Anders Hallén

Composition of the Vaginal Microbiota in Women of Reproductive Age – Sensitive and Specific Molecular Diagnosis of Bacterial Vaginosis Is Possible?

Background and Objective Bacterial vaginosis (BV) is the most common vaginal disorder, characterized by depletion of the normal lactobacillus-dominant microbiota and overgrowth of commensal anaerobic bacteria. This study aimed to investigate the composition of the vaginal microbiota in women of reproductive age (healthy women and women with BV), with the view of developing molecular criteria for BV diagnosis. Materials and Methods Vaginal samples from 163 women (79 control, 73 BV and 11 intermediate (Lactobacillary grade II flora) cases) were analyzed using 454 pyrosequencing of the hypervariable regions V3–V4 of the 16S rRNA gene and 16 quantitative bacterial species/genus-specific real-time PCR assays. Sensitivities and specificities of potential BV markers were computed using the Amsel criteria as reference standard for BV. The use of quantitative thresholds for prediction of BV, determined for both relative abundance measured with 454 pyrosequencing and bacterial load measured with qPCR, was evaluated. Results Relative to the healthy women, the BV patients had in their vaginal microbiota significantly higher prevalence, loads and relative abundances of the majority of BV associated bacteria. However, only Gardnerella vaginalis, Atopobium vaginae, Eggerthella, Prevotella, BVAB2 and Megasphaera type 1 detected at or above optimal thresholds were highly predictable for BV, with the best diagnostic accuracy shown for A. vaginae. The depletion of Lactobacillus species combined with the presence of either G. vaginalis or A. vaginae at diagnostic levels was a highly accurate BV predictor. Conclusions Quantitative determination of the presence of G. vaginalis, A. vaginae, Eggerthella, Prevotella, BVAB2 and Megasphaera type 1 as well as the depletion of Lactobacillus was highly accurate for BV diagnosis. Measurements of abundance of normal and BV microbiota relative to total bacteria in vaginal fluid may provide more accurate BV diagnosis, and be used for test-of-cure, rather than qualitative detection or absolute counts of BV related microorganisms.

Bacterial vaginosis in women attending STD clinic: diagnostic criteria and prevalence of Mobiluncus spp.

The diagnostic criteria of bacterial vaginosis (BV) and the prevalence of Mobiluncus spp as detected by monoclonal antibodies were investigated in all new women patients attending the sexually transmitted disease (STD) clinic in Uppsala during a four month period. Of 455 patients, 164 fulfilled the generally accepted criteria for BV, but in 57 of them simultaneous infection with a recognised pathogen was diagnosed. BV was thus the only clinical diagnosis in 107 (24%) of the women. The sniff test and clue cells in the wet smear were the two criteria most relevant for the diagnosis of BV. The sniff test was positive in 95% (156) of the 164 patients with BV and negative in all other cases. The corresponding figure for the clue cells was 98% (160 of 164), but clue cells were also detected in 19 patients without BV. Though 99% (162) of women with BV had a vaginal pH of more than 4.5, so did 83 women without BV. Only 59% (96) of women fulfilling the criteria of BV had a characteristic discharge. Mobiluncus spp were present in 20% (90) of the 455 women and in 50% (53) of the 107 women with BV only. Of the 90 Mobiluncus spp isolates, M curtisii comprised 44% (40), M mulieris 34% (31), and both strains together 21% (19). Mobiluncus spp were detected with monoclonal antibodies in 35 women who had no motile curved rods on wet smear microscopy. Furthermore, Mobiluncus spp were often detected in women infected with recognised pathogens, as well as in a few women without signs of genital infection.

Mailed urine samples are not an effective screening approach for Chlamydia trachomatis case finding among young men

Background  Frequency of testing is known to be low for sexually transmitted infections (STIs) in men aged 20–24 years. The use of mailed, home‐obtained urine specimens could increase the uptake of young men and facilitate screening programmes for the detection of asymptomatic Chlamydia trachomatis.

Guidelines for the laboratory diagnosis of trichomoniasis in East European countries

The laboratory diagnosis of sexually transmitted infections in many Eastern European countries remains suboptimal. The main objective of the present evidence‐based guidelines is to provide comprehensive information regarding the laboratory diagnosis of infections caused by Trichomonas vaginalis in East European countries. In particular, the present guidelines recommend: (i) to encourage examination of the wet mounts of vaginal exudates, instead of stained smears, at all clinical settings; (ii) nucleic acid amplification tests (NAATs) or culture could be employed if no trichomonads are detected on microscopic examination of the wet preparation and there is a strong indication of infection and (iii) the use of NAATs is encouraged in screening, using non‐invasive specimens, or high volume testing situations. In the absence of internationally recognized commercial NAAT systems, tests developed in‐house should be validated using obtainable international standards and quality assured strictly. Individual East European countries may be required to make minor national adjustments to these guidelines as a result of lack of accessibility to some reagents or equipment, or laws in a specific country.

Guidelines for the laboratory diagnosis of syphilis in East European countries

The present guidelines aim to provide comprehensive and precise information regarding the laboratory diagnosis of the sexually transmitted infection (STI) syphilis in East European countries. These recommendations contain important information for laboratory staff working with STIs and/or STI‐related issues. Individual East European countries may be required to make minor national adjustments to these guidelines as a result of lack of accessibility to some reagents or equipment, or laws in a specific country.

Laboratory diagnosis of sexually transmitted infections in Estonia in 2001-2002 : Shortcomings with impact on diagnostic quality and surveillance

Objectives: The objectives of this study were to comprehensively characterize the range, content, and performance of sexually transmitted infection (STI) testing services in Estonia during the period 2001 to 2002 and to determine if the observed diagnostic laboratory practices and methods adhered to international evidence-based recommendations. Study: Survey data, focusing on organization and performance characteristics of STI diagnostics services, were assessed using questionnaires, telephone interviews, and site visits to all responding facilities providing STI diagnostics services in Estonia. Guidelines of international evidence-based recommendations for STI testing were used as references. Results: There were significant shortcomings in STI testing availability and practices. Among all participating laboratories diagnosing STIs, only a minority (n = 16, 28%) offered testing for the full minimum range of relevant STIs in Estonia, i.e., Treponema pallidum, Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. In addition, because testing methods used were not properly selected, confirmation of several infections in accordance with evidence-based requirements was not possible, which has an impact both on STI diagnostic quality and surveillance.

Rectal occurrence of Mobiluncus species.

The simultaneous occurrence of Mobiluncus spp in the vagina and rectum was studied in women attending a sexually transmitted diseases (STD) department. Of 43 women with bacterial vaginosis (BV), 32 had Mobiluncus spp in the vagina and 23 in the rectum. In 20 women the same Mobiluncus species was found concomitantly in the vagina and the rectum. Mobiluncus spp were found in the rectum only in two women with BV, one with candidal vaginitis, and one healthy woman. In a treatment study of 23 women, BV was cured in nine out of 10 treated with metronidazole and six out of 13 treated with tetracycline. After treatment Mobiluncus spp persisted in the vaginas of two out of 19 women and in the rectums of two out of 10.

Diagnosis of non-viral sexually transmitted infections in Lithuania and international recommendations

The aim of this study is to evaluate the range, quality and availability of diagnostic services for non-viral sexually transmitted infections (STIs), i.e. C. trachomatis, N. gonorrhoeae, T. vaginalis and T. pallidum, in Lithuania from September 2002 to December 2003. Surveillance data describing the organisation and performance characteristics of non-viral STI diagnostic services in Lithuania were collected using a questionnaire and subsequent site-visits. International evidence-based recommendations for non-viral STI diagnosis were used to evaluate the quality of the STI diagnostics. There were 171 facilities providing non-viral STI diagnostic services for the 3.5 million inhabitants of Lithuania. However, only 6% (n=9) of the respondents (n=153) could provide a confirmatory diagnosis, in accordance with international recommendations, for the full minimum range of relevant non-viral STIs in Lithuania, i.e. C. trachomatis, N. gonorrhoeae, T. pallidum, and T. vaginalis. In addition, accessibility to STI diagnostic services differed significantly among the different counties in Lithuania. Several of the respondents analysed low numbers of samples each year, and overall the sampling size was extremely low, especially for C. trachomatis diagnostics. In Lithuania, optimisation of non-viral STI diagnostics as well as of epidemiological surveillance and management of STIs is crucial. It may be worth considering a decrease in the number of laboratories, with those remaining having the possibility of performing STI diagnostic services that are optimised, in concordance with international recommendations, standardised, and quality assured using systematic internal and external quality controls and systems. In addition, establishment of national inter-laboratory networks and reference centres for non-viral STIs is recommended.

Cervical, Urine and Vaginal Specimens for Detection of Chlamydia trachomatis by Ligase Chain Reaction in Women: A Comparison

Screening for Chlamydia trachomatis in women is generally done using only one specimen from each patient in order to minimize costs. In this study the aim was to compare the performances of vaginal, cervical and urinary specimens in a population of young women with sparse symptoms. During 1998, specimens from 1,001 women at the Departments of Venereology and Youth Health Care at the University Hospital of Uppsala, Sweden were examined by both ligase chain reaction and cell culture for detection of C. trachomatis. The samples from the cervix, vagina and urine were tested by ligase chain reaction, while specimens for cell culture were collected from the cervix and urethra. The prevalence of genital C. trachomatis infections was 5.1%. A single urine specimen had a sensitivity of 80.0%, while the sensitivity of a single vaginal specimen was 96.0%. The specificity was 100% for the urine specimens and 99.4% for the vaginal specimens. The sensitivity and specificity of a single cervical specimen was 92.0% and 99.6%, respectively. Although the urine ligase chain reaction seemed to have the lowest sensitivity of the compared specimens for testing of C. trachomatis infections in this population, the differences in sensitivity between urine, cervical and vaginal specimens were not statistically significant.

Guidelines for the laboratory diagnosis of Chlamydia trachomatis infections in East European countries

The present guidelines aim to provide comprehensive information regarding the laboratory diagnosis of infections caused by Chlamydia trachomatis in East European countries. These recommendations contain important information for laboratory staff working with sexually transmitted infections (STIs) and/or STI‐related issues. Individual East European countries may be required to make minor national adjustments to these guidelines as a result of lack of accessibility to some reagents or equipment, or laws in a specific country.