Streptococcal vaginosis.

OBJECTIVE: This study was initiated to discover the etiology and pathogenesis of persistent vulvovaginal symptoms after adequate and appropriate therapy for bacterial vaginosis. MATERIALS AND METHODS: Included in this study, which spanned the period from January 1988 to June 1996, were all patients who were referred by their gynecologists for continuing vulvovaginal symptoms after treatment for bacterial vaginosis. History, pelvic examination, saline wet-mount and 10% potassium hydroxide preparations, and aerobic and anaerobic cultures were performed. Several antibiotic regimens were prescribed, and results were tabulated. Patients were considered to be cured when asymptomatic, when the saline wet-mount preparation showed lactobacillus-dominant flora, and when cultures were reported as normal or mixed vaginal flora. RESULTS: Twenty-four patients were recruited for this study. These patients had been treated for a total of 554 months prior to their referral for vulvovaginal consultation. After saline wet-mount examination, 90% had no lactobacilli and showed an abundance of coccal bacterial forms. Twenty-six cultures were performed, of which 92% were positive for streptococci. Group B streptococci were reported in 71%, group D in 29%, and group A in none. The most successful therapy was amoxicillin, 500 mg three times daily for 10 days. Treatment for 7 days was inadequate. CONCLUSIONS: Overgrowth of streptococci after appropriate therapy for bacterial vaginosis produces continuing vulvovaginal symptoms. Amoxicillin, 500 mg three times daily for 10 days, returns lactobacillus-dominated flora and an asymptomatic patient in a majority of cases.

Vaginal lactobacillosis.

OBJECTIVES: Our purpose was to study a cyclic condition characterized by vaginal discharge and discomfort occurring 7 to 10 days before menses and associated with the occurrence of long serpiginous rodlike organisms, visible in wet mount preparations. STUDY DESIGN: Thirty-seven patients and 30 controls were studied prospectively. The vaginal flora was analyzed, including isolation of anaerobic bacteria and fungi. Species of lactobacilli isolated from some of the women were identified and the antibiotic susceptibility was determined. Recent episodes of vaginitis and therapy were recorded. RESULTS: Ninety-two percent of the patients had a history of recent episodes of vaginosis lasting for an average of 22.2 months, and 57% had received triazole or imidazole antifungal therapy. Anaerobic lactobacilli were isolated from 97% of the vaginosis patients and from 40% of the controls. The average length of the organism seen was 60 microns in the patients and 10 microns in the comparison group. Amoxicillin and clavulanate potassium proved to be an effective therapy symptomatically and resulted in disappearance of the extremely long organisms in vaginal smears. CONCLUSIONS: Lactobacilli vaginosis is associated with extremely long lactobacilli. The cause of this morphologic transformation is unknown. The condition can be effectively treated with antibiotics.

Evolving pathogens in vulvovaginal candidiasis: implications for patient care.

Over the past two decades, an increasing trend in the number of vaginal infections attributable to yeasts other than Candida albicans has emerged. Of these non-albicans species, C. tropicalis and C. glabrata appear to be the most important. The change in incidence pattern of yeast vaginitis can be expected to impact greatly on the treatment of this condition, because many currently used drug therapies (e.g., imidazoles) for C. albicans vaginitis do not adequately eradicate non-albicans species. A possible explanation for the recent increased selection of these species may be the shortened antifungal therapies that have been introduced during the past decade. These 1- to 3-day regimens with the older imidazoles may suppress C. albicans, but create an imbalance of flora that facilitate an overgrowth of non-albicans species. The recognition of yeast speciation and the need for use of a broad-spectrum antifungal preparation that covers these organisms is now apparent.

Mycotic vulvovaginitis: a broad overview.

The incidence of mycotic vulvovaginitis is rising dramatically in the United States mainly because of an increase in infections caused by Candida species. Accurate diagnosis depends on culture techniques that will yield correct identification of fungal pathogen(s). Recurrences are common and require culture specimens from sexual partners and appropriate antifungal therapy. The imidazoles and more recently the broader spectrum triazoles are used for vaginal therapy.

Interferon therapy for condylomatous vulvitis.

During a 3-year period, 30 patients were referred for symptoms of vulvar pain characteristic of the vulvar vestibulitis syndrome. Colposcopic examination with a blue filter and pathologic biopsy revealed evidence of papillomavirus in 17 patients. Interferon alpha-2b recombinant was injected intradermally into the vestibule in a specific pattern three times weekly for 4 weeks. Fifteen women responded favorably with total absence of vulvar pain. Five women reported flu-like symptoms as a result of the injections. Patients without evidence of papillomavirus failed to respond to interferon therapy. Women with evidence of vulvar papillomavirus failed to respond to placebo but did respond to retreatment with interferon; vulvar biopsy specimens after therapy were negative. Interferon alpha-2b recombinant appears to offer an inexpensive, safe alternative to the more traumatic therapies currently recommended in the specific subset of vulvar vestibulitis patients in whom papillomavirus can be confirmed.

Antifungal therapy in the management of chronic candidiasis.

The most pathogenic Candida species are identified and the structure of imidazole compounds and their mechanism of action on yeast cells are described. Not all yeast species react in the same way to imidazole preparations, and these actions are documented.

Sexual transmission of Candida.

Mycotic cultures of 33 couples, in which the women had a diagnosis of chronic recurrent vulvovaginitis, were prepared from the oral cavity, the rectum, the vagina, and the male ejaculate. Reservoirs of infection were found in the oral cavities of 36% of the couples, the rectum in 33%, and the ejaculate in 15%. Prostatic cultures of the male were negative in each case. In most instances, the same organism was present in the reservoir and in the vagina. Elimination of the mycotic organisms in each site and restriction of sexual contact with the reservoir of mycotic organisms effected cures in these previously recurrent vulvovaginitis patients.

Topical flucytosine therapy for chronic recurrent Candida tropicalis infections.

Forty-one women with a culture-proven diagnosis of Candida tropicalis were treated with miconazole or clotrimazole cream topically or ketoconazole orally. In 15 patients the infection recurred or remained uncured. Five-fluorocytosine was compounded into a topical vaginal cream and applied nightly for seven nights. In 14 of the 15 patients the infection disappeared. One patient remains uncured.

Candida tropicalis vulvovaginitis.

In a majority of patients with candidal vulvovaginitis, drug therapy is convenient and effective. A small but significant group of patients remain symptomatic with recurrent, chronic candidiasis. A study of 805 patients was undertaken to delineate microbiologically candidal species. The study revealed that the recurrence rate for Candida tropicalis was twice the rate for Candida albicans, and that despite continuous medical care and multiple therapies, the recurrent C tropicalis patients remained symptomatic with persistence of the organism. The difficulty encountered with eradication of C tropicalis may have been due to the lack of susceptibility of the cell membrane to the commonly used antifungal agents.

Sugar chromatography studies in recurrent Candida vulvovaginitis.

Because of the apparent increase in vulvovaginitis caused by Candida species, the chronic disability caused by this infection and its stubborn resistance to current therapy, a study of 100 women was undertaken to attempt to gain insight into the role of dietary sugar ingestion in the pathogenesis of this disease. Urinary sugar patterns of glucose, arabinose and ribose were elevated. These excretion patterns correlated well with the excessive oral ingestion of dairy products, artificial sweeteners and sucrose. Eliminating excessive use of these foods brought about a dramatic reduction in the incidence and severity of Candida vulvovaginitis.