Gilles R.G. Monif

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.

Classification and pathogenesis of vulvovaginal candidiasis.

Although candidiasis of the female genital tract is one of the most common of the vaginitides, it is a poorly understood disease entity. Vulvovaginal candidiasis is a monoetiologic disease, but the pathways by which pathogenic expression is attained are sufficiently divergent to constitute a classification schema that influences therapy. For selection of appropriate therapy, the following three broad categories are proposed: (1) primary candidiasis, (2) antibiotic-induced candidiasis, and (3) systemically induced candidiasis.

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.

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.

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.

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.

Choice of antibiotics and length of therapy in the treatment of acute salpingitis

This article reviews the rationale for the therapy of acute salpingitis and the conceptual basis for the length of therapy. The key to therapy of acute salpingitis is the need to accommodate polymicrobial etiology, polymicrobial bacterial superinfection, and the potential presence of penicillinase-producing strains of Neisseria gonorrhoeae into a therapeutic equation that has been determined by the appropriate staging of disease. The anticipated therapeutic response identified for monomicrobial disease due to Neisseria gonorrhoeae constitutes the end titration point for drug administration. Duration of continued therapy beyond this point is governed by the need to complete therapy for Chlamydia trachomatis or to assure resolution of advanced disease.

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.

Ligneous cellulitis following spontaneous vaginal delivery.

igneous cellulitis is a rare chronic indolent cellulitis that often includes the parametrium or retroperitoneal tissues. 1-5 Clinically, at a time reasonably distant from surgery, the patient may report fatigue, anorexia, vague pelvic discomfort, and/or weight loss. She may or may not be febrile. Not infrequently, abnormal or prolonged uterine bleeding may be the main reason the patient seeks medical care. Bimanual examination reveals fixation of the pelvis. The pelvic floor has a characteristic woody, hard, smooth texture. The purpose of this paper is to report a case of early ligneous cellulitis that developed after spon-

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.