when fluorescent monoclonal antibodies are used. Bacterial vaginosis may be diagnosed in the clinic by detecting three or more of the following on examination: (1) homogeneous adherent discharge, (2) vaginal fluid pH greater than 4.5, (3) amine odor, and (4) clue cells. A diagnosis may also be made by detecting the replacement of lactobacilli by a mixed presumably anaerobic flora. This is accomplished by examining a Gram stain of vaginal fluid. It is not uncommon for a woman to have more than one microbial source for her vaginal signs and symptoms. A vaginal examination should include appropriate tests for detection of all three of these agents.