Leukocyte Esterase Activity in Vaginal Fluid of Pregnant and Non-Pregnant Women with Vaginitis/Vaginosis and in Controls

Infect Dis Obstet Gynecol 2003;11:19–26

Leukocyte esterase activity in vaginal fluid of pregnant and non-pregnant women with vaginitis/vaginosis and in controls

Per-Anders Mårdh 1, Natalia Novikova 1, Ola Niklasson 1, Zoltan Bekassy 1 and Lennart Skude 2

1Department of Obstetrics and Gynecology, University Hospital, Lund and 2Department of Clinical Chemistry, County Hospital, Halmstad, Sweden

Objectives: Todeterminethe leukocyteesterase (LE) activity invaginal lavage fluid ofwomen with acuteand recurrentvulvovaginal candidosis (VVC and RVVC respectively), bacterial vaginosis(BV), and in pregnant and non-pregnantwomen without evidenceof the threeconditions. Also tocompare the resultof LEtestsin women consultingat differentweeks inthe cycle andtrimesters of pregnancy.The LEactivity was correlatedto vaginal pH, numberof inflammatory cells instained vaginal smears,type of predominatingvaginal bacteria andpresence of yeast morphotypes. Methods: Onehundred and thirteen women with ahistoryof RVVC,i.e.with at leastfour attacks of the conditionduring the previousyear and who had consultedwith anassumed new attack ofthe condition,were studied.Furthermore, we studied16 women with VVC,15 women with BV,and27 women attendingfor control of cytological abnormalities, who all presentedwithout evidenceof either vaginitisor vaginosis. Finally, 73 pregnantwomen wereinvestigated. The LEactivity invaginal fluid duringdifferent weeks inthe cycle of 53 of the women was measured. Results: Inthe non-pregnantwomen, anincreased LE activity was foundin 96, 88, 73 and56% of those with RVVC,VVCandBV andin the non-VVC/BVcases,respectively. In 73% of pregnantwomen inthe second trimester,and 76% of thosein the third,the LEtestwas positive.In all groupsof non-pregnantwomen tested, the LEactivity correlatedwith the numberof leukocytesin vaginal smears,but it didnot in those who were pregnant.There was nocorrelation between LE activity andweek incycle. The vaginal pHshowed nocorrelation to LE activity in any of the groups studied. Conclusions: The useof commercial LEdipstickshas alimited valuein the differential diagnosisof RVVC,VVCand BV.Thereis no correlation between the LEactivity invaginal secretionon one hand andvaginal pH,week in the menstrualcycle andtrimester in pregnancy on the other.Women with BVoftenhave signsof inflammation as evidenced by a positive LE test and inflammatory cells in genital smears.

Key words:L EUKOCYTE ESTERASE; VULVOVAGINAL CANDIDOSIS; RECURRENT VULVOVAGINAL CANDIDOSIS; BACTERIAL VAGINOSIS; PREGNANCY

Ifthe office diagnosis ofvaginitis/ vaginosis is genital tract, forexample ofvaginitis, microscopy onlybased on history and clinical examination, ofvaginal fluidfor detection of granulocytes has theaccuracy will beunacceptablylow 1–3. To diag- beenthe standard procedure. Bacterial vaginosis noseinflammatory reactions inthe lower female (BV) has beenconsidered to be an– osis, thatis, a

Correspondenceto: Per-AndersMå rdh, Department of Obstetrics and Gynecology, Lund University Hospital, SE22185Lund, Sweden. E-mail: [email protected]

ã 2003 The Parthenon Publishing Group 19 Leukocyte esterase activity in vaginal fluid Mårdh et al. non-inflammatorycondition. Amsel’ s criteria 4, TheLE activity was correlatedwith the pre- whichdo not include the presence ofinflamma- dominatingbacterial flora, independentof the torycells invaginal fluid,have generally been presence ofcandida morphotypes. The presence employed to diagnose BV. ofextremely elongatedGram-positive rods(of Leukocyteesterase (LE) tests have been lactobacilli morphotype) was also noted. launchedas oneof several chemical tests ondip- sticks employedin the diagnosis ofurinary tract infections(UTI). Contradictoryresults ofthe Patients with a history of recurrent vulvovaginal diagnosticvalue ofLEtests have beenreported 5,6. candidosis Anumberof studies have reportedon theuse of Oneof thecohorts studied comprised 113 women anLE dipsticktest ofurine to diagnose urthritis witha historyof RVVC, i.e. patientswho had in males7,8,while onlysingle studies have used hadat least fourattacks of the condition during suchtests inthe diagnosis offemale genital theprevious year, andwho had consulted with infections9–11. symptoms suggesting anewattack of RVVC. The TheLE test is basedon detectionof an enzyme diagnosticcriteria appliedhave beendescribed in thathydrolyses indoxyl carboxylic acid ester to detail elsewhere 13,14.Thenumberof these women indoxyl,which in turn reacts witha diazoniumsalt whohad a positive LEtest has already been to produce a purple colour 12. reportedin a previous study 13.Inthepresent study, Thepresent study was aimed todetermine the weexpandedour investigation bycomparingthe LEactivity invaginal secretion ofpregnant and LEtest results withfindings of candida morpho- non-pregnantwomen with and without evidence types, i.e. ofblastoconidia and pseudohyphae, in ofvaginitis andvaginosis. Samples collectedat Gram- andmethylene blue-stainedvaginal smears. differentweeks ofthemenstrual cycleand at the Themethodsused to identifythose with a positive secondand third trimesters ofthe gestational candidaculture have beenreported in detail else- periodwere studied.We also studiedany correla- where15.Inbrief, vaginal introitaland posterior tionbetween the LE test results andthe number vaginal fornixsamples were culturedon Sabouraud of inflammatory cells in vaginal smears. andchromogenic agar 16.Speciationof isolated candidastrains was donewithAPI 50C kitsandthe Vitek® automised identificationsystem (bothfrom SUBJECTS AND METHODS BioMerieu, Paris). Thevaginal pHwas determined bypHindicatorstrips (Merck, Darmstadt). Leukocyte esterase tests and pH determinations TheLE activity invaginal flushingfluid samples TheLE activity was measured bya commercial was determined byCombur-4 ® (Roche,Basle) kit (Ecur4-Test, Boehringer–Mannheim, later stick. renamed Combur-4and sold by Roche, Basle). Onedrop (approximately 0.3 ml) ofvaginal lavage Patients attending for control of cytological fluidwas mixed with3 ml of0.1M TRIS HCl abnormalities buffer,pH 7.3 orwith physiological saline. The tests were performedwithin a coupleof minutes Twenty-seven womenin whom a previous cyto- ofsampling. Accordingto the package insert, color logical screening hadshown cell abnormalities changesof grades 1, 2and3 correspondto 10–25, (butno signs ofcervical cancer) were investigated. approximately75, andapproximately 500 granu- Thepatients, all ofwhom were non-pregnant,had locytes/ml, respectively. nosigns orsymptoms ofVVCorBV.Thepatients Another1– 2 dropsof the vaginal lavage were were tested forLE activity, vaginal pHand for placedon anindicator strip forpH determination presence ofinflammatory cells andpredominating (Merck, Darmstadt, Germany). Vaginal samples bacterial flora, i.e. either apredominanceof were tested forLE activity withinsome minutes as Gram-positive rods(of lactobacilli morphotypes) well asafter 6hours’storage 2 at roomtemperature oramixture ofbacterial morphotypes(‘ BVflora’). in TRIS buffer and in physiological saline. Furthermore,Amsel’ s criteria were searched for:

20 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY Leukocyte esterase activity in vaginal fluid Mårdh et al.

Table 1 Relationbetween vaginal pH andleukocyte esterase activityin vaginal lavage fluid of women with ahistory of and an assumed new attack of recurrent vulvovaginal candidiasis

Number of women with indicated test result*

Number of cases Grades 0–1 Grade 2 Grade 3 Vaginal pH (n = 113) (n = 14) (n = 22) (n = 77) p-value

£ 4.4 57 6 13 (12%) 38 (34%) 0.904 4.5–5.4 43 6 7 (6%) 30 (27%) 0.903 ³ 5.5–6.4 13 2 2 9 (69%) 0.927

*Grading according to package insert (Combur-4 Ò, Roche, Basle) increased vaginal pH, acharacteristic gray homo- Statistical analyses geneousvaginal content,presence ofclue cells Data were analysed using c2 and student t-tests. (in methylene blue-and Gram-stained vaginal A p-value <0.05 was considered significant. smears), anda positive amine test obtainedby adding 15% KOH to vaginal fluid. RESULTS Patients with vulvovaginal candidosis and Leukocyte esterase activity in cases with history bacterial vaginosis and non-pregnant healthy of recurrent vulvovaginal candidosis women Inthe 113 cases witha historyof RVVC and Sixteen womenwith the diagnosis ofVVC and withsymptoms suggestive ofanewattack of the 15with BV were tested forLE activity invaginal condition,there was acorrelationbetween the secretion. BVwas diagnosedif three offour of LEactivity andthe result ofthe yeast cultures Amsel’s criteria were fulfilled 4. The VVC and fromthe genital tract( p <0.05). Thus,of the63 BV women were all non-pregnant. candidaculture-positive women,all hadpositive Thediagnostic methods were thesame as LEtests. Ofthe 50 culture-negative women,45 thoseapplied in the cases withcytological had such an increased activity. abnormalities. Anacute attack of VVC was con- Therewas nocorrelationbetween the result of sidered whenthe woman reported symptoms pHdeterminationof vaginal lavage andthe result suchas pruritus,discharge and pain. Signs, suchas oftheLEtests (Table 1). Thus,of 57 womenwith oedema anderythema ofthe introitus and the avaginal pHofless than4.5, 51(89%) hadan LE vaginal mucosawith plaques, and/ oranincreased test ofgrades 2and3, while ofthe43 women with vaginal discharge(often of cotton-cheese type), apHof 4.5– 5.4, 37(86%) hadsuch a result. were required.The presence ofcandida blasto- Eleven ofthe 113 women with an even higher conidiaand/ orhyphae in stained vaginal smears pH had a positive LE test (10%). was also requiredto confirm the diagnosis ofVVC. Leukocyte esterase activity in correlation to pH Pregnant women in women without vaginitis/vaginosis Seventy-three pregnantwomen were studied.The Table2 lists theLE activities inthe patients who sampling was made inconjunction with routine hadno symptoms and/orsigns ofeither VVCor maternal check-upsin the second (17– 18 weeks of BV, inrelation tothevaginal pH. Thus,of the97 gestation) andthird trimester (32–34 weeks of womenstudied, 76 (78%) hada vaginal secretion gestation). Thediagnostic methods used for the pHof4.7 orless, 45(59%) ofwhomhad a positive pregnantwomen were thesame as thoseapplied LEtest (grades 1–3). Ofthe 21 women with an to the women with cytologic abnormalities. elevated vaginal fluidpH (above 4.7), 16(76%) had

INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY 21 Leukocyte esterase activity in vaginal fluid Mårdh et al. apositive LEtest. Alsoin this group,there was no leukocyteesterase –grades 0, 1, 2or3according correlationbetween vaginal pHand LE activity topackage insert –inthe VVC ( p = 0.021), (Table 2). BV (p =0.023) andin the non-VVC/ BVcases (p = 0.002). Table3 also showsthe presence ofleukocytes Leukocyte esterase activity in vulvovaginal instained smears ofvaginal secretion inrelation candidosis and bacterial vaginosis and toLE activity inthe vaginitis andvaginosis cases non-vaginitis/vaginosis cases: correlation with andin women with no signs ofthese conditions. occurrence of leukocytes in vaginal lavage fluid In12 (75%) ofthe 16 VVC cases, andin eight Table3 showsthe LE test results inthe VVC, BV, (54%) ofthe 15 BV patients, there were more andnon-VVC and non-BV cases studied.In 14 thanfive leukocytesper HPF. Inthe 97 non- (88%) ofthe 16 VVC cases, theLE activity was VVC/BVcases, 33(34%) hadsuch a numberof elevated (grades 1–3). Inthe 15 BV cases, this leukocytesin vaginal lavage fluid.There was was thecase in11 (73%) patients. Inthe 97 acorrelationbetween the number of leuko- non-VVC/BVcases, LEactivity was elevated in cytes andLE activity inthe VVC ( p = 0.023), 54(56%) ofthe cases investigated. Allthe VVC BV (p =0.031) andnon-vaginitis/ vaginosis cases were symptomatic, as were six ofthe BV groups (p = 0.008). cases. Thenumber of granulocytesin the vaginal Thepositive (PPV) andnegative (NPV) predic- smears (less thanfive, six tonine, ormore than tive values fortheLE test (grades 2–3) toforesee an tenleukocytes per high-power field, HPF)from increased numberof leukocytes (six ormore per the128 women, is shownin Table 3. Therewas HPF) inthe patients’ stained smears were 53.1 and acorrelationbetween the degree ofactivity of 77.5%, respectively.

Table 2 Correlation betweengrade* of leukocyte esterase (LE)activity in vaginal secretion andpH ofthe test sample in women without symptoms and clinical signs of vulvovaginal candidosis and bacterial vaginosis

Number of cases with indicated LE activity

Total number of women Grade 0 Grade 1 Grade 2 Grade 3 Vaginal pH (n = 97) (n = 36) (n = 17) (n = 16) (n = 28) p-value

£ 4.7 76 31 15 9 21 0.07 > 4.7 21 5 2 7 7 0.086

*Grading according to package insert (Combur-4 Ò, Roche, Basle)

Table 3 Correlation betweengrade* of leukocyte esterase (LE)activity and number of leukocytes in vaginal secretion inwomen with vulvovaginalcandidosis (VVC) and bacterial vaginosis(BV) and in womenwithout evidence of these conditions (controls)

Number of women with given LE activity and leukocyte count

0 1 2 3 Number tested Condition (n = 128) A B C A B C A B C A B C

VVC 16 1 1 2 2 3 1 6 BV 15 3 1 4 1 1 8 3 1 1 Controls 97 34 3 6 8 1 2 10 2 4 12 4 11

*Grading according to package insert (Combur-4 Ò, Roche, Basle); A,< 5 leukocytes per high power field (HPF) (x1000); B, 6–9 leukocytes per HPF; C, > 10 leukocytes per HPF

22 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY Leukocyte esterase activity in vaginal fluid Mårdh et al.

Leukocyte esterase activity in relation to week inthe second ( p =0.75) norinthe third ( p = 0.74) in menstrual cycle trimester. Onlythree ofthe64 non-pregnantwomen were menstruatingat thedayofexamination. LEactivity Leukocyte esterase activity in relation to inrelation to the start oflast menstruationwas predominating bacterial morphotypes in registered in53 women. There was nocorrelation the vagina betweenLE activity andthe number of days thathad passed since thestart oflast menstrua- In56 (63%) ofthe89 womenwith a lactobacilli- tion (Table 4). dominatedvaginal flora, independentof the Twelve patients hadamenorrhoea, eight of presence ofcandida morphotypes, LE activity them dueto hormonal contraception. The LE was increased. In13 (23%) ofthe 56 women, test result in this group is also shown in Table 4. elongated,non-divided rods of lactobacilli- morphologywere detected.In the remaining 43women with a mixed bacterial flora, increased Leukocyte esterase activity in relation to LEactivity was foundin 24 (56%). Elongated different trimesters bacteria were presentin six (14%) ofthe 43 Ofthe73 pregnantwomen studied, 54 (74%) had women,three (50%) ofwhom had elevated anLE activity ofgrades 1–3 (Table 5). Ofthepreg- LE activity. nantwomen, 44 were inthe second trimester, while theremaining 29women had reached the Influence of storage time on leukocyte esterase thirdtrimester. Inthe former group,32 (73%) activity in samples stored in TRIS buffer versus andin the latter 22(76%) womenhad an increased saline LEactivity invaginal secretion. Incontrast withthe non-pregnant women, there was nocor- Therewas nodifference in LE activity between relationbetween the degree ofLEactivity, neither vaginal lavage samples collectedin TRIS buffer

Table 4 Leukocyte esterase (LE) activity in relation to the number of weeks since the start of last menstruation

Number of women with indicated LE activity

Number of weeks since Number tested 0 1 2–3 last menstruation (n = 53) (n = 33) (n = 7) (n = 13) p-value

0–1* 13 10 1 2 0.332 2 12 8 1 3 0.335 3–4** 28 15 5 8 0.090 amenorrhoea 11 5 3 3

*Ongoing or first week after last menstruation; **or longer

Table 5 Leukocyte esterase (LE) activity in vaginal lavage of pregnant women in relation to gestational time

LE activity*

Gestational Number of women tested Grade 0 Grade 1 Grade 2 Grade 3 period (n = 73) (n = 19) (n = 8) (n = 17) (n = 29) p-value

Second trimester 44 12 6 9 17 0.752 Third trimester 29 7 2 8 12 0.742

*Grading according to package insert (Combur-4 Ò, Roche, Basle)

INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY 23 Leukocyte esterase activity in vaginal fluid Mårdh et al. orsaline. Nor was there anydifference in LE LEdipsticktests ofurinefrom men withsymp- activity whenanalyses were made some minutes tomatictrichomoniasis have ahighersensitivity after collectioncompared with the result when (80%) thanspecificity (40%) 22.Intheasymptom- thesame samples hadbeen stored for up to6 hours atic cases oftrichomoniasis, thecorresponding at room temperature. values were 60and 68%, respectively. Anegative LEtest seems toexclude trichomoniasis. Inour clinical setting, trichomoniasis is todaya rare condition,which was never diagnosedin any of DISCUSSION the cases presented in our study. Thedetermination of LEactivity withthe aid of LEtests have beenused to detectasymptomatic differentcommercial dipstickshas beenused to bacteriuria inobstetric patients 23,24, and also screen forUTI. Some studies have favoredtheir ‘vaginitis ofunspecificaetiology’ in such patients. use9,while othershave deniedtheir usefulness Thus,Abbasi and co-workers 9 foundLE dipstick for this purpose 5,6. tests tohave a100%sensitivity and90% specifi- Althoughthe most commonapplication of cityfor detection of such latter cases. Theyalso LEdipstickshas beenin investigations of reporteda sensitivity andspecificity of100% for voidedurine for UTI 5,11,12,17,18 orurethritis 7,8, detectionof UTIintheir patients. Inthecurrent single reportshave describedtheir use intests of study,none of ourpregnant women had a recent vaginal9 and amniotic fluids 10. history of UTI. LEtests are oftensold in combination with BVis generally believed tobe an ‘ –osis’and otherchemical tests, suchas tests fornitrate, hemo- notan ‘ –itis’. Inthe present study, we used globinand glucose, whichall appearon thesame Amsel’s criteria 4 todiagnose BV. These criteria dipstick.Evaluation ofthe value ofLE tests for donot include any tests forthe absence of bacteriuria have oftenbeen made inthe context leukorrhea.However, ofour15 BVpatients, seven ofconcomitant tests fornitrate. However, the (47%) hadan increased numberof leukocytes in specificity fordetection of significant bacteriuria, vaginal secretion. Furthermore,more thantwo- even byuse ofsucha combinationof tests, is low 6. thirds(11/ 15) oftheBV cases (definedby Amsel’s Storageconditions of samples may influencethe criteria) hada positive LEtest. BVhas beencon- LEtest outcome 18.Thus,after 24hours’storage, sidered arisk factorfor premature birth,although there is arisk forpositive samples toturnnegative. this is contradictedby several recentprophylactic Inthe present study, the tests inthe RVVC cases antibioticstudies 25.Thereappears tobe aneedto were performedat most afewhours after sampling, recognizethe subgroup of pregnantwomen with while in the other studies, within minutes. BVthatseems tobe at particularrisk todeliver LEtests have beenused in screening programs beforeterm. Thepossibility touse LEtests of forgenital infectionsof given etiologies, such vaginal fluidfor identifying women at risk should as chlamydial urethritis andgonorrhoea 7,19–21. be explored. Samples witha positive LEtest have thenbeen ThepH ofvaginal secretions didnot correlate subjectedto adefiniteetiologic test. Althoughthe withLE activity inthe VVC, BVandnon-BV, sensitivity ofLEtests fordetection of urethritis in non-VVCcases. However, some ofthe women males may behigh, the specificity is toolow for whowere diagnosedwith BV (i.e. presentedwith accuratelydiagnosing chlamydial andgonococcal three ofthe four Amsel’ s criteria) hada normal infections7.Inastudyof voidedurine samples of vaginal pH, justas some ofthe VVC cases had 224male military recruits and443 male sexually anincreased pH. These observations contradict transmitted infectionclinic patients, weusedtwo the‘ textbook knowledge’ on both vaginosis enzyme immunoassays, onechemilumminometric and vaginitis. assay andan immunofluorescence test todetect Thecycle day might have influencedthe LE Chamydia trachomatis .ThePPV ofLE tests for test result. We foundmore positive LEtests in detectionof a genital chlamydial infectionwas theluteal thanin the follicular phase, butthe only 44.6%21. differencewas notsignificant. Onlythree ofthe

24 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY Leukocyte esterase activity in vaginal fluid Mårdh et al. patients were menstruatingwhen tested (butnote InRVVC, thevaginal contenthas oftenbeen thatperformance of the LE test is notinterfered describedas beingdominated by monocytes.Our withby thepresence ofbloodin the test sample). studyalso showedleukocytes to be presentin high Noneof the women were usingimipenem, numbers in many of the VVC and RVVC cases. meropenem orclavulanic acid, whichall can Ourstudy points to the value ofexamining interfere withthe LE test andproduce false posi- vaginal smears inthe work-up of cases suspected tive results. Neither hadthey been prescribed sufferingfrom RVVC 13.Ifthe diagnosis ofthis cephalexinor gentamycin, whichcan diminish the conditionis basedonly on history and clinical coloron the test stickif takenin high doses. In examination, approximatelyhalf of all such addition,excessive excretionof glucose in urine cases will provenegative for Candida species2. thatcontaminates vaginal secretion canhave such Differentiationbetween candida-positive and aninfluence. In all thepregnant women studied, candida-negative cases amongwomen presenting carefulevaluation ofthe presence ofmetabolic withsymptoms andsigns generally associated with syndromehad been made as partof the routine RVVC is notpossible withany high degree of maternal check-upat theclinic. Twowomenwith accuracy14.Theuse ofoneor more doctors’office gestational diabetes were includedin the study,but tests, suchas culturesand/ ormicroscopyof stained they were both metabolically well-controlled. introitaland vaginal smears, is essential inthe ThePPV ofLE dipsticktests fordetection of work-upof cases consultingwith genital symp- polymorphonuclearleukocytes in urine samples is toms. However, ourstudy did not show any low26.Thiswas also truein the present study benefitfrom LE determinations bydipstick tests ofvaginal secretions ofwomen with vaginitis. of vaginal secretion in this conjunction.

REFERENCES 1. HolmesKK, StammWE. Lower genitaltract 7. ShaferMA, Schachter J,Moscicki AB, et al. Urine syndrome.In Holmes KK, SparlingF, Mårdh leukocyteesterase screening test for asympto- P-A, et al, eds. SexuallyTransmitted Diseases . matic chlamydialand gonococcal infections in New York: McGraw Hill 1999;761–81 males. J Am Med Assoc 1989;262:2562–6 2. Ledger WJ.Current problemsin thediagnosis and 8. CherneskyM, JangD, Krepel J,Selleor J, treatmentof candida vaginitis. Ital JObstGyn MahonyJ. Impactof reference standardsensitivity 1999;11:25–9 onaccuracy ofrapid antigen detection assays and 3. Mårdh P-A, RodriguesAG, GençM, et al. Facts aleukocyteesterase dipstick for diagnosis of andmyths on recurrent vulvovaginal candidosis– a Chlamydia trachomatis infirst-void urine specimens review onepidemiology, clinical manifestations, from men. J Clin Microbiol 1999;37:2777–8 diagnosis,pathogenesis and therapy. Int J STD 9. AbbasiIA, HessLW, JohnsonTR, McFaddenE, AIDS 2002;13:522–39 ChernowB. Leukocyteesterase activity in the 4. AmselR, TottenPA, SpiegelCA, ChenK, rapiddetection of urinary tract andlow genital HolmesKK. Nonspecificvaginitis: diagnostic tract infection inobstetric patients. AmJPerinatol criteria andmicrobial andepidemiologic associa- 1985;2:311–13 tions. Am J Med 1983;74:14–22 10. HoskinIA, Katz J,Ordorica SA,YoungBK. 5. ZamanZ, BorremansA, VerhaegenJ, VerbiestL, Esteraseactivity insecond and third trimester BlanckaertN. Disappointingdipstick screening amnioticfluid: an indicator ofchorioamnionitis. ofurinary tract infection inhospitalized patients. Am J Obstet Gynecol 1989;161:1543–5 J Clin Pathol 1998;51:471–2 11. PrestonA, O’DonnellT, PhillipsCA. Screening 6. SemeniukH, ChurchD. Evaluationof theleuko- forurinary tract infectionsin a gynaecological cyte esteraseand nitrate dipstickscreening tests setting:validity andcost-effectiveness of reagent fordetection of bacteriuria inwomen with strips. Br J Biomed Sci 1999;56:253–7 suspecteduncomplicated urinary tract infections. 12. KusumiRK, GrowerPJ, KuninCM. Rapiddetec- J Clin Microbiol 1999;37:3051–2 tionof pyuriaby leukocyteesterase activity. J Am Med Assoc 1981;245:1653–5

INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY 25 Leukocyte esterase activity in vaginal fluid Mårdh et al.

13. NovikovaN, Yasseievich E,Mårdh P-A. methodfor the detection of asymptomatic Microscopy ofstained smears of genital secretion chlamydialand gonococcal infection in men. in thediagnosis of recurrent vulvovaginal J Infect Dis 1992;165:573–6 candidosis. Int J STD AIDS 2002;13:318–22 21. DomeikaMA, BasseriM, Mårdh P-A. Non- 14. NovikovaN, Mårdh P-A. Characterization of invasive samplingfor detection of genital infection womenwith a historyof recurrent vulvovaginal with Chlamydia trachomatis inmales utilizing candidosis. Acta Obstet GynecolScand 2000;81: urinaryleukocyte esterase tests and immuno- 1047–52 assays. Infection 1994;22:65–8 15. NovikovaN, RodriguesA, Mårdh P-A. Canthe 22. McNair RD,McDonaldSR, DooleySL, diagnosisof recurrent vulvovaginal candidosis PettersonLR. Evaluationof the centrifuged beimprovedby useof vaginallavage samples and Gram-stainedsmear, urinalysis, and reagent cultures onchromogenic agar? InfDis Obstet striptesting to detect asymptomaticbacteriuria in Gynecol 2002;10:89–92 obstetric patients. Am JObstet Gynecol 2000;182: 16. OddsFC, BernaertsR. CHROMagar Candida,a 1076–9 newdifferential isolationmedium for presumptive 23. Watson-JonesD, MugeyeK, MayaudP, et al. identification ofclinically important Candida Highprevalence oftrichomoniasis in rural men species. J Clin Microbiol 1994;32:1923–9 inMwanza, Tanzania: results from a population- 17. GillenwaterJY. Detection ofurinary leukocytes based study. Sex Trans Dis 2000;76:355–62 by Chemstrip. J Urol 1981;125:383–4 24. RobertsonAW, DuffP. Thenitrate andleukocyte 18. FroomP, Bieganiec B,Ehrenrich Z,Barck M. esterasetests for the evaluation of asymptomatic Stabilityof common analytes in urine refrigerated bacteriuria inobstetric patients. Obstet Gynecol for24 hbeforeautomated analysis by test strips. 1988;71:878–81 Clin Chem 2000;46:1384–6 25. Mårdh P-A. Bacterial vaginosis:a treat torepro- 19. O’Brien SF,Bell TA, Farrow JA.Useofleukocyte ductive health?Historical perspectives, current esterasedipstick to detect Chlamydia trachomatis knowledge,controversies andresearch demands. and Neisseria gonorrhoeae urethritis inasymptomatic Eur JContraception Reprod Health Care 2000;5:1–12 adolescentmale detainees. Am JPublicHealth 26. JacobsJA, DeBrauwer EI, CornelissenEI, Drent 1988;78:1583–4 M.Correlation ofleukocyte esterase detection 20. McNagnySE, ParkerRM, ZenilmanJM, Lewis byreagent strips and the presence of neutrophils: JS.Urinaryleukocyte esterase test: ascreening a study in BAL fluid. Chest 2000;118:1450–4

RECEIVED 03/14/02; A CCEPTED 09/10/02

26 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY M EDIATORSof INFLAMMATION

The Scientific Gastroenterology Journal of Research and Practice Diabetes Research Disease Markers World Journal Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of International Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Submit your manuscripts at http://www.hindawi.com

BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal of Obesity

Evidence-Based Journal of Stem Cells Complementary and Journal of Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Parkinson’s Disease

Computational and Mathematical Methods Behavioural AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014