Understanding the bacterial flora of the female genital tract.

The microbiological flora of the lower female genital tract provides a dynamic, complex example of microbial colonization, the regulation of which is not fully understood. When an exogenous bacterial species, with its array of virulence factors, is introduced into the host, disease does not always occur. Conversely, under selected conditions, commensal endogenous bacteria-for example, Gardnerella vaginalis and group B streptococci-can participate in disease processes. Disease caused by both exogenous and endogenous bacteria correlates positively with a markedly increased level of bacterial replication. The key question is what determines the quantity of a given bacterium at any given time. For disease to occur, exogenous or endogenous bacteria that possess pathogenic prerequisites must attain replicative dominance. Their ability to do so is potentially governed by inhibitory or synergistic interrelationships with other microbes.

Concerns regarding the Centers for Disease Control's published guidelines for pelvic inflammatory disease.

The International-Infectious Disease Society for Obstetrics and Gynecology-USA (I-IDSOG-USA) has concerns about the most recently published Centers for Disease Control and Prevention (CDC) guidelines for pelvic inflammatory disease (PID). I-IDSOG-USA advocates the following changes when the guidelines are revised. We recommend the use of the term "upper genital tract infection" (UGTI), followed by the designation of the etiologic agent, instead of the currently employed term, "pelvic inflammatory disease," or PID. In diagnoses, there should be greater emphasis on signs and symptoms related to subclinical or occult UGTI. Therapeutic recommendation for the treatment of UGTI should be documented for various stages of this diverse disease entity. There should be greater emphasis on hospitalization for infected nulligravida teenagers. This permits monitoring of antibiotic treatment and provides a site for medical educational efforts to teach this medically underserved segment of our society how to protect their future fertility, their health, and their lives.

Maternal risk factors for perinatal septicemia due to the Enterobacteriaceae.

Cases of perinatal septicemia due to the Enterobactericeae, which manifest in the first 24 hr of life were analyzed for the presence or absence of the maternal risk factors defined in the CDC group B streptococcus (GBS) risk-factor protocol. Microbiological data involving blood culture isolates were reviewed for the recovery of an Enterobacteriaceae from January 1975 through June 1995. Enterobacteriaceae perinatal septicemia was defined as the recovery an Enterobacteriaceae from one or more set of blood cultures in the first 24-36 hr of life in conjuncture with clinical evidence of neonatal stress in the first 24 hr. A case would also be considered of perinatal origin for cultures obtained up to 36 hr provided that evidence of clinical disease was present in the first 24 hr of life. Fifteen cases of perinatal septicemia due to the Enterobacteriaceae were analyzed. All but four shared one or more maternal risk factors. The maternal risk criteria established to avert early-onset GBS disease are commonly encountered in women destined to have newborns with perinatal septicemia due to the Enterobacteriaceae. Antibiotic selection for risk-driven protocols for GBS avoidance may need to be broadened to address the issue of coverage for penicillin-sensitive and penicillin-resistant Enterobacteriaceae.

Trichomonas vaginalis and bacterial vaginosis. Coexistence in vaginal wet mount preparations from pregnant women.

OBJECTIVE: To identify how frequently trichomoniasis and characteristics of bacterial vaginosis (BV) occur concomitantly in wet mount preparations from pregnant women. STUDY DESIGN: Diagnosis of trichomoniasis was predicted on visualization of the organism. Diagnosis of BV required a positive volatile (whiff) test, presence of "clue cells" and one of two minor criteria: (1) absence of lactobacilli, or (2) a pH > 4.5. Pregnant women from January 1995 to July 1997 at our clinic had wet mount/KOH preparations performed as standard prenatal care. Corresponding medical charts were analyzed for symptoms, race, BV, sexually transmitted diseases, urinary tract infections and other infections. RESULTS: Of 191 pregnant women identified, 69 had trichomoniasis. Seventy-nine percent of the 69 were African American. Fifteen percent of pregnant women (17) had concomitant trichomoniasis and BV. Irrespective of race, 35-38% of pregnant women with trichomoniasis had another sexually transmitted disease or a urinary tract infection diagnosed in that pregnancy. CONCLUSION: BV, or bacteria excess syndrome, is a frequent coinfection in pregnant women harboring Trichomonas vaginalis.

Semiquantitative bacterial observations with group B streptococcal vulvovaginitis.

OBJECTIVE: Group B streptococcal (GBS) vulvovaginitis is a poorly-delineated clinical entity. The purpose of this study is to report semiquantitative data from four cases of GBS vulvovaginitis and to comment on their significance in terms of the in vitro inhibitory capabilities of GBS. METHODOLOGY: Four patients whose clinical presentations were consistent with GBS vulvovaginitis, from whom GBS was isolated and for whom semi-quantitative as well as qualitative microbiologic data existed, were identified. RESULTS: To produce vulvovaginitis, GBS must be at a high multiplicity (10(8) CFU/g of vaginal fluid). Single coisolates were identified in three of the four cases (two cases of Escherichia coli and one case of Staphylococcus aureus). Group B streptococcus does not inhibit either of these bacteria in vitro. CONCLUSION: When the growth requirements for the demonstration of in vitro inhibition for GBS or lack thereof are met in vivo, the in vivo observations are consistent with those projected from the in vitro data.

The great douching debate: to douche, or not to douche.

It has been implied douching causes chlamydial infection, acute salpingitis, ectopic pregnancy, and reduced fertility. However, the incriminating articles do not represent a vast accumulation of data from diverging sources; rather, most reflect repetitive analysis of data from a limited population base by an institutionally interrelated group of investigators. The conclusions reached were reintroduced periodically into the literature in different journals. An equally plausible alternate hypothesis is that douching is a marker for increased probability of one or more sexually transmitted diseases and their sequelae. Review of microbiologic rather than epidemiologic data published on douching revealed that douching with a preparation containing acetic acid caused a small reduction in total bacterial counts. Most of that change was attributable to washing. When povidone-iodine was present, significant reductions occurred, but these were short-lived. The first bacteria to recover are usually the lactobacilli, which might explain partial efficacy of prolonged douching with commercial preparations of povidone-iodine.

Female genital tract bacterial coisolates with Candida albicans in patients without clinical vaginitis.

OBJECTIVE: In vitro, Candida albicans has demonstrated the ability to inhibit replication of selected bacteria. Little information exists on the impact of C. albicans on the vaginal bacterial flora in vivo. The purpose of this study is to identify the coexisting bacterial flora when C. albicans is isolated from vaginal cultures submitted to a hospital-based testing facility for reasons other than vulvovaginitis. METHODOLOGY: All specimens (240) received from ambulatory care clinics over a six-month period were cultured for aerobic and anaerobic bacteria and Candida species. Those specimens submitted for cervicitis, vaginitis, or vaginal discharge and those from which yeasts other than C. albicans were isolated were eliminated. To control for sample biases, a subgroup composed of all pregnant women for whom cultures were done as screening procedures was similarly studied. Chi-square analyses, comparing the prevalence of individual bacteria isolated with and without the presence of C. albicans, were done for all study populations using SPSS for Windows software (1994). RESULTS: Two hundred and forty consecutive specimens were bacteriologically analyzed. Of the 220 vaginal samples used in the study, C. albicans was isolated in 44 instances (20%). Neither the presence of the lactobacilli nor the presence of Gardnerella vaginalis markedly influenced the isolation rate of C. albicans. The group B streptococci had a greater probability of coisolation when C. albicans was present (27.3% verses 16%), but this was not statistically significant (P < 0.8). Dissociation between the presence of C. albicans and the coisolation of Peptostreptococcus species and anaerobic gram-positive cocci and/or bacilli was noted (P < 0.0819), while the incidence of gram-positive aerobic bacilli was reduced in the presence of C. albicans (30/176 [17.1%] versus 6/44 [13.6%]), this reduced incidence was not statistically significant. Isolation data of the subgroup of pregnant women supported these observations. CONCLUSION: Within the limitations of the study, statistically, the data suggests that an inverse relationship exists between the presence of C. albicans and recovery of Peptostreptococcus and anaerobic gram-positive cocci and bacilli.

Interrelationships within the bacterial flora of the female genital tract.

Analysis of 240 consecutive vaginal swabs using the compatibility profile technique revealed that only 2 bacteria have the ability to be a sole isolate and as such a candidate to be a major aerobic regulator of the bacterial flora of the female genital tract (BFFGT). Compatibility profiles of Lactobacillus and Gardnerella vaginalis have shown that these organisms shared compatibility profiling for the majority of the normal bacterial constituents of the female genital tract. Dominance disruption appears to come from the addition of compatible co-isolates and presumed loss of numerical superiority. These phenomena appear to be the keys to reregulation of BFFGT. Lactobacillus appears to be the major regulator of both G. vaginalis and anaerobic bacteria. When additional organisms are added to the bacterial flora, they may add to or partially negate the inhibitory influence of Lactobacillus on the BFFGT. Inhibitor interrelationships appear to exist between coagulase-negative staphylococci and Staphylococcus aureus and the group B streptococci (GBS) and other beta hemolytic streptococci. Facilitating interrelationships appear to exist between S. aureus and the GBS and selected Enterobacteriaceae.

Expanding disease spectrum associated with puerperal mastitis.

BACKGROUND: Staphylococcus aureus and the beta-hemolytic streptococci are the commonest causes of puerperal mastitis which tends to be a localized disease process. This report describes 2 cases attributable to these bacteria that resulted in extramammary involvement and augmented morbidity. CASES: Two cases of postpartum mastitis are described, one leading to necrotizing fasciitis caused by group A streptococci and the other leading to toxic shock syndrome (TSS) caused by S. aureus. CONCLUSION: The spectrum of disease commonly attributed to mastitis occurring in this setting should be expanded.

Ampicillin vs. Penicillin for in utero therapy.

The pharmacokinetics of penicillin G and ampicillin are reviewed as they pertain to their potential use in in vitro therapy.

Impact of anaerobic growth conditions on toxic shock syndrome toxin-i production by Staphylococcus aureus.

OBJECTIVE: The impact of anaerobic growth conditions on the Staphylococcus aureus toxic shock syndrome toxin-1 (TSST-1) production was studied. METHODS: Ten strains of S. aureus derived from patients with toxic shock syndrome (TSS), 10 isolates of S. aureus, and documented TSST-1-producing strains recovered from patients with either staphylococcal septicemia or staphylococcal nongenital abscesses were grown under aerobic and anaerobic conditions. The bacterial growth was measured using optical density (OD) determinations at 520 nm. The toxin production was assayed using the TS-RPLA latex agglutination test. RESULTS: Both TSS and non-TSS strains of S. aureus grown under aerobic and anaerobic conditions exhibited comparable OD patterns of growth, and the levels of toxin production remained constant during the logarithmic phase. Toxin titers developed during the logarithmic growth phase and peaked after 24 h of incubation. When stationary-phase isolates grown initially under aerobic conditions were subjected to strict anaerobic conditions, subsequent toxin titers, compared with isolates grown in the continued presence of oxygen, were depressed 2-fold, peaking at a later time. CONCLUSIONS: TSST-1 production is diminished under continued anaerobic conditions.

In vitro ability of the group B streptococci to inhibit gram-positive and gram-variable constituents of the bacterial flora of the female genital tract.

OBJECTIVE: The purpose of this study was to analyze the ability of septicemic and nonsepticemic isolates of group B streptococci (GBS) to inhibit in vitro the principal bacterial groups found in the normal bacterial flora of the female genital tract. METHODS: The target groups were composed of 1) 10 strains each of the following: viridans streptococci, nonhemolytic streptococci (not group B or D), group A streptococci, GBS, peptostreptococci, coagulase-negative staphylococci, Staphylococcus aureus, and Gardnerella vaginalis; 2) 9 strains of enterococci; 3) 9 strains of group C or G streptococci; 4) 7 strains of lactobacilli; and 5) 7 strains of diphtheroids. All target groups were tested for inhibition by a test panel of either a group of 10 or 41 GBS isolates. If the GBS isolates failed to inhibit a target group, that group was tested for its ability to inhibit the GBS test panel. RESULTS: The GBS test panel did not inhibit the growth of coagulase-negative staphylococci or S. aureus but uniformly inhibited groups A, B, C, and G streptococci, lactobacilli, and G. vaginalis. One of the 7 strains of diphtheroids was inhibited by 37 of the 41 GBS isolates; the other 6 strains of diphtheroids were uniformly inhibited. Variable inhibition by GBS was observed with viridans streptococci, nonhemolytic (not group B or D) streptococci, peptostreptococci, and enterococci; however, inhibition or noninhibition was uniform for a given target strain against the entire GBS test panel. The 23 GBS isolates obtained from septicemic neonates or adults did not differ from the 18 nonsepticemic isolates in their ability to inhibit other species of streptococci or other gram-positive or gram-variable constituents of the bacterial flora of the female genital tract. When converse testing was done, all 10 GBS isolates were uniformly inhibited by coagulase-negative staphylococci and by the majority of enterococci, but were not inhibited by S. aureus. CONCLUSIONS: These studies suggest that GBS may be significant regulators of other beta-hemolytic streptococci, diphtheroids, lactobacilli, and G. vaginalis within the bacterial flora of the female genital tract. Moreover, the absence of GBS in the vaginal flora may be the result of mediation by coagulase-negative staphylococci and selected strains of enterococci.

Streptococcus pneumoniae as a Cause of Salpingitis.

BACKGROUND: A case of pneumococcal septicemia associated with laparoscopically documented acute salpingitis is reported. CASE: Gram-stained cul-de-sac pus revealed gram-positive encapsulated diplococci. CONCLUSION: This case coupled with reanalysis of prior genital tract involvement in nonpregnant individuals argues that Streptococcus pneumoniae can mimic gonococcal diseases.