Sumathi Muralidhar

Comparative study of syndromic and etiological diagnosis of reproductive tract infections/sexually transmitted infections in women in Delhi

BACKGROUND The adequacy of the World Health Organizations syndromic approach for the diagnosis and management of sexually transmitted diseases (STDs), especially at primary health centers (PHCs) and at other levels, is still debatable in different settings in India and requires validation. OBJECTIVES A cross-sectional study was carried out in women attending the peripheral government clinics of Delhi in order to (1) enumerate their self-reported reproductive tract infection (RTI)/sexually transmitted infection (STI) symptoms; (2) assess their clinical status; (3) determine the syndromic diagnosis of RTI/STI in symptomatic women and etiological diagnosis in both symptomatic and asymptomatic women; and (4) compare the level of agreement between self-reporting of morbidity and syndromic and etiological diagnosis. MATERIALS AND METHODS The study was conducted over 26 months in 4090 women attending peripheral government healthcare centers, both rural and urban, in four zones of Delhi. They were recruited into four different study groups: group I, non-pregnant, reporting with symptoms of RTI/STI; group II, with a bad obstetric history or infertility; group III, pregnant women in any trimester attending the antenatal clinic; and group IV, the control group. Gynecological examination, followed by the collection of genital specimens and blood, were performed after informed and written consent was obtained. Every symptomatic patient was managed on the basis of algorithms of the syndromic approach as recommended by the National AIDS Control Organisation (NACO), India. All specimens were transported to the STD Reference Laboratory, Safdarjung Hospital, New Delhi and processed by standard methods to diagnose the various STDs. Laboratory reports were sent to the clinicians and appropriate treatment was instituted. Data were analyzed by applying statistical methods. RESULTS Overall, self-reporting of morbidity was 65.0%. However, the percentage of women with some STD-related syndrome was 71.4%. The rural women were observed to have significantly more STD syndromes than their urban counterparts. The etiological diagnosis could be established in only 32.2% of cases. CONCLUSIONS This study highlights the wide variation between self-reporting of morbidity and syndromic- and etiology-based diagnosis in women from both rural and urban settings. This has implications for the syndromic approach to STI case management. These observations call for a review of the diagnostic policy for RTIs/STIs by national authorities in order to avoid the overuse of antimicrobials. The study also highlights the need for the introduction and/or strengthening of facilities for simple diagnostic tests for RTIs/STIs, especially at the peripheral healthcare level.

Candida nivariensis as an etiologic agent of vulvovaginal candidiasis in a tertiary care hospital of New Delhi, India

Candida nivariensis is a cryptic species, phenotypically indistinguishable from Candida glabrata and identified by molecular methods. Aside its isolation from broncho-alveolar lavage, we report for the first time the etiologic role of C. nivariensis in 4 patients with vulvovaginal candidiasis. Of 100 phenotypically identified C. glabrata isolates originating from vaginal swabs, 4 were identified as C. nivariensis by polymerase chain reaction and confirmed by sequencing. All of the C. nivariensis isolates exhibited white colonies on CHROMagar. Phylogenetic analysis revealed genotypic diversity in the C. nivariensis isolates originating from within or outside of India. Barring a solitary C. nivariensis isolate with MIC, 16 μg/mL of fluconazole, the rest were susceptible to voriconazole, itraconazole, posaconazole, isavuconazole, amphotericin B, and echinocandins. The patient with high fluconazole MIC did not respond to fluconazole therapy. It is suggested that the prevalence of this species is likely to be much higher than apparent from the sporadic published reports.

Multilocus sequence typing of Candida africana from patients with vulvovaginal candidiasis in New Delhi, India.

We investigated the prevalence of vulvovaginal candidiasis due to C. africana in an STD clinic in India and analysed the genetic relatedness of these C. africana isolates with those outside India. A total of 283 germ‐tube‐positive yeasts were identified by VITEK2. Molecular characterisation of all isolates was carried out by hwp1‐gene‐specific PCR. Of 283 germ‐tube‐positive yeast isolates, four were identified as C. africana using hwp1‐gene‐specific PCR. All hwp1 PCR positive C. africana were subjected to antifungal susceptibility testing, ITS and D1/D2 region sequencing and were typed by using MLST approach. Similar to C. africana isolates from the United Kingdom and unlike those from Africa, the Indian C. africana grew at 42°C. Sequencing of eight gene fragments in MLST identified all four strains to have different genotypes not reported previously. Furthermore, though the Indian C. africana isolates were susceptible to most of the 14 tested antifungal drugs, differences in susceptibility were observed among the four strains. Our results indicate genetic and phenotypic heterogeneity among C. africana from different geographical regions. Due to lack of data on epidemiology and genetic variability of this under‐reported yeast, more studies using molecular methods are warranted.

Contraceptive Methods: Needs, Options and Utilization

ObjectivesBackground-Contraception is the intentional prevention of conception through the use of various devices, sexual practices, chemicals, drugs or surgical procedures. An effective contraception allows a physical relationship without fear of an unwanted pregnancy and ensures freedom to have children when desired. The aim is to achieve contraception in maximum comfort and privacy, with minimum cost and side effects. Some methods, like male and female condoms, also provide twin advantage of protection from sexually transmitted diseases. The burden of unsafe abortion lies primarily in developing countries. Here, contraceptive prevalence is measured among currently married women of reproductive age, and levels have not yet reached those that exist in developed countries.ConclusionIn countries like India, there is a dire need for contraceptive methods to be more women friendly, accessible and provide adequate privacy. Providers also need to be sensitive to special needs of adolescents as they are at a critically vulnerable segment.

Prevalence of Chlamydia trachomatis and its association with other sexually transmitted infections in a tertiary care center in North India

The asymptomatic nature of chlamydial genital infections coupled with the occurrence of severe sequelae in untreated patients, makes the laboratory evaluation of great importance in the diagnosis of the disease. Genital chlamydial infections are the leading cause of preventable sexually transmitted infections (STIs) worldwide, with 43 million new cases in Southeast Asia. The present study was designed to determine the prevalence of genital chlamydial infection in women attending a sexually transmitted disease (STD) outpatient department and to determine the association of the disease with other STIs. A total of 276 female patients with a complaint of genital discharge or ulcer were enrolled for the study. Genital discharge specimens (endocervical, vaginal, and urethral swabs) were collected from all the patients. The patients were investigated for the presence of antigen and antibody of Chlamydia trachomatis with the help of the Direct fluorescent Antibody test (DFA) and the Enzyme Linked Immunosorbant Assay (ELISA), respectively. Investigations for aetio-pathogens of other STIs were carried out using the standard methods. Chlamydial infection was found in 19.9% of the patients (10.1% by DFA technique and 10.9% by ELISA). Both the antigen and antibody were positive in only three (1.1%) cases. The overall incidence of other aetio-pathogens was low. In two (0.7%) cases multiple infections were seen. Chlamydia trachomatis was found to be most commonly associated with Candida albicans . However, there was no co-infection of Chlamydia trachomatis with Neisseria gonorrhoeae .

Assessment of reactivity of three treponemal tests in non-treponemal non-reactive cases from sexually transmitted diseases clinic, antenatal clinic, integrated counselling and testing centre, other different outdoor patient departments/indoor patients of a tertiary care centre and peripheral health clinic attendees

In India, many state reference centres for sexually transmitted infections perform only a single screening assay for syphilis diagnosis. In this study, Treponema pallidum haemagglutination (TPHA) was performed on 1115 Venereal Disease Research Laboratory (VDRL)/rapid plasma regain (RPR) non-reactive and 107 reactive sera out of 10,489 tested by VDRL/RPR according to the National AIDS Control Organisation syphilis testing protocol. A total of 47 Specimens reactive in TPHA and non-reactive with VDRL test were subjected to fluorescent treponemal antibody absorption and enzyme-immunoassay. Seroprevalence considering both VDRL and TPHA positivity was highest (4.4%) in sexually transmitted diseases clinic attendees than in other subject groups. Positivity by two treponemal tests in 24 (2.2%) cases non-reactive by VDRL/RPR was representative of the fully treated patients or latent or late syphilis cases. The findings highlight that a suitable treponemal confirmatory test should be performed in all the diagnostic laboratories.

Molecular methods in the laboratory diagnosis of sexually transmitted infections.

Sexually transmitted infections (STIs) are a public health problem, and their prevalence is rising even in developed nations, in the era of HIV/AIDS. While the consequences of STIs can be serious, the good news is that many of these complications are preventable if appropriate screening is done in high-risk individuals, when infection is strongly suspected. The diagnostic tests for STIs serve many purposes. Apart from aiding in the diagnosis of typical cases, they help diagnose atypical cases, asymptomatic infections and also multiple infections. But, the test methods used must fulfill the criteria of accuracy, affordability, accessibility, efficiency, sensitivity, specificity and ease of handling. The results must be rapid, cost-effective and reliable. Most importantly, they have to be less dependent on collection techniques. The existing diagnostic methods for STIs are fraught with several challenges, including delay in results, lack of sensitivity and specificity. With the rise of the machines in diagnostic microbiology, molecular methods offer increased sensitivity, specificity and speed. They are especially useful for microorganisms that cannot be, or are difficult to cultivate. With the newer diagnostic technologies, we are on the verge of a major change in the approach to STI control. When diagnostic methods are faster and results more accurate, they are bound to improve patient care. As automation and standardization increase and human error decreases, more laboratories will adopt molecular testing methods. An overview of these methods is given here, including a note on the point-of-care tests and their usefulness in the era of rapid diagnostic tests.

Issues in antifungal stewardship: an opportunity that should not be lost

Many countries have observed an increase in the incidence of invasive fungal infections (IFIs) over the past two decades with emergence of new risk factors and isolation of new fungal pathogens. Early diagnosis and appropriate antifungal treatment remain the cornerstones of successful outcomes. However, due to non-specific clinical presentations and limited availability of rapid diagnostic tests, in more than half of cases antifungal treatment is inappropriate. As a result, the emergence of antifungal resistance both in yeasts and mycelial fungi is becoming increasingly common. The Delhi Chapter of the Indian Association of Medical Microbiologists (IAMM-DC) organized a 1 day workshop in collaboration with BSAC on 10 December 2015 in New Delhi to design a road map towards the development of a robust antifungal stewardship programme in the context of conditions in India. The workshop aimed at developing a road map for optimizing better outcomes in patients with IFIs while minimizing unintended consequences of antifungal use, ultimately leading to reduced healthcare costs and prevention development of resistance to antifungals. The workshop was a conclave of all stakeholders, eminent experts from India and the UK, including clinical microbiologists, critical care specialists and infectious disease physicians. Various issues in managing IFIs were discussed, including epidemiology, diagnostic and therapeutic algorithms in different healthcare settings. At the end of the deliberations, a consensus opinion and key messages were formulated, outlining a step-by-step approach to tackling the growing incidence of IFIs and antifungal resistance, particularly in the Indian scenario.

Antifungal resistance patterns, virulence attributes and spectrum of oral Candida species in patients with periodontal disease.

Aims: To observe the antifungal resistance pattern, virulence attributes and spectrum of Candida species in oral cavities of patients with periodontal diseases and healthy individuals. Study Design: A total number of 52 patients with periodontal disease and 100 healthy subjects were included in the study. Place and Duration: The study was carried out in the Apex Regional STD Teaching, Training and Research Centre, VMMC and Safdarjang Hospital and Department of Biosciences, Jamia Millia Islamia, New Delhi. Duration of the study was from December 2011 to June 2013. Methodology: Oral swabs were collected from the patients and control group. The specimens Original Research Article Kumar et al.; BMRJ, 5(1): 68-75, 2015; Article no. BMRJ.2015.008 69 were cultured for Candida and the species identified, according to standard protocols. Antifungal susceptibility testing and virulence tests were performed. Results: Out of 52 patients screened 11 yielded (21%) different Candida species, with Candida albicans (83%) being the commonest and non Candida albicans Candida (NCAC) species accounting for 17 %. Among 100 healthy controls, 23 were colonized by various Candida species, with Candida albicans again as the predominant species. A significant difference (P =.002) was observed in the secretion of proteinase enzyme between the isolates from cases and controls. However, in the distribution of Candida species, antifungal resistance patterns, phospholipase secretion and biofilm formation there was no such significant difference. Conclusion: Our results reveal that there is no significant difference in the distribution of Candida species among healthy subjects and patients with periodontal diseases. Antifungal resistance patterns and expression of some of the important virulence attributes also revealed no differences between the isolates from patients and control populations.

Diagnosis of syphilitic genital ulcer- the quest for a reliable laboratory method

The diagnosis of Syphilitic genital ulcer poses a challenge to venereologists, because atypical presentations and multiple aetiologies are common occurrences. It is important to diagnose and manage these cases appropriately, as they are known to facilitate the spread and acquisition of HIV infection.1 With the shift from bacterial to viral genital ulcer diseases (GUD), syphilitic genital ulcers are no longer as common as herpetic ulcers, and the HIV epidemic has been blamed for this.2–4 For effective control of syphilis, it is important to have inexpensive and sensitive diagnostic tests, followed by an effective and affordable treatment. Lack of reliable diagnostic tests for syphilis, hampers the efforts at controlling the disease. The perils of untreated syphilis include dire consequences of latent or tertiary stages as well as transmission of infection from mother to foetus with resultant congenital syphilis.1 Because T.pallidum is too fragile an organism to be stained or cultured by simple methods, diagnostic tests rely on clinical evaluation, detecting the organism from lesions by dark field microscopy or fluorescent microscopy, and confirmation of the disease by serological diagnostic methods, since most infected individuals have no symptoms or have transient lesions.5 Although serodiagnosis is the mainstay of diagnosis of all stages of syphilis, conventional serology is a two step approach with a non-specific test done first, followed by a specific test. Dark field microscopy (DFM) is a very useful diagnostic method that allows visualization of live treponemes obtained from cutaneous or mucous membrane lesions. But the sensitivity of this test is quite low, at less than 80%, and declines over time, or if the patient has applied topical antibiotics to the lesion. Oral specimens cannot be used for DFM, because of the possibility of false-positive results.6 Molecular methods have emerged as very important tools for detection of Treponema pallidum. Polymerase chain reaction (PCR), and recently, the Realtime PCR,