Microbiology of vaginal discharge in general practice

A wet smear criterion for bacterial vaginosis

OBJECTIVE

To evaluate a simpler criterion for bacterial vaginosis than the recommended criterion of Amsel.

DESIGN

Cross-sectional study comparing diagnostic data with a recommended standard.

SETTING

Danish general practice.

PARTICIPANTS

595 non-pregnant women aged 15-49 years who were gynaecologically examined, were divided into two groups in accordance with a complaint of vaginal discharge.

MAIN OUTCOME MEASURE

The associations of pH > 4.5, homogeneity, amine odour, clue cells, and wet smear assessment of predominance of lactobacilli, Gardnerella vaginalis, motile rods with the criterion of Amsel.

RESULTS

The four components of Amsel showed a considerable variation of association. Predominance of GV was more highly associated than several of the components. The association of a wet smear criterion composed of the presence of clue cells in combination with predominance of Gardnerella vaginalis and absence of lactobacilli was superior to other combinations. In the group without a complaint of vaginal discharge, preceding screening with use of a pH-measurement seemed advantageous.

CONCLUSION

The wet smear criterion seems suitable for use in general practice. But before a definitive establishment, calculation of the reproducibility of interpretation of this criterion, preferably with a more explicit setting of the components, has to be carried out.

Treatment of bacterial vaginosis with metronidazole or pivampicillin

In a double-blind randomized controlled trial from general practice, we assessed the efficacy of treatment with either metronidazole or pivampicillin in patients fulfilling the diagnostic criteria of bacterial vaginosis. 50 women were treated with metronidazole 500 mg twice daily and 54 with pivampicillin 700 mg twice daily, both for seven days. Evaluated four weeks after the start of treatment, we found a significantly higher cure rate in the metronidazole group (90%) than in the pivampicillin group (69%) (p = 0.01). Cure was defined as lack of fulfillment of the diagnostic criteria of bacterial vaginosis. Test for confounding according to parity and complaint of vaginal discharge showed no influence. Side-effects were significantly commoner in the pivampicillin group (28%) than in the metronidazole group (8%). We consider that metronidazole is a potent drug in the treatment of bacterial vaginosis, with pivampicillin as a useful alternative.

The diagnosis of candida vaginitis in general practice

In a multi-practice study, 29 general practitioners registered 361 women with increased vaginal discharge, malodour, or pruritus, and 229 women without vaginal complants. A wet-smear was examined for Candida by the general practitioner. Culture for Candida was performed in the general practitioner's laboratory, and at a microbiological laboratory. Candida was found by microscopy or culture in 140 (39%) women with vaginal symptoms, compared with 51 (22%) without vaginal complaints (p less than 0.001). In 34 women with symptoms (24%) Candida was found by wet-smear microscopy, in 98 (76%) by microscopy or culture in the general practitioner's laboratory, and in 126 (90%) by microscopy or culture at the microbiological laboratory. No relation was found between the number of Candida isolated and the presence of vaginal symptoms (p greater than 0.05). The sensitivity of microscopy was low compared with previous studies and underlines the need for multi-practice studies in the evaluation of diagnostic procedures. Vagicult is recommended for general practice, but problems exist in the interpretation of a positive culture result.