|Year : 2004 | Volume
| Issue : 1 | Page : 47-50
Diagnosis of bacterial vaginosis in a rural setup: Comparison of clinical algorithm, smear scoring and culture by semiquantitative technique
PS Rao , S Devi , A Shriyan , M Rajaram , K Jagdishchandra
Department of Microbiology, Kasturba Medical College, Manipal - 576 119, Karnataka, India
Department of Microbiology, Kasturba Medical College, Manipal - 576 119, Karnataka, India
This study was undertaken to estimate the prevalence of bacterial vaginosis (BV) and other sexually transmitted infections (STIs) in a rural set up and compare the smear scoring system to that of culture by semiquantitative technique. A total of 505 married women, who were in sexually active age group of 15-44 years, were selected from three different villages. High vaginal swabs, endocervical swabs, vaginal discharge and blood were collected and processed in the laboratory. Overall prevalence of 29% reproductive tract infection was detected. Endogenous infection was commonly observed (27.92%), and very low prevalence of STIs (Trichomonas 1.18%, Syphilis 0%, Gonorrhea 0%) was detected. Diagnosis of BV was possible in 104 (20.5%) women by smear alone and 88 (17.42%) women by semiquantitative culture.
|How to cite this article:|
Rao P S, Devi S, Shriyan A, Rajaram M, Jagdishchandra K. Diagnosis of bacterial vaginosis in a rural setup: Comparison of clinical algorithm, smear scoring and culture by semiquantitative technique. Indian J Med Microbiol 2004;22:47-50
|How to cite this URL:|
Rao P S, Devi S, Shriyan A, Rajaram M, Jagdishchandra K. Diagnosis of bacterial vaginosis in a rural setup: Comparison of clinical algorithm, smear scoring and culture by semiquantitative technique. Indian J Med Microbiol [serial online] 2004 [cited 2020 Aug 7];22:47-50. Available from: http://www.ijmm.org/text.asp?2004/22/1/47/8062
Bacterial vaginosis (BV) is a common cause of vaginitis in women who are sexually active during childbearing age. pH changes and change in normal vaginal flora allow organisms like Gardnerella vaginalis, Peptostreptococci, anaerobic gram negative bacilli, Mobiluncus and Mycoplasma hominis to overgrow and cause chronic infection and discharge. The manifestations vary from asymptomatic state to increased homogenous grayish white vaginal discharge, pruritus, lower abdominal pain, pain during coitus etc. Vaginal discharge is one of the most common clinical complaints among women of reproductive age in many parts of the world.
Considering nonavailability of laboratory facilities in many parts of the rural areas in developing countries, WHO has developed a set of syndromic management guidelines for treatment of men and women with symptoms presenting to basic health care services. These clinical algorithms recognize that there are several possible causes of common clinical syndromes and recommend treatment based on the most common causative organisms. One good example is the relationship between sexually transmitted infections (STIs) and HIV.
This study was undertaken to estimate the prevalence of bacterial vaginosis and other STIs in a rural set up and compare the smear scoring system to that of culture by semiquantitative technique. The aim was to detect the prevalence of common organisms in rural areas so that specific treatment could be provided.
| ~ Materials and Methods|| |
A total of 505 married women in the age group of 15-44 years were selected from three different villages namely Kukkundoor of Karkala taluk, Ujire, Belthangade taluk, and Talagodu, Mudigeri taluk. All the widows, divorcees, antenatal cases and women who were temporarily residing in the study area were excluded from the study. Predesigned and pretested proforma was given to the study population. Based on the syndromic approach, women with reproductive tract infection (RTI) were further examined after taking consent, on a specific day at TMA Pai Rotary Hospital, Karkala, or in the respective primary health centre.
A thorough gynaecological examination was done and high vaginal swabs were taken for Gram staining and wet mount preparation. The ectocervix was cleaned with sterile cotton wool and swabs collected from endocervix were plated onto Thayer Martin medium. On removal of the speculum the vaginal fluid was tested for pH and few drops of 10% KOH were added to the discharge on a glass slide and sniffed for detection of fishy odour. A sample of the blood was collected for serology for syphilis. Subsequently, clinical diagnosis was compared with laboratory based diagnosis for each women.
Light microscopy of immediate wet mounts was done to identify motile trichomonads. Candida was diagnosed when fungal hyphae or budding yeast cells were seen on wet mount or growth on Sabouraud's dextrose agar occurred with in five days. The presence of bacterial vaginosis was defined by scoring the smears in Department of microbiology, KMC, Manipal, by different individuals according to Nugents criteria as shown in [Table - 1].
Cultures were incubated at 37°C in carbon dioxide for maximum of 72 hrs. for detection of Neisseria More Details gonorrhoeae. Culture for Gardenerella and anaerobes were done on brain heart infusion blood agar, Columbia blood agar, human blood bilayer medium with tween 80 (HBT medium) and neomycin blood agar by semiquantitative techniques., The plates were incubated at 37°C in carbondioxide for Gardenerella and in anaerobic jar for anaerobes. Approximate grading was done by grading as 1+ growth on one quadrant as 1+ to 4+ if growth was seen on all four quadrants. The colonies were identified by standard methods.
| ~ Results|| |
In the present study, overall prevalence of reproductive tract infection was 29% (104 out of 505), but STI prevalence was very low (Trichomonas infection 1.18%, Gonorrhoea 0%, Syphilis 0%). Vaginal discharge and low backache were the common symptoms present in all patients. Laboratory confirmation of bacterial vaginosis was possible in 104 (20.5%) of 505 subjects by smear alone and 88 (17.42%) by semiquantitative culture as depicted in [Table - 2].
Among the culture isolates, Gardnerella, Candida and non sporing anaerobes were isolated in 26.05%, 38.02% and 49.99% respectively as shown in [Table - 3].
When smear scoring was considered, clue cells were taken as single most important criteria to detect BV [Figure]. Comparison between smear scoring and culture grading is shown in [Table - 4].
Growth present in one quadrant (1+), two quadrants (2+), three quadrants (3+) and four quadrants (4+)
| ~ Discussion|| |
Bacterial vaginosis in sexually active group varies from 33-47%. Our study included all patients based on symptomatology and showed prevalence of 20.5% by smear and 17.42% by culture. Prevalence of STIs was very low compared to studies done in Africa and Bangladesh. Trichomonas infection was detected in 6 (1.18%) women and none of them had Gonorrhoea and Syphilis. There are many reports of prevalence of HIV and STD in commercial sex workers in our country but very few community data is available. Simple Gram staining of vaginal smears has very good sensitivity of 89-93%., Our study detected 100% cases by smear examination. The presence of clue cells is a single most reliable predictor of BV. Number of pus cells would also give a correlation to the severity of infection.
Culture of vaginal discharge in rural setup is difficult. However, isolation of yeast compares well to smear findings. This finding is comparable to other studies. In addition, estimation of number of colonies and antibiotic susceptibility are possible by doing culture. In our study, yeast was detected in 7.32% cases by smear when compared to 10.69% by culture on SDA. This was comparable to other studies. Unlike the findings in this study, in a study done in Tamil Nadu, prevalence of STDs was 14.6%. We did not detect a single case of Gonorrhoea or Syphilis.
| ~ Acknowledgement|| |
Authors thank the doctors and paramedical staff of TMA Pai Rotary hospital, Karkala and primary health centers of Ujire and Talagodu. The support from NACO to conduct the rural camps in Ujire and Talagodu is also thankfully acknowledged.
| ~ References|| |
|1.||Ramani bai JT, Kavita R, Legori M. Prevalence of bacterial vaginosis in women attending antenatal, Gynecology and STD clinics of medical college, Thiruvananthapuram. J Academy Clinical Microbiologist 1998;1:107-111. |
|2.||Eschenbach DA, Hillier S, Critchlow C, Stevens C, De Rousen T, Holmes KK. Diagnosis and clinical manifestations of BV. Am J Obstet Gynaecol 1988;158:819-828. |
|3.||Hayes R, Wawer M, Gray R, Whitworth J, Grosskurtyh H, Mabey D. Randomised trials of STD treatment for HIV prevention: Report of an International workshop. Genitourin Med 1997;73:432-443. |
|4.||Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosis of BV is improved by a standardised method of Gram stain interpretation. J Clin Microbiol 1991;29(2):297-301. |
|5.||Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous catheter related infections. N Engl J Med 1977;296(23):1305-09. |
|6.||Sitges-serra A, Linares J. Limitations of semiquantitative method for catheter culture (letter) J Clin Microbiol 1998;26:1074-1076. |
|7.||Chaudhury A, Bhujuwala RA, Shriniwas. Gardnerella vaginalis isolation and identification. Indian J Pathol Microbiol 1990;33(2):151-156. |
|8.||Gravett MG, Nelson P, De Rouen T. Independent association of BV and C.trachomatis infection in adverse pregnancy outcome. JAMA 1986;256:1899-1903. |
|9.||Brabin L, Kemp J, Obunge OK, et al. Reproductive tract infections and abortions among adolescent girls in rural Nigeria. Lancet 1994;344:300-304. |
|10.||Hawkes S, Morison L, Foster S, Gausia K, Chakraborty J, Peeling RW, Mabey D. Reproductive tract infections in women in low income, low prevalence situations: assessment of syndromic management in mat lab, Bangladesh. Lancet 1999;354:1776-1781. |
|11.||Mazzulli T, Simor AE, Low DE. Reproducibility of interpretation of Gram stained vaginal smears for the diagnosis of BV. J Clin Microbiol 1990;28(7):1506-1512. |
|12.||Thomas K, Thygarajan SP, Jayasheelan L, Verghese JC, Krishnamurthy P, et al. Community prevalence of sexually transmitted diseases and human immunodeficiency virus infection in Tamil Nadu, India: A probability proportional to size cluster survey. The National Medical J India 2002;15:135-140. |