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Self-Taken Vaginal Swabs Versus Clinician-Taken for Detection of Candida and Bacterial Vaginosis: a Case-Control Study in Primary Care

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Self-Taken Vaginal Swabs Versus Clinician-Taken for Detection of Candida and Bacterial Vaginosis: a Case-Control Study in Primary Care Research Pam Barnes, Rute Vieira, Jayne Harwood and Mayur Chauhan Self-taken vaginal swabs versus clinician-taken for detection of candida and bacterial vaginosis: a case-control study in primary care INTRODUCTION chlamydia, gonorrhoea, and trichomonas, For a female presenting for the first time particularly in females <25 years of age.2 with a change in vaginal discharge, current Non-infective causes of vulval irritation/ guidelines for management in general itching are common (up to half the females practice do not generally advocate high in one study presenting with symptoms 1 vaginal swab (HVS) as a diagnostic tool. suggestive of V VC were shown to have 4 Abstract However, a number of clinical scenarios do another condition). These include atopy, require microbiological confirmation for the eczema, lichen sclerosis, and vulval Background diagnosis of abnormal discharge.2 Bacterial carcinoma. In order to make a definitive Vaginal discharge and vulvitis are common vaginosis (BV) is the commonest cause of diagnosis, clinicians should ideally perform presenting symptoms in general practice. Few studies have specifically looked at the validity of infective vaginal discharge in females of a genital examination that includes the self-taken low vulvovaginal swabs (LVS) for the reproductive age.3 Vulvovaginal candidiasis insertion of a speculum and the collection diagnosis of vulvovaginal candidiasis (VVC) and (VVC) is the second most common and of bacteriological samples for microscopy, bacterial vaginosis (BV). particularly affects females aged 20 to culture, and sensitivity. Aim 30 years.3,4 Symptomatic vulvovaginal In general practice, HVS has a place in To assess if patient self-taken LVS are a valid discharge and vulval irritation are frequent the first-line management of a number alternative to clinician-taken high vaginal swabs and often distressing presenting symptoms of specific clinical scenarios. Box 1 shows (HVS) for the detection of VVC and BV. in females attending both general practice instances where HVS is recommended for Design and setting surgeries5 and sexual health services.4,6 the detection of vaginal flora in females of Case-control study with the patient acting as Classical symptoms of WC are vulval reproductive age with a vaginal discharge.2 In their own control in an urban sexual health centre in Newcastle upon Tyne, UK. itching associated with a thick, white, curdy the management of an uncomplicated first discharge whereas BV typically presents presentation of abnormal vaginal discharge Method as a non-irritant, thin, grey, offensive it is however of debatable use, particularly in Females aged 16–65 years attending with 4,6 2,3 symptomatic vaginal discharge, vulval irritation, discharge. However, vaginal symptoms the diagnosis of BV. The flora typical of BV genital pain, and an offensive genital smell and signs are not a reliable indicator of can be found in up to 40% of asymptomatic were recruited into the study. Participants took underlying aetiology. BV may cause vulval females in the UK6 whereas Candida a self-taken LVS before vaginal examination, irritation7 whereas V VC may present albicans is an asymptomatic commensal in during which a clinician took an HVS (reference 8 4 standard). Main outcome measures were the solely with a change in discharge. Even 10–20% of females. diagnosis of BV or VVC infection. females with previously confirmed episodes In primary care, various constraints such 9 Results of V VC are poor at self-diagnosis and as time pressure and lack of a chaperone, A total of 104 females were enrolled. Of those, as few as 16% of females with recurrent combined with a patient’s reluctance to be 45 were diagnosed with VVC and 26 with BV. symptoms typical of candida have V VC examined, can conspire to make a genital The sensitivities of self-taken LVS for VVC and confirmed on culture.10 Other infective inspection with speculum examination BV were 95.5% and 88.5% respectively. Cohen’s causes of a discharge should always be difficult if not impossible. Clinicians may κ coefficient showed ‘strong agreement’ for the detection of both VVC and BV. Vulval itching was considered and screening is offered for therefore opt to treat vaginal discharge the most common symptom associated with V VC (69%), whereas 50% of females diagnosed with BV presented with an offensive discharge. P Barnes, MBBS, DipGUM, specialty doctor Address for correspondence Both symptoms had poor positive predictive in sexual health; M Chauhan, MD, FRCOG, Pam Barnes, New Croft Centre, Market Street values (0.63 and 0.50, respectively). consultant genitourinary medicine, New Croft East, Newcastle upon Tyne, NE1 6ND, UK. Conclusion Centre for Sexual Health, Newcastle upon Tyne E-mail: [email protected] Self-taken LVS appears to be a valid alternative Hospitals, NHS Foundation Trust, Newcastle upon Submitted: 29 November 2016; Editor’s response: to clinician-taken HVS for detecting VVC and BV Tyne. R Vieira, PhD, medical statistician, Institute 5 January 2017; final acceptance: 29 May 2017. infections. Symptoms were found to be a poor of Health and Society, Faculty of Medical Sciences, ©British Journal of General Practice indicator of underlying infection. Newcastle University, Newcastle upon Tyne. This is the full-length article (published online Keywords J Harwood, BSc, healthcare scientist (serology), 21 Nov 2017) of an abridged version published in bacterial vaginosis; general practice; vaginal Microbiology Department, Freeman Hospital, print. Cite this version as: Br J Gen Pract 2017; examinations; vulvovaginal candidiasis. Newcastle upon Tyne. DOI: https://doi.org/10.3399/bjgp17X693629 1 British Journal of General Practice, Online First 2017 Data collection How this fits in Those enrolled in the trial were seen In general practice a number of constraints by either a doctor or a nurse trained in such as time pressure and lack of a genitourinary medicine (GUM) and were chaperone may limit the suitability of given both verbal and written instructions examination of a female presenting with on how to perform an LVS. They were vaginal discharge. This study aimed to advised to insert the cotton end of the determine the validity of a self-taken swab stick 6 cm into the vagina, rotate it for vaginal swab. The findings confirm that a self-taken low vulvovaginal swab (LVS) is 10 seconds, and then place the swab into a valid alternative to a clinician-taken high Amies transport medium. The females then vaginal swab (HVS) in assisting with the underwent a speculum examination and diagnosis of bacterial vaginosis (BV) and an HVS was collected from the posterior vulvovaginal candidiasis (V VC). fornix by the examining clinician. This was also placed into different Amies transport medium. Symptom data were collated by summarising the presenting complaints and vulval irritation syndromically without into four categories: microbiological evidence of infection.5 In cases where vulval itching is not in fact • vulval irritation/itching; due to candidiasis but is triggered by other pathology such as atopy, atrophic vaginitis, • offensive discharge; or lichen sclerosis, females may experience • genital pain with abnormal discharge; and symptomatic relief from the moisturising • any other changes to the female’s normal action of antifungal creams, particularly if discharge. combined with the anti-inflammatory action Laboratory assessment of hydrocortisone, further muddying the Both self-taken and physician-collected waters with regard to diagnosis. swabs were sent to the microbiology If an HVS is required there is a general laboratory for microscopy and culture for consensus in current guidelines that candida species and organisms causing a blind swab is acceptable.1,2 Two large, BV. For the diagnosis of candida, the HVS well-conducted studies in Leeds in 2012 specimen was cultured on Sabouraud showed that a self-taken low vaginal swab culture medium incubated in air at 35–38ºC (LVS) is in fact superior to a clinician-taken for 48 hours and any growing colonies endocervical swab for the detection of analysed for candida.16 The diagnosis of 11,12 chlamydia and gonorrhoea, and current BV was made by Gram staining the swab guidelines have changed to reflect this with specimens and then using the Hay–Ison regard to sexually transmitted infection (STI) scoring methodology.17 In addition to swabs 13 screening. There is a reasonable body being sent for laboratory diagnosis, all of research to support the use of a self- patients had in-house wet-mount phase taken LVS for detection of abnormal vaginal microscopy for trichomoniasis and gram bacteria but very little on the validity of this staining of specimens looking for evidence 14,15 method for the detection of candida. of candida plus Hay–Ison scoring for BV. The current study was therefore designed Patients with candidiasis were treated with to determine if a patient self-taken LVS is a single dose of oral fluconazole 150 mg; as reliable as clinician-taken HVS in the those with BV were given oral metronidazole diagnosis of both VVC and BV. 400 mg twice daily for 7 days. METHOD Data analysis Study population Data were analysed using VassarStats From May to August 2015, females between online statistical computation version 2017. 16 and 65 years of age who presented to Descriptive analyses were conducted for Box 1. First-line management the New Croft Centre for Sexual Health in all relevant variables and outcomes, using indications for taking a high Newcastle upon Tyne, UK, with symptoms appropriate measures of location (mean vaginal swab in primary care of vaginal discharge, genital irritation, or or median) and dispersion (standard Previous treatment failure. offensive genital smell were recruited deviation or range) for continuous variables. Recurrent (≥4 episodes/year). into the study, after providing informed Categorical variables were summarised Pre- or post-gynaecological surgery. consent. Females already diagnosed with using absolute frequencies and proportions. Pre- or post-termination of pregnancy.
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