A longitudinal cohort study of sexually active women 18–30 years of age was conducted to identify variables associated with the acquisition of herpes simplex virus type 2 (HSV-2) infections. Six ...hundred seventy HSV-2–seronegative women were followed up at 4-month intervals for 1 year; acquisition of HSV-2 antibodies was detected in 32 of these women. Black race, ⩽12 years of education, having a new sex partner, and bacterial vaginosis (BV) were associated with HSV-2 seroconversion on univariate analysis. Antecedent HSV-1 infection was not protective against HSV-2 acquisition. After controlling for other identified risk factors in multivariable models, the diagnosis of BV remained associated with an increased risk of acquiring HSV-2 infection (hazard ratio, 2.1; 95% confidence interval, 1.0–4.5; P = .05). In this study, the population attributable risk of BV for HSV-2 seroconversion was 21%. Additional studies are needed to determine whether screening and treatment of BV could reduce susceptibility to the acquisition of HSV-2 in women.
Clinical guidelines produced in developed nations may not be appropriate in resource-constrained environments, due to differences in cultural, societal, economic and policy contexts. The purpose of ...this article is to describe an innovative and resource-efficient method to develop a clinical practice guideline (CPG), using the CPG contextualisation approach.
The four phased contextualisation framework was applied to produce a contextualised, multidisciplinary CPG for the primary health care of adults with chronic musculoskeletal pain (CMSP) in the South African context. The four phases were: a contextual analysis, evidence synthesis, contextual integration and external evaluation. Qualitative methodology was used to investigate context factors influencing health care in this environment. A systematic review was conducted to identify current, high-quality CPGs on the topic, and to synthesise a core set of clinical recommendations from the CPGs. Consensus methods were used to integrate context information with recommendations. A multidisciplinary panel of local experts authenticated and contextualised recommendations. The resultant CPG was externally reviewed using a survey.
The results from the contextual analysis phase indicated a wide range of contextual factors that could influence the applicability and implementability of the recommendations, including: the personal characteristics of the patient and clinician, social and environmental circumstances, healthcare interventions available, and healthcare system factors. During phase two, six existent high quality CPGs were identified and a core set of multidisciplinary recommendations were sourced from them. The contextual integration phase produced the validated recommendations, accompanied by its underpinning body of evidence and context specific information. The outcome of phase four (external review) was that the recommendations were confirmed as relevant for the intended setting.
CPG contextualisation was found to be a practical approach to develop a contextualised multidisciplinary CPG for the primary health care of adults with CMSP in a South African setting. The contextualisation approach enhanced the integration of multiple stakeholder perspectives and highlighted the importance of considering clinical, social and economic complexities during CPG development. Attention to contextual information is advocated to enhance the uptake of CPG recommendations, particularly in resource constrained settings.
Health Research Ethics Committee of Stellenbosch University, South Africa (S14/01/018); the review protocol was registered on PROSPERO (registration number CRD42015022098 ).
A prospective cohort study was conducted to examine the relationship between vaginal colonization with lactobacilli, bacterial vaginosis (BV), and acquisition of human immunodeficiency virus type 1 ...(HIV-1) and sexually transmitted diseases in a population of sex workers in Mombasa, Kenya. In total, 657 HIV-1—seronegative women were enrolled and followed at monthly intervals. At baseline, only 26% of women were colonized with Lactobacillus species. During follow-up, absence of vaginal lactobacilli on culture was associated with an increased risk of acquiring HIV-1 infection (hazard ratio HR, 2.0; 95% confidence interval CI, 1.2–3.5) and gonorrhea (HR, 1.7; 95% CI, 1.1–2.6), after controlling for other identified risk factors in separate multivariate models. Presence of abnormal vaginal flora on Gram's stain was associated with increased risk of both HIV-1 acquisition (HR, 1.9; 95% CI, 1.1–3.1) and Trichomonas infection (HR, 1.8; 95% CI, 1.3–2.4). Treatment of BV and promotion of vaginal colonization with lactobacilli should be evaluated as potential interventions to reduce a woman's risk of acquiring HIV-1, gonorrhea, and trichomoniasis.
Lactobacillus acidophilus has been reported to be the predominant vaginal species. Vaginal lactobacilli isolated from 215 sexually active women were identified using whole-chromosomal DNA probes to ...20 American Type Culture Collection Lactobacillus strains. Most women were colonized by L. crispatus (32%), followed by L. jensenii (23%), a previously undescribed species designated L. 1086V (15%), L. gasseri (5%), L. fermentum (0.3%), L. oris (0.3%), L. reuteri (0.3%), L. ruminis (0.3%), and L. vaginalis (0.3%). H2O2 was produced by 95% of L. crispatus and 94% of L. jensenii isolates, compared with only 9% of L. 1086V. Colonization by L. crispatus or L. jensenii was positively associated with being white (P<.001),age ⩾20 years (P = .05), barrier contraceptive usage (P = .008), and lower frequency of bacterial vaginosis (P<.001) and gonorrhea (P = .03). L. crispatus and L. jensenii, not L. acidophilus, are the most common species of vaginal lactobacilli.
Background. Chlamydia trachomatis and/or Neisseria gonorrhoeae account for approximately one-third to one-half of pelvic inflammatory disease (PID) cases. Thus, up to 70% of cases have an unknown, ...nongonococcal/nonchlamydial microbial etiology. Methods. We investigated the associations of N. gonorrhoeae, C. trachomatis, bacterial vaginosis, anaerobic bacteria, facultative bacteria, and lactobacilli with endometritis among 278 women with complete endometrial histology and culture from the PID Evaluation and Clinical Health Study. Results. Women with acute endometritis were less likely to have H2O2-producing Lactobacillus species (odds ratio OR, 0.1; 95% confidence interval CI, 0.01–0.8) and more likely to be infected with C. trachomatis (OR, 16.2; 95% CI, 4.6–56.6), N. gonorrhoeae (OR, 11.6; 95% CI, 4.5–29.9), diphtheroids (OR, 5.0; 95% CI, 2.1–12.2), black-pigmented gram-negative rods (OR, 3.1; 95% CI, 1.4–7.0), and anaerobic gram-positive cocci (OR, 2.1; 95% CI, 1.0–4.3) and to have bacterial vaginosis (OR, 2.4; 95% CI, 1.3–4.3). Conclusions. We conclude that bacterial vaginosis—associated organisms are frequent among women with PID. Because these organisms were strongly associated with endometritis, we recommend that all women with PID be treated with regimens that include metronidazole.
To compare the frequencies, concentrations, and antimicrobial susceptibilities of vaginal microbes isolated from women with bacterial vaginosis (BV) before and after therapy, 119 nonpregnant women ...aged 18 to 45 with clinical and Gram stain evidence of BV were randomized to receive intravaginal clindamycin or metronidazole. Vaginal swabs were collected at baseline and 7 to 12 days, 35 to 45 days, and 70 to 90 days following therapy for quantitative vaginal culture. For the 99 women completing all four visits, statistical analyses were performed comparing differences in vaginal microflora between the two treatment arms and between visits in the same treatment group. Antimicrobial susceptibility testing using the agar dilution method was performed for anaerobic gram-negative rods. Although both therapies resulted in decreased colonization by Gardnerella vaginalis and Mycoplasma hominis, only metronidazole treatment resulted in a significant decrease in the frequency and concentration of Prevotella bivia and black-pigmented Prevotella species. Of the 865 anaerobic gram-negative rods evaluated for susceptibility, only 3 (0.3%) were resistant to metronidazole, whereas clindamycin resistance increased significantly for P. bivia and black-pigmented anaerobic gram-negative rods persisting following clindamycin therapy. Clindamycin-resistant subpopulations of P. bivia and black-pigmented Prevotella species emerged 7 to 12 days after therapy even among women colonized initially by clindamycin-susceptible strains. These resistant subpopulations persisted at high frequencies (42 to 50%) 70 to 90 days following therapy. The two topical agents for treatment of BV have differing microbiologic effects on the vaginal microflora. The emergence of clindamycin-resistant anaerobic gram-negative rods following therapy is of concern.
Lactobacilli colonizing the rectum may be a reservoir for vaginal lactobacilli. In a cross-sectional study of 531 females, vaginal and rectal colonization by lactobacilli were assessed by culture ...methods. A subset of isolates was identified to the species level by use of whole-chromosomal DNA probes. Lactobacillus crispatus (16%), L. jensenii (10%), and L. gasseri (10%) were the prevalent lactobacilli colonizing the rectums of 290 females. Only 13 (9%) of 147 females colonized by L. crispatus or L. jensenii vaginally and/or rectally had bacterial vaginosis (BV), compared with 12 (44%) of 27 females colonized by other H2O2-producing lactobacilli (P<.001). Cocolonization of the vagina and rectum by H2O2-producing lactobacilli was associated with the lowest prevalence of BV (5%), whereas females colonized only vaginally, only rectally, or at neither site had a successively increased risk of BV (P<.001). Lactobacillus species in the rectum may contribute to the maintenance of vaginal microflora
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