Microbiological features of vulvovaginitis in prepubertal age

Papanagiotou A,1 Vlachos S,1 Charalabopoulou A,1 Prifti E,1 Avlonitou A,1 Michala L,2 Apostolou D,1 Tzanetou K.1

1Microbiology Department, 2Pediatric and Adolescent Gynecology, 1st Department of Obstetrics and Gynecology, University of Athens, “Alexandra” General Hospital of Athens, Athens, Greece Background p The aetiology of most cases of vulvovaginitis in prepubertal age is not specific p However in some girls the symptoms are caused by specific bacterial or fungal pathogens Objectives p To evaluate the prevalence of various pathogens involved in the pathology of vulvovaginitis in girls of prepubertal age over a two-year period Materials and Methods p Three hundred eighty (380) prepubertal girls of age from 1 to 10 years, presenting at the paediatric gynaecology clinic from October 2009 to October 2011 with symptoms and signs of vulvovaginitis (vaginal discharge, erythema or pruritus), were tested for bacterial and fungal pathogens p Swabs of vaginal secretions were obtained and placed in normal saline for wet preparation and in Stuart transport medium for culture Culture media and identification methods p The wet preparation was examined for yeasts, Trichomonas and polymorphonuclear leucocytes p The swab in transport medium was cultured onto chocolate agar for Haemophilus influenzae growth, Columbia CNA blood agar with colistin and nalidixic acid for Streptococcus isolation, chromogenic sabouraud dextrose agar for Candida isolation and species identification and MacConkey agar for isolation and differentiation of Enterobacteriaceae, and non- Enterobacteriaceae p Urea-Arginine broth for specimen collection and A7 Mycoplasma agar for culture of U. urealyticum and M. hominis were not routinely used p A rapid latex agglutination test was performed for identification of Lancefield A, B, C, D, F and G group antigens of streptococci (SLIDEX® Strepto-Plus, bioMérieux SA Lyon, France) Results

C. albicans (mixed infection) were isolated in 23

girlsgirls, respectively whereas in 332(table (87.37%) 1, fig. 2) girls non-specific pathogens were identified (fig. 1) p Of the 48 culture-positive cases, group A Streptococcus (S. pyogenes), group B Streptococcus (S. agalactiae), non-Candida albicans, Candida albicans, Haemophilus influenzae, Escherichia coli, Ureaplasma urealyticum and S. pyogenes with non- C. albicans (mixed infection) were isolated in 23 (6.05%), 13 (3.42%), 6 (1.58%), 2 (0.53%), 1 (0.26%), 1 (0.26%), 1 (0.26%), and 1 (0.26%), girls respectively (table 1, fig. 2) Identification of specific and non-specific pathogens (sample of 380 girls) Culture positive 12,63%

Non-culture positive 87,37% Table 1. Infectious causes of vulvovaginitis in prepubertal age

Pathogens No. of culture-positive Frequency of cases isolation (%) Group A Streptococcus (GAS) 23 6,05% Group B Streptococcus (GBS) 13 3,42% non-Candida albicans 6 1,58% Candida albicans 2 0,53% Escherichia coli 1 0,26% Haemophilus influenzae 1 0,26% Ureaplasma urealyticum 1 0,26% GAS & non-Candida albicans 1 0,26% Total 48 12,63% Infectious causes of vulvovaginitis in prepubertal age (sample of 48 culture-positive cases) non-Candida albicans 12,50%

Candida albicans Group B Streptococcus (GBS) 4,17% 27,08% Escherichia coli 2,08%

Haemophilus influenzae 2,08%

Ureaplasma urealyticum 2,08%

GAS & non-Candida albicans 2,08%

Group A Streptococcus (GAS) 47,92% Conclusions p In most cases of vulvovaginitis in prepubertal girls non-specific bacterial or fungal pathogens are identified as causative agents p The most common infectious cause of vulvovaginitis in prepubertal age is S. pyogenes followed by S. agalactiae and Candida spp.