401 Sex Transm Infect: first published as 10.1136/sti.2003.009134 on 30 September 2004. Downloaded from DIAGNOSTICS Vaginal leucocyte counts in women with bacterial vaginosis: relation to vaginal and cervical infections W M Geisler, S Yu, M Venglarik, J R Schwebke ............................................................................................................................... Sex Transm Infect 2004;80:401–405. doi: 10.1136/sti.2003.009134 Objectives: To evaluate whether an elevated vaginal leucocyte count in women with bacterial vaginosis (BV) predicts the presence of vaginal or cervical infections, and to assess the relation of vaginal WBC See end of article for counts to clinical manifestations. authors’ affiliations Methods: We retrospectively analysed the relation of vaginal leucocyte counts to vaginal and cervical ....................... infections and to clinical manifestations in non-pregnant women diagnosed with BV at an STD clinic visit. Correspondence to: Results: Of 296 women with BV studied, the median age was 24 years and 81% were African-American. William M Geisler, UAB Elevated vaginal leucocyte counts were associated with objective signs of vaginitis and cervicitis and also STD Program, 703 19th St predicted candidiasis (OR 7.9, 95% CI 2.2 to 28.9), chlamydia (OR 3.1, 95% CI 1.4 to 6.7), gonorrhoea South, 242 Zeigler (OR 2.7, 95% CI 1.3 to 5.4), or trichomoniasis (OR 3.4, 95% CI 1.6 to 7.3). In general, as a screening test Research Building, Birmingham, AL 35294– for vaginal or cervical infections, vaginal leucocyte count had moderate sensitivities and specificities, low 0007, USA; wgeisler@ positive predictive values, and high negative predictive values. uab.edu Conclusions: An elevated vaginal leucocyte count in women with BV was a strong predictor of vaginal or Accepted for publication cervical infections. Vaginal leucocyte quantification may provide an alternative approach to assessing 10 March 2004 need for empirical therapy for chlamydia and gonorrhoea, particularly in resource-limited high STD risk ....................... settings that provide syndromic management. acterial vaginosis (BV) is a common disorder of the means to further test for these pathogens. Addressing genital tract in women characterised by an alteration of limitations of previous related studies, we evaluated whether Ba normal acidic lactobacilli predominant vaginal ecosys- an elevated vaginal WBC count in women with BV diagnosed tem to a vaginal environment dominated by organisms such at a routine first time STD clinic visit predicted the presence as Gardnerella vaginalis, Mycoplasma sp, and anaerobes, with an of vulvovaginal candidiasis (VVC) or STDs, and we explore accompanying increase in pH. BV has been associated with the relation of vaginal WBC counts to clinical manifestations upper genital tract infection,1 and has been reported to be a of such diseases. Further, we assess how the finding of strong predictor of chlamydial and gonococcal cervicitis.2 mucopurulent cervical discharge compares to vaginal WBC While diagnosis of BV is based on reliable established count in predicting chlamydial and gonococcal infections. criteria,3 diagnosis of cervical infection is more problematic http://sti.bmj.com/ and the significant medical and economic implications of METHODS untreated chlamydial or gonococcal infection influence Study population and data collection empirical approaches to these disorders. Through a computerised databank, we identified all women Although BV has traditionally been considered a non- who were seen by a single, experienced provider for a routine inflammatory syndrome without an association with first time visit from 1998 through 2002 at the Jefferson 4 increased vaginal leucorrhoea, several studies have demon- County Department of Public Health (JCDH)-STD Clinic and strated the presence of vaginal leucocytes (white blood cells, who were diagnosed with BV at that visit. BV affects a on September 29, 2021 by guest. Protected copyright. 4–8 WBCs) in women with bacterial vaginosis. Recent studies significant proportion of women presenting to the JCDH-STD have reported an association of BV with elevated inflamma- Clinic. A routine visit consisted of data collection and 8–10 tory cytokines. Some studies have reported an association laboratory testing for either screening for STDs or evaluation of vaginal WBCs in women who have BV with concomitant of a specific complaint. Individuals presenting for treatment chlamydial or gonococcal cervicitis56or histological endome- of a laboratory confirmed STD, those pregnant, women with tritis,7 though possible limitations in some of these studies a previous hysterectomy, and those with missing data relative may have influenced the validity of the findings. Such to vaginal WBC counts or the diagnoses of BV, VVC, or limitations include small sample size, provider inexperience, concomitant STDs were excluded. having multiple providers, use of a vaginal WBC count Demographic, clinical, and laboratory data (relevant to definition with lower sensitivity, and not addressing con- vaginal WBC counts and clinical disease) on study subjects comitant vaginal infections. There is also a paucity of studies were retrospectively collected from the JCDH-STD Clinic characterising the relation of vaginal WBC counts to clinical computerised database. Laboratory data routinely collected manifestations of vaginal and cervical infections. included vaginal WBC counts and results of evaluation for An improved understanding of the relation of vaginal WBC BV, chlamydia, gonorrhoea, trichomoniasis, and VVC. counts to vaginal and cervical infections, along with Vaginal WBCs were previously quantified after visualisation associated clinical manifestations of these diseases, would of a minimum of five fields (range 5–15 based on whether be important in the assessment of risk for sexually there was a paucity of WBCs present) under light microscopy transmitted diseases (STDs) and need for empirical therapy, at 6400. Vaginal WBC counts were routinely categorised into particularly for chlamydia and gonorrhoea, in a resource limited setting with a high prevalence of STDs that may Abbreviations: BV, bacterial vaginosis; OCP, oral contraceptive pill; practise syndromic management because of insufficient VVC, vulvovaginal candidiasis; WBCs, white blood cells www.stijournal.com 402 Geisler, Yu, Venglarik, et al Sex Transm Infect: first published as 10.1136/sti.2003.009134 on 30 September 2004. Downloaded from either (5 WBCs per 6400 in all visualised fields (represent- contraceptive pill (OCP) use, VVC, gonorrhoea, chlamydia, ing minimal or no inflammation) or .5 WBCs per 6400 in at trichomoniasis, and genital herpes. Age and OCP use were least one field visualised (considered elevated and more included in the multivariate model a priori as they were suggestive of significant inflammation). During the study considered to be potential confounders; age data were period, the diagnosis of BV was routinely made based on the transformed into the natural log. The sensitivity, specificity, criteria of Amsel et al3 and required the presence of three of and predictive values of vaginal WBC count for the diagnosis the following findings: (1) vaginal pH.4.5; (2) visualisation of VVC or an STD were calculated by using 262 tables. To of clue cells by light microscopy at 6400; (3) a positive whiff assess correlation between vaginal WBC count and the test on application of 10% potassium hydroxide to vaginal finding of mucopurulent cervical discharge, a correlation fluid; or (4) homogeneous vaginal discharge. Chlamydia coefficient was determined. The relation of either mucopuru- trachomatis was detected by culture of an endocervical swab lent cervical discharge alone or combined with vaginal WBC specimen using DEAE pretreated McCoy cells on 96 well count to cervical chlamydia and gonorrhoea was assessed microtitre plates and identification of chlamydial inclusions through multivariate analysis controlled for co-variates as as previously described.11 Neisseria gonorrhoeae was detected by described above. culture of an endocervical swab specimen on modified Thayer-Martin medium using a standard method12 or by Gonostat (Sierra Diagnostics, Inc, Sonora, CA, USA). RESULTS Trichomoniasis was detected in most women by visualisation Characteristics of subjects and relation to vaginal of trichomonads on a vaginal wet preparation by light leucocyte count microscopy at 6400. Some women, who were being screened From 1998 through 2002, 296 women seen for a routine first for future enrolment in other research studies, also had time visit at the JCDH-STD Clinic were diagnosed with BV additional testing by culture for Trichomonas vaginalis in and were eligible for study. The median age was 24 years modified Diamond’s media as previously described13; pro- (range 14–61). Eighty one per cent of women were African- portion of individuals receiving culture did not differ by American and 19% were of other racial/ethnic backgrounds vaginal WBC count category. VVC was diagnosed based on (predominately white). Sixteen per cent of women used OCPs the presence of vaginal discharge on examination and for contraception. The most frequent symptom reported was visualisation of budding yeast or pseudohyphae on a vaginal discharge (46%), with vaginal odour (28%), genital vaginal wet preparation by light microscopy at 6400. The itching (15%), lower abdominal pain (13%), and dysuria diagnosis of genital herpes was based on characteristic (7%) being