Amsel criteria based computer vision for diagnosing bacterial vaginosis

BackgroundVaginal colonization with specific bacterial vaginosis (BV)-associated bacteria has been associated with individual BV signs and symptoms (Amsel criteria). Bacterial colonization and associations with Amsel criteria may vary between populations....

Background:Bacterial vaginosis (BV) is the most common cause of vaginal discharge (VD) in women of reproductive age group. It is marked by displacement of beneficial Lactobacillus sp. by polymicrobial flora. BV is becoming a major public health concern as it is associated with adverse birth outcomes and increased susceptibility to sexually transmitted infections (STIs). Diagnosis of BV is currently done using clinical criteria (Amsel's) and the microbiological criteria (Nugent's scoring), the latter being the gold standard. Many out patient settings lack in microscopy facility and also skilled microbiologists, so reliance is placed on findings of clinical examination.Aims and Objectives:The aim of the study was to correlate Amsel's criteria with low (7–8) versus high (9–10) positive Nugent's scores for better understanding on utility of clinical criteria.Material and Methods:Patients with self-reported symptoms of vaginal discharge, genital itching were included and their pelvic examination was performed. Two swab samples were collected from lateral wall of vagina and posterior fornix and tested for BV infection using both Amsel's criteria and Nugent's score.Results:Of the total 125 women, 29 (23.2%) were positive for BV by Amsel's criteria, whereas 34 (27.2%) were positive by Nugent's scoring. Amsel's criteria showed a sensitivity of 100% with high Nugent's scores and 81% with low scores, thereby implying very few cases of diseased individuals being missed.Conclusion:This study demonstrates the continued utility of the Clinical criteria in outpatient setting as a screening test.

Untreated vaginal discharge is a risk factor for complications. Correct diagnosis is crucial. The purpose of this study was to apply Femoflor-16 to study the vaginal microbiome in women with genital tract discharge. Material/Methods: A total of 45 women were included in the study. Vaginal/cervical swab - one for routine tests and Gram staining and another for PCR Femoflor-16, were tested. Clinical diagnosis of bacterial vaginosis (BV) was done by using Amsel's criteria. Microbiologically, BV was assessed by applying a Nugent score system and Femoflor-16. Results: A total of 45 women with genital tract discharge were included in the study. Based on Amsel's clinical criteria, 9 (20%) of them were diagnosed with BV. Based on Nugent's score system, 11(24,4%) were categorized as having BV. Only 40 samples were compared, and the results were tested using Femoflor-16 and Nugent score system. Of them, 33 (83%) were in agreement as a result of using both methods. Femoflor-16 detected species such as aerobic bacteria (Enterobacteriасeae, Streptococcus spp., Staphylococcus spp.), Mycoplasma spp., Ureaplasma spp. and yeast-like microorganisms (Candida spp.). Conclusions: A reliable, comprehensive, and on-time diagnosis of BV is needed. Nucleic acid amplification tests nowadays complement the "classic" laboratory methods. The real time multiplex PCR test Femoflor-16 can be effectively used in vaginal microbiota evaluation in women with discharge. It can identify a wide range of microorganisms, including bacteria that are difficult to culture, normal Lactobacilli microflora and complex of aerobic and anaerobic microorganisms, mycoplasmas and Candida spp. In addition, it is able to determine the number and ratio of microorganisms in the total bacterial mass, which further orients to the disease state and the role of the microorganism as an opportunistic or obligate pathogen.

Bacterial vaginosis (BV) is characterized by a vaginal microbiota low in lactobacilli; it affects one-quarter to one-third of reproductive-age cisgender women. 1 Approximately one-half of cases are symptomatic, with abnormal vaginal discharge and/or amine or fishy vaginal odor. 1 BV contributes to adverse sexual and reproductive outcomes, including HIV and/or sexually transmitted infection (STI) acquisition and preterm birth, and symptoms can negatively impact psychosocial well-being and sexual satisfaction. 1The BV treatment landscape has not appreciably changed in decades: in the US, metronidazole and clindamycin are recommended as first-line treatments for symptomatic BV, and secnidazole and tinidazole are used as alternatives.Although these treatments are effective in the short term, up to 60% of women experience BV recurrence within 1 year of treatment. 2Some have frequent recurrences, and options are limited for these individuals and may involve onerous suppressive regimens with twice-weekly application of intravaginal antibiotics for extended time periods.Suppressive vaginal metronidazole fails for 25% of patients and leads to secondary vulvovaginal candidiasis (VVC) in up to 40%, and many patients have BV recurrence after stopping suppressive therapy. 3It is imperative that we expand the toolkit of available BV treatments.Alternatives that are at least as effective as nitroimidazoles and clindamycin would be welcome additions.Treatments that effect a lasting cure would be paradigm-shifting.One option may be dequalinium chloride (DQC), a locally delivered antiseptic with broad antibacterial and antifungal activity. 4Its antibacterial activity is attributed to interaction with the bacterial cytoplasmic membrane and perturbation of cellular permeability, protein denaturation and subsequent alteration of ribosomal protein synthesis, and nucleic acid precipitation. 4A prior trial 5 reported that intravaginal DQC was noninferior to intravaginal clindamycin for BV treatment (discussed later), motivating Raba and colleagues 6 to evaluate its efficacy vs metronidazole.In a European, phase 4, multicenter, triple-blinded, randomized trial including 147 women, Raba et al 6 found that intravaginal DQC (10 mg tablet daily for 6 days) was noninferior to oral metronidazole (500 mg twice daily for 7 days) for treating BV defined by all four Amsel criteria. 6Clinical cure rates in both groups were 92.8% to 93.2% upon completing treatment, and DQC tolerability was significantly higher than for metronidazole. 6Notably, 27.9% of participants had a Nugent score of 3 or lower at enrollment (indicating non-BV microbiota) despite all 4 Amsel criteria being present; although there is some variation in the literature, this discrepancy is greater than the approximately 10% reported in a sentinel study. 7However, these participants were evenly distributed across groups. 6e trial by Raba et al 6 is the second to compare DQC with standard-of-care BV treatment.In 2012, Weissenbacher and colleagues 5 reported that intravaginal DQC was noninferior to intravaginal clindamycin (2% cream for 7 days) in a trial of 315 participants.Like Raba et al, 6 they enrolled women presenting with 4 Amsel criteria from multiple European clinical sites.Clinical cure rates for DQC and antibiotic groups at early and late time points were somewhat lower than in the trial by Raba et al, which may reflect slightly different clinical cure definitions and outcome assessment timing (7 and 20-40 days after starting treatment for Raba et al, 6 and 7 and 25 days after completing treatment for Weissenbacher et al 5 ).It is encouraging that both trials demonstrated noninferiority using the same 15% noninferiority margin and showed 75% to 80% clinical cure up to 5 weeks after DQC. 5,

There are significant racial disparities in the prevalence of sexually transmitted infections (STIs) in the United States. The purpose of this study was to evaluate whether the association of bacterial vaginosis and incident STI is modified by race even after adjustment for sexual practices and other potential confounding variables. We evaluated the association of bacterial vaginosis (BV) and STI acquisition in a group of 523 women at high risk for unplanned pregnancies and STI. BV was diagnosed by both Gram stain and Amsel criteria. STIs included Chlamydia trachomatis, Neisseria gonorrhoeae, pelvic inflammatory disease, trichomoniasis, syphilis, and HIV. Cox regression estimated the associations and the synergy index assessed whether race modified the association of BV and incident STI. Sixteen percent of participants developed an STI during the 2-year follow-up. Compared with white women without BV at baseline, the adjusted hazard ratios were as follows: white women with BV = 0.59; African American women without BV = 1.96; and African American women with BV = 2.86. The synergy index of 3.38 implies a combined association of BV and African American race with STI in excess of each factor individually. African American race modifies the association of BV and incident STI. Future research should strive to determine the relative contributions of other factors, such as biologic variation, social network or the consequences of socioeconomic position, in this disparity.

Background: In recent years Bacterial vaginosis has emerged as a global issue of concern due to its association with cervicitis, salphingitis, endometritis, postoperative infections, Urinary tract infections, pelvic inflammatory infections, spontaneous abortions, preterm delivery, abnormal Pap smears and increased susceptibility to HIV. Bacterial vaginosis is one of the most common lower genital tract infections among women of childbearing age and yet its diagnosis can be problematic. Gardnerella has been reported in upto 50% of women with no signs or symptoms of Bacterial vaginosis. So, it is important to know the prevalence and risk factors of Bacterial vaginosis, so that requirement of screening, early diagnosis and management can be planned.Methods: After obtaining ethical committee approval, hundred consenting patients between 20-45 yrs of women, diagnosis by Amsel’s criteria was done in gynaecology outpatient department and diagnosis by Nugent criteria was done in microbiology laboratory.Results: In present study authors had a prevalence of 37% and among them 48.65% were asymptomatic. Bacterial vaginosis was statistically significantly associated with multipara and the trend was more towards low socio-economic group and lower education. In our study we considered Nugent’s criteria as gold standard and found that Amsel’s criteria had positive predictive value = 88.88%, negative predictive value = 79.67%, sensitivity = 71.11% and specificity = 92.73%.Conclusions: Prevalence of bacterial vaginosis was 37%, which is a significant proportion and therefore screening for bacterial vaginosis may be useful to detect and treat the cases, larger trials are required before any recommendation can be made.

To determine the frequency of bacterial vaginosis (BV) in women with vaginal discharge, and to compare different diagnostic tests for its diagnosis. Cross-sectional study. The Aga Khan University Hospital from June 1998 to May 2000. All women attending the Obstetrics and Gynecology clinics at The Aga Khan University Hospital, with the complaints of vaginal discharge, were examined with the help of a speculum. The vaginal pH was measured, samples for bacterial cultures were obtained. A slide was prepared for the gram's stain and Whiff-test was also performed. BV was diagnosed, when the vaginal discharge fulfilled at least three of the composite clinical criteria (Amsel's criteria), a standard method for the diagnosis of bacterial vaginosis: homogenous (pasty) discharge, pH more than 4.5, positive Whiff-test and the presence of clue cells. The frequency of BV was observed to be 16.1% . The culture for Gardnerella vaginalis was compared with the composite clinical criteria. The sensitivity, specificity, positive and negative predictive values of the culture, calculated for the diagnosis of BV were 93.8%, 70%, 37.7% and 98% respectively. The use of laboratory tests in conjunction with clinical findings is necessary for diagnosis of BV. The composite clinical criteria for the diagnosis of BV are rapid, reliable and inexpensive method.

Previous studies have described bacterial vaginosis (BV) as associated with increased cell-shedding from the cervicovaginal epithelium. Cell-shedding in excess of cell-proliferation is thought to decrease epithelial barrier function and increase susceptibility to infection. This study evaluated the number of shed cells in mid-vaginal smears from women with a diagnosis of symptomatic BV (sBV, n = 17), asymptomatic BV (aBV, n = 71), or no BV (n = 104) by Amsel criteria. The sBV smears contained significantly more shed cells (median 158/100X field) than no BV smears (median 91/100X field), p = 7.2e−9. However, we observed that aBV smears contained significantly fewer shed cells (median 35/100X field) than no BV smears, p = 22.0e−16. The sizes of cell-aggregates (cells shed in sometimes multilayered sections with intact cell-cell attachments) followed the same pattern. Cell-aggregates in sBV smears were significantly larger (median ~220,000 μm2) than those in no BV smears (median ~50,000 μm2), p = 1.8e−6, but cell-aggregates in aBV smears were significantly smaller (median ~7,000 μm2) than those in no BV smears, p = 0.0028. We also compared the superficial cell index (SCI), a measure of cervicovaginal epithelial cell maturity, in no BV and aBV smears with relatively low numbers of shed cells (≤50/100X field). The SCI of no BV smears was significantly higher (median 0.86) than that of aBV smears (median 0.35), p = 4.3e−98, suggesting a depletion of mature cells with exposure and shedding of underlying immature cells in aBV with low number of shed cells. These results indicate that aBV may contribute disproportionately to the increased susceptibility to reproductive tract infections associated with BV. Our findings remained true when considering only those smears in which the microbiota comprised a diverse set of strict and facultative anaerobic bacteria [Community State Type IV (n = 162)], thus excluding those dominated by Lactobacillus spp. This is consistent with our developing hypothesis that high-shedding sBV and low-shedding aBV could be temporally separated phases of the same condition, rather than two separate forms of BV. These findings might inform future work on clinical management of symptomatic and asymptomatic bacterial vaginosis.

SummaryUrinary tract infections (UTIs) and bacterial vaginosis are common problems in pregnancy and are associated with serious obstetric complications. We evaluated the risk of UTIs in pregnant women with bacterial vaginosis. A total of 322 pregnant women who presented for a prenatal visit were evaluated for bacterial vaginosis and UTIs, between March 2003 and September 2004. Bacterial vaginosis was diagnosed based on Amsel's criteria. Women using antibiotic or other vaginal cream, with specific vaginitis or vaginal bleeding were excluded. Data were analysed using χ2, Student t-test and multiple logistic regression. A total of 76 women had bacterial vaginosis and 246 women did not; and 18 women (23.6%) with bacterial vaginosis had UTIs, compared with 24 (9.8%) of those without. Bacterial vaginosis was associated with an increased risk of UTIs (odds ratio (OR) 3.05; 95% CI: 1.47 – 6.33). Pregnant women with bacterial vaginosis are at increased risk for UTIs.

Predicting spontaneous preterm birth (SPTB) during mid-trimester would be very useful. We used a multimodality screening approach mainly focusing on urogenital infections among unselected obstetric population between 18 and 24weeks in a tertiary center. Diagnosis of lower genital tract infection (LGTI) was attempted among 228 pregnant women using several factors-symptom of vaginal discharge, characteristic appearance of discharge on speculum, point of care tests using Amsel's criteria and gram staining of vaginal swab. Nugent's scoring was taken as gold standard. Urine microscopy/culture was obtained. Serum inflammatory markers were done. Total leukocyte count, neutrophil/lymphocyte ratio and C-reactive protein were obtained. Data on cervical length were obtained from mid-trimester scan. Thirty patients complained of vaginal discharge. Speculum examination revealed discharge in 221 (96.92%), appearing pathological in 192 (86.87%). Amsel's criteria showed poor sensitivity to detect full (57%) and partial (24%) bacterial vaginosis (BV). On gram staining, 104 (45.61%) showed evidence of LGTI; 14 full BV (6.1%); 45 partial BV (19.5%); 40 candidiasis (17.5%); and two each of trichomoniasis and aerobic vaginitis. Appearance of vaginal discharge and microscopic diagnosis of LGTI were poorly correlated. Forty women (17.5%) had SPTB, 24 following membrane rupture and 16 following spontaneous labor. The presence of BV (specifically partial) increased the likelihood of SPTB with OR of 3.347 (CI 1.642, 6.823). Three of seven women with short cervix delivered preterm. No other screening modality was associated with SPTB. Active screening for LGTI between 18 and 24weeks shows high prevalence of BV in Indian setting. There is a strong link between partial BV and SPTB.

Bacterial vaginosis (BV) is diagnosed by the microbiological Nugent scoring method or clinical Amsel's criteria. Assessment of 404 vaginal samples (293 women) identified 110 (27.2%), 108 (26.7%) and 161 (39.9%) samples to be BV-positive using Nugent's method, standard Amsel's criteria and simplified Amsel's criteria respectively. The sensitivity, specificity, and kappa statistic (κ) for standard and simplified Amsel's criteria were 71.8% (95% CI=62.4-80.0), 90.1% (95% CI=62.4-86.1), 0.62 (95% CI=0.53-0.72) and 88.2% (95% CI=80.6-93.6), 78.2% (95% CI=73.1-82.8), 0.58 (95% CI=0.49-0.67), respectively. A combination of vaginal pH and clue cells exhibited the highest concordance (κ=0.64, 95% CI=0.54-0.74) with Nugent's method and may be used for simplified BV diagnosis.

Bacterial vaginosis (BV) is a common vaginal infection among women of reproductive age. Increasing evidence suggests BV may be sexually transmitted indicating a potential role for the treatment of sexual partners. If partner treatment reduces BV recurrence in women, real-world success will depend on sexual partners’ willingness to accept it. However, a lack of data exists on the acceptability of partner treatment among sexual partners, and no data exists on male partners’ experience of BV specifically. The aim of this study was to explore male partners’ views and experience of BV and their attitudes toward associated partner treatment. A social constructionist approach informed the framework of this study. Semi structured interviews were conducted with eleven men who participated in a BV partner treatment trial. Interviews were transcribed verbatim and analysed thematically. In the absence of symptoms in themselves, BV had little impact on men beyond their concerns for their partner’s health and self-esteem. Acceptance of treatment was largely a demonstration of care and support. While all participants had accepted treatment, men surmised the primary reasons other men may reject treatment as being: if they felt BV had “nothing to do with them”, which was related to not wanting to be viewed as having a ‘problem’ and exacerbated by norms of masculinity and STI-related stigma; lack of a diagnostic test to indicate if a male “had BV”; and a casual or less established relationship. Men’s attitudes to BV and partner treatment were primarily influenced by the nature of their relationships. The ambiguous aetiology of BV appears to attenuate STI related stigma and questions of infidelity.

Background. Currently, the search for the most effective methods to treat bacterial vaginosis remains relevant because of the high recurrence rate and resistance of the associated bacteria to antimicrobial drugs, along with the potential side effects of antibiotic therapy. This study aimed to assess the effectiveness and tolerability of using clindamycin and lactic acid sequentially, in comparison to lactic acid monotherapy, for women with bacterial vaginosis.
 Materials and methods. An open, randomized, comparative clinical study was conducted with 20 women (aged 18–45 years) who had bacterial vaginosis diagnosed according to R. Amsel criteria. The patients were randomly allocated into two groups, each comprising 10 patients. Group 1 took lactic acid, whereas group 2 employed clindamycin and lactic acid. After 14 days, clinical and laboratory efficacy was assessed based on Amsel criteria.
 Results. Objective and subjective symptoms such as vaginal discharge of whitish-gray color with unpleasant odor were not observed in both groups 2 weeks after the end of treatment. Positive dynamics of vaginal pH was recorded in both groups; however, a more pronounced effect was observed in women who used clindamycin and lactic acid.
 Conclusions. Both sequential clindamycin and lactic acid monotherapy demonstrated high clinical efficacy and good tolerability. Posttreatment pH values did not differ significantly between the two groups; however, a greater pH deviation was observed in the clindamycin and lactic acid sequential group. Further evaluations of long-term results are necessary.

BackgroundBacterial vaginosis (BV) is a polymicrobial infection and the most common cause of vaginal discharge in women during their reproductive years. A randomised, evaluator-blinded, parallel group pivotal study was carried...

Lactobacillus species play an integral part in the health of the vaginal microbiota. We compared vaginal Lactobacillus species in women from India and the USA with and without bacterial vaginosis (BV). Between July 2009 and November 2010, a cross-sectional study was conducted among 40 women attending a women's health clinic in Mysore, India, and a sexually transmitted diseases clinic in San Francisco, USA. Women were diagnosed with BV using Amsel's criteria and the Nugent score. Lactobacillus 16S rDNA was sequenced to speciate the cultured isolates. Ten Indian and 10 US women without BV were compared with an equal number of women with BV. Lactobacilli were isolated from all healthy women, but from only 10% of Indian and 50% of US women with BV. 16S rDNA from 164 Lactobacillus colonies was sequenced from healthy women (126 colonies) and women with BV (38 colonies). Seven cultivable Lactobacillus species were isolated from 11 Indian women and nine species from 15 US women. The majority of Lactobacillus species among Indian women were L. crispatus (25.0%), L. jensenii (25.0%) and L. reuteri (16.7%). Among US women, L. crispatus (32.0%), L. jensenii (20.0%) and L. coleohominis (12.0%) predominated. L. jensenii and L. crispatus dominated the vaginal flora of healthy Indian and US women. Indian women appeared to have a higher percentage of obligate heterofermentative species, suggesting the need for a larger degree of metabolic flexibility and a more challenging vaginal environment.