The high vaginal swab in general practice: clinical correlates of possible pathogens

Diagnostic and therapeutic advancements for aerobic vaginitis

BACKGROUND

Aerobic vaginitis (AV) is a newly defined clinical entity that is distinct from candidiasis, trichomoniasis and bacterial vaginosis (BV). Because of the poor recognition of AV, this condition can lead to treatment failures and is associated with severe complications, such as pelvic inflammatory disease, infertility, preterm birth and foetal infections.

OBJECTIVE

This review describes the diagnosis and treatment of AV and the relationship between AV and pregnancy.

RESULTS

The characteristics of AV include severely depressed levels of lactobacilli, increased levels of aerobic bacteria and an inflamed vagina. The diagnosis is made by microscopy on wet mounts of fresh vaginal fluid, and some distinct clinical features are recognized. Vaginal suppositories that contain kanamycin or clindamycin have shown curative effects in nonpregnant women. Additionally, the application of topical probiotics can restore the vaginal flora and reduce the recurrence of AV. Clindamycin vaginal suppositories and probiotics may be a better choice for gravida with AV than metronidazole. AV requires prompt attention, and the early diagnosis and treatment of AV during pregnancy significantly improves perinatal outcomes.

CONCLUSION

Further research is needed to define the pathogenesis, diagnostic criteria and standard treatment guidelines for AV.

Observational study of Streptococcus pyogenes isolated from vaginal swabs of adult women in a hospital and community laboratory

AIMS

Streptococcus pyogenes or group A streptococcus (GAS) is a common cause of vulvo-vaginitis in pre-pubertal females but is uncommonly isolated from the vaginal swabs of adult females. We aimed to describe the clinical and laboratory findings of adult females with GAS isolated from vaginal swabs in a community and hospital laboratory.

METHODS

Over a 19 week period the two laboratories identified females ≥ 15 years of age with GAS isolated from vaginal swabs. At least 2 weeks after reporting, the referring doctor or midwife was telephoned by the authors for clinical information or the clinical notes were reviewed. Laboratory data were also collected.

RESULTS

One hundred adult females with GAS isolated from vaginal swabs were identified from approximately 4500-5000 community laboratory, and 20 from approximately 2000 hospital laboratory swabs. Community patients were more likely to have presented with vaginal symptoms such as discharge, while hospital patients were more likely to have ascending infection related to pregnancy/recent delivery. Of the community patients, 15% were asymptomatic compared with 5% of the hospital patients. Review of Gram stain and culture quantification was not found to be particularly useful for discriminating between clinical infection and asymptomatic colonisation.

CONCLUSIONS

Isolation of GAS from the vaginal swabs of adult females is uncommon. In the community setting it may represent infection with vulvo-vaginitis or asymptomatic colonisation. In the hospital setting, its isolation is frequently associated with pregnancy-related infectious complications.

An unusual cause of persistent postpartum vaginal discharge

We describe the case of a 27-year-old woman with a three-month history of persistent green vaginal discharge following vaginal delivery of her first child. Group C β-haemolytic streptococcus was ultimately isolated, which appears to be an uncommon cause of this clinical presentation.

Prevalence and treatment of aerobic vaginitis among non-pregnant women: evaluation of the evidence for an underestimated clinical entity

We sought to evaluate the evidence on the prevalence of aerobic vaginitis (AV) among symptomatic non-pregnant women, as well as the treatment administered for this clinical entity. The PubMed and Scopus databases were systematically searched. Sixteen studies met the inclusion criteria, 11 of which reported on the prevalence of possible AV, two on the prevalence of diagnosed AV, and three on the treatment and outcomes of women with diagnosed AV. The prevalence of diagnosed AV varied from 5 to 10.5 %. Streptococcus spp., Staphylococcus aureus, and coagulase-negative staphylococci were the most commonly identified Gram-positive pathogens among women with possible AV, with prevalences of up to 58.7, 41.7, and 37.4 %, respectively, while Escherichia coli was the most common Gram-negative pathogen identified, with a prevalence of up to 23 % among symptomatic women. Regarding antibiotic treatment for AV, the antibiotic schemes administered, which mainly consisted of suppositories of aminoglycosides, showed good effectiveness without serious adverse events provided by any of the included studies. The currently available data suggest that the prevalence of AV is not negligible, while the prevalence of possible AV is considerable. Well-designed studies comparing the prevalence of aerobic pathogens between symptomatic and asymptomatic women are warranted.

Antimicrobial resistance in clinical isolates of Staphylococcus aureus from hospital and community sources in southern Jamaica

OBJECTIVES

In this study, we assessed the antimicrobial susceptibility patterns and prevalence of methicillin resistance among Staphylococcus aureus isolates from hospital and community sources in southern Jamaica.

METHODS

Eighty isolates of S. aureus obtained from hospital and community-based patients with staphylococcal infections were collected, and antimicrobial susceptibilities were determined by disk diffusion.

RESULTS

While all specimens yielded isolates, multidrug-resistant isolates were obtained only from urine, high vaginal swab, abscess aspirate, and catheter tip samples. The overall prevalence of methicillin-resistant S. aureus (MRSA) was 23%. The proportions of MRSA isolated from hospital sources (18/39) and community sources were 46% and 0%, respectively (p<0.05). The pattern of antibiotic susceptibility of S. aureus differed significantly between MRSA and methicillin-susceptible (MSSA) isolates. For MRSA isolates, multiple-drug resistance was common and only few antibiotics were active against these isolates. However, no MRSA was resistant to vancomycin. Except for penicillin and to some extent co-trimoxazole (trimethoprim-sulfamethoxazole), most MSSA isolates were susceptible to nearly all antimicrobial agents used in this study.

CONCLUSIONS

This is the first report of MRSA from this region of Jamaica. Because methicillin resistance is associated with multiple-drug resistance in S. aureus, it is imperative that surveillance initiatives be focused on both the hospital and community in order to monitor and limit the spread of this organism.

How is the high vaginal swab used to investigate vaginal discharge in primary care and how do GPs' expectations of the test match the tests performed by their microbiology services?

OBJECTIVES

To describe the management of vaginal discharge in general practice, with particular regard to the use of the high vaginal swab (HVS), and to compare GPs' expectations of this test with the processing and reporting undertaken by different laboratories.

METHODS

A postal questionnaire survey of 2146 GPs in the North Thames area and postal questionnaire study of the 22 laboratories serving the same GPs were carried out. GPs were asked how they would manage a young woman with vaginal discharge and what information they would like on an HVS report. Laboratories were asked how they would process and report on the HVS sample from the same patient.

RESULTS

Response rate was 26%. 72% of GPs would take an HVS and 62% would refer on to a genitourinary medicine (GUM) clinic. 45% would offer empirical therapy and 47% of these would treat for candida initially. 75% of GPs routinely request "M,C&S" on HVS samples but 55% only want to be informed about specific pathogens. Routine processing of HVS samples varies widely between laboratories and 86% only report specific pathogens. 78% of GPs would like to be offered a suggested diagnosis on HVS reports, and 74% would like a suggested treatment. 43% of laboratories ever provide a diagnosis, and 14% provide a suggested treatment.

CONCLUSIONS

GPs frequently manage vaginal discharge and most of them utilise the HVS. GPs' expectations of the test are not well matched to laboratory processing or reporting of the samples.