ISSN: 2581-7566 Volume 1: 2 J Appl Microb Res 2018 Journal of Applied Microbiological Research Diagnosing Bacterial Vaginosis with a Novel, Clinically-Actionable Molecular Diagnostic Tool Joseph P Jarvis1 Doug Rains2 1Coriell Life Sciences, Pennsylvania, USA Steven J Kradel1 2Quantigen Genomics, Indiana, USA James Elliott2 3ThermoFisher Scientific, USA Evan E Diamond3 4Primex Clinical Laboratories, California, USA Erik Avaniss-Aghajani4 5Maternity & Infertility Institute, California, USA Farid Yasharpour5 Jeffrey A Shaman1* Abstract Article Information Bacterial vaginosis is a common condition among women of Article Type: Research reproductive age and is associated with potentially serious side-effects, Article Number: JAMBR109 including an increased risk of preterm birth. Recent advancements in Received Date: 15 June, 2018 microbiome sequencing technologies have produced novel insights Accepted Date: 11 July, 2018 into the complicated mechanisms underlying bacterial vaginosis and Published Date: 18 July, 2018 have given rise to new methods of diagnosis. Here we report on the validation of a quantitative, molecular diagnostic algorithm based on *Corresponding author: Dr. Jeffrey A Shaman, Coriell the relative abundances of ten potentially pathogenic bacteria and four Life Sciences, Philadelphia, Pennsylvania, USA. Tel: + 609 357 0578; Email: jshaman(at)coriell.com as symptomatic (n=149) or asymptomatic (n=23). We observe a clear #These Authors are Joint First Authors on this Work. commensal Lactobacillus species in research subjects (n=172) classified and reinforcing pattern among patients diagnosed by the algorithm that Citation: Jarvis JP, Rains D, Kradel SJ, Elliott J, Diamond is consistent with the current understanding of biological dynamics EE, Avaniss-Aghajani E, Yasharpour F, Shaman JA (2018) and dysregulation of the vaginal microbiome during infection. Using Diagnosing Bacterial Vaginosis with a Novel, Clinically- this enhanced assessment of the underlying biology of infection, we Actionable Molecular Diagnostic Tool. J Appl Microb Res Vol: 1, Issu: 2 (01-08). (90%) relative to current diagnostic tools. Our algorithm also appears Copyright: © 2018 Jarvis JP, et al. This is an open-access todemonstrate provide enhanced improved diagnostic diagnostic capabilities sensitivity in (93%)ambiguous and specificityclasses of article distributed under the terms of the Creative Commons patients for whom diagnosis and medical decision-making is complicated, Attribution License, which permits unrestricted use, including asymptomatic patients and those deemed “intermediate” distribution, and reproduction in any medium, provided the by Nugent scoring. Ultimately, we establish CLS2.0q as a quantitative, original author and source are credited. diagnosis of bacterial vaginosis-importantly, one that is also ideal for thesensitive, differential specific, diagnosis accurate, of robust, non-BV and infections flexible algorithm with clinically for the clinicalsimilar presentations. Keywords: Bacterial vaginosis, Molecular diagnostic tool, Microbiome. Introduction Bacterial vaginosis (BV) is widely considered to be the most common vaginal disorder among women of reproductive age [1]. In a sample of self-collected vaginal swabs from 3,700 women, the prevalence of BV was estimated at 29% in the general population of women aged 14-49 years and 50% in African-American women [2]. Typically, affected patients itching, and pain. That said, clinical presentation can vary considerably, withpresent asymptomatic with inflammation infections of beingthe vagina noted that with can great result regularity in discharge, [2]. A aswide well variety as race of and risk ethnicity factors [2]. for Important BV have been complications noted, including of BV infection sexual activity [3,4], the presence of other sexually transmitted infections [5], www. innovationinfo. org include an increased risk of preterm delivery in pregnant variable morphology or lacking a cell wall, are regularly women [6] and of HIV acquisition and transmission [7]. In some women, clearance of the infection, even with standard • misidentifiedSome 20% of orsymptomatic overlooked subjects [9]; score between 4 and 6, rendering their status “intermediate”—an ambiguous recurrent symptoms [8]. of care, is difficult to achieve, often resulting in chronic or diagnosis that is not helpful for the healthcare provider Improved strategies for detecting BV infection have been [15] and may lead to inappropriate clinical intervention, the subject of much discussion, due to the reduction in the or, conversely, to no intervention when it is actually quality of life that can result from an active infection and needed. the reasonably high prevalence of BV in women [9]. Recent advances in technology have driven interest in DNA-based, known to be associated with disease, the second of these quantitative, diagnostic algorithms that are theoretically shortcomingsGiven the complexitymay account of formicrobiome Nugent’s reportedlyalterations poornow quicker to perform than culture, more accurate in their results, and are potential candidates as point-of-care devices. has also been shown to occasionally miss differential diagnosessensitivity suchand as specificity Trichomonas [14]. vaginalis Finally, infections Nugent [16] scoring with of BV infection, along with important limitations in “gold- potentially problematic effects on patient well-being due to standard”However, approaches,the seemingly have complex complicated biology these and efforts. dynamics inappropriate therapy. One confounding factor is the consistent observation An older and more commonly used diagnostic tool is that BV is associated not with a single causative pathogen, but rather with a broad disruptive shift in the microbial in 1983, requires the satisfaction of at least three of four population: from a healthy Lactobacilli-dominated criteriathe application to qualify of Amsel’sfor a BV criteria. diagnosis: This elevatedtest, first pH described (>4.5), environment to one largely overtaken by organisms such as Gardnerella, various mycoplasma, and a heterogeneous 10% KOH to a slide prep, and the microscopic visualization collection of facultative anaerobes [10]. With this shift come ofcharacteristic “clue cells” (smallerdischarge, bacteria fishy odoradhering upon to theepithelial addition cells) of changes in the underlying interactions among different in a wet mount [17]. However, while easy to implement in organisms, changes in the metabolites produced by the local theory, Amsel’s criteria are reportedly underutilized in bacterial community, and changes to the host’s immune clinical settings [18] and are technically limited by the lack response. Together, these factors produce key signs and of consideration of the abundance of healthy Lactobacillus symptoms of infection. This dynamic mechanism of disease species [19]. manifestation results in a condition with all the standard These and other acknowledged failings of the gold- clinically in numerous ways, and individual symptoms can standard diagnostic techniques for BV have recently fueled behallmarks the result of a ofcomplex multiple etiology. systematic For example,shifts in BVthe presents vaginal a search for alternatives leveraging new technology. Today, microbiome in favor of a variety of pathogenic organisms. there are a variety of alternatives in the marketplace that as well as reduced cost. Relatively few of these can be used Sometimes women experience no clinical symptoms; in fact, a claim ease of testing, enhanced sensitivity and specificity, ofsignificant pregnancy, percentage where it of has affected been patients shown thatare asymptomatic BV infection, tests require sending a sample–often in the form of a vaginal whether[11,12]. This symptomatic statistic is particularlyor not, is associated important within the preterm context at the point-of care (PoC) [20,21]; rather, most available birth [6]. as a PoC diagnostic, at 1 to 2 days for a result after sample transportswab–to a andlaboratory testing, forversus testing. minutes Though to nothours as expedientfor a PoC In addition, the vaginal microbiota has recently been offers several key advantages. Most notably, some clinical that is, changes are seen to occur in near-real time over days result, the referencing of samples to an external laboratory shown to be longitudinally dynamic in healthy individuals; laboratories can simultaneously screen samples for a broad range of microbial targets covering multiple conditions, not on the maintenance of bacterial community homeostasis, merely BV. The ability to offer a differential diagnosis is a onand the weeks resolution [13]. The of symptomsimpact of post-infection,microbial population and on fluxthe key advantage for symptomatic patients, since infections repression of symptoms in asymptomatic women is not well other than BV can present with very similar signs and understood. Nevertheless, an oft-changing microbiota poses presence/absence or semi-quantitative information, while testing depends on samples taken at a singular point in time. symptoms. Many labs can also generate bacteria-specific difficulties for accurate diagnosis, since efficient molecular microorganisms. Such data offer the potential for healthcare presentation, it is unsurprising that diagnosis of BV infections providers,also detecting who difficult-to-culture, are often faced with anaerobic, interpreting and commensalambiguous hasGiven historically the complexity been a challenge. of the dynamics While