TATALAKSANA DIAGNOSIS VAGINITIS

dr. Simon Yosonegoro Liem

PPDS Mikrobiologi Klinik FKUI
(Stase Obgin FKUI-RSCM, April-Mei 2021)

Dosen pembimbing Obgin: Prof. Dr. dr. Dwiana Ocviyanti, Sp.OG (K), MPH
Dosen pembimbing Mikrobiologi: dr. Fera Ibrahim, MSc, PhD, Sp.MK (K)
 VAGINITIS
• Characterized by pruritus, dyspareunia, and • The 3 most common types of vaginitis are bacterial
malodorous discharge. vaginosis (30-50%), trichomoniasis (20-25%), and
candidiasis (15-20%). Other: gonorrhea, chlamydia, etc.
• Vaginal microbiota: diverse, may include:
• lactobacilli (eg, L. crispatus, L. gasseri), • BV by Nugent criteria in a study in Karawang, Indonesia
was 30.7%. (Ocviyanti et al, 2010).
• diphtheroids,
• Candida albicans,
• Gardnerella vaginalis,
• Escherichia coli ,
• mycoplasmas, and
• group B streptococci.
• Physiologic pH ±4 → primarily influenced by lactic
acid produced by L crispatus → inhibiting the
overgrowth of pathologic bacteria.
• Physiologic vaginal fluid → typically white &
odorless.
1. Betty Chou, Jessica L. Bienstock, Andrew J. Satin - The Johns Hopkins Manual of Gynecology and Obstetrics South Asian Edition-Wolters Kluwer India (2020)
2. Mulley AG. Appproach to the patient with a vaginal discharge. In: Primary Care Medicine: Office evaluation and managment of the adult patient, Philadelphia 2000. p.702-7.
3. Koumans, Emilia H., et al. "The prevalence of bacterial vaginosis in the United States, 2001–2004." Sexually transmitted diseases 34.11 (2007): 864-869.
4. Ocviyanti, Dwiana, et al. "Risk factors for bacterial vaginosis among Indonesian women." Medical Journal of Indonesia 19.2 (2010): 130-5.
 GUIDELINE

Amy L. Leber - Clinical Microbiology Procedures Handbook (3 Volume Set)-ASM Press (2016)
 DIAGNOSIS OF BACTERIAL VAGINOSIS:
AMSEL’S CRITERIA VS NUGENT’S SCORING

• Amsel clinical criteria (positif

if ≥3):
1) homogenous thin discharge
coating the vaginal walls,
2) vaginal pH > 4.5,
3) > 20% clue cells on microscopic
examination by light microscopy
at x400,
4) fishy odor before or after the
addition of 10% KOH to the
sample (whiff test).

1. Betty Chou, JL Bienstock, Andrew J. Satin - The Johns Hopkins Manual of Gynecology and Obstetrics South Asian Edition-Wolters Kluwer India (2020)
2. Rao, D. S. R., et al. "Diagnosis of bacterial vaginosis: Amsel’s Criteria vs Nugent’s scoring." Sch J Appl Med Sci 4.6 (2016): 2027-31.
3. Geisler, W. M., et al. "Vaginal leucocyte counts in women with bacterial vaginosis: relation to vaginal and cervical infections." Sexually transmitted infections 80.5 (2004): 401-405.
 DIAGNOSIS OF BACTERIAL VAGINOSIS:
AMSEL’S CRITERIA VS NUGENT’S SCORING

• From 362 patients in reproductive age Amsel (test) VS Nugent (Gold standard):
group with complaints of vaginal discharge:
• Sensitivity = 78.72%
• Specificity = 92.35%
• PPV = 75.51%
• NPV = 93.54%

Amsel’s criteria is as good as Nugent’s

scoring in diagnosis of BV and it is
simple, easy, cost effective, fast and
reliable, and can be done in OPD (out
patient department) which can be
used for precise and fast treatment.

Rao, D. S. R., et al. "Diagnosis of bacterial vaginosis: Amsel’s Criteria vs Nugent’s scoring." Sch J Appl Med Sci 4.6 (2016): 2027-31.
 SPECIMEN COLLECTION: VAGINA
For married (sexually active) ✓Collect fluid from the vagina
patient:
with sterile pipette or Dacron
• Use sterile speculum. swab.
• Collect specimen from posterior
fornix mucosa using sterile swab. ✓Successful self-collection of
• Take 2 specimen and each vaginal swabs can be done.
inoculated into different
transport media → if possible, NOTE: microscopic examination → WBC
one swab for slide → 10 cells (leukocytosis) in vaginal fluid in
microscopic exam. the absence of Trichomonas infection →
If patient is unmarried → don’t use might indicate endocervical
speculum, instead take specimen inflammation due specifically to
form vaginal introitus using sterile Chlamydia trachomatis or Neisseria
swab. gonorrhoeae infection.
Dacron swab
@Rp.2500 – Rp.5500
1. Sudiro TM, Saharman YR, et at. Buku Panduan Penanganan Spesimen untuk Pemeriksaan Mikrobiologi, FKUI, Jakarta (2017)
2. Amy L. Leber - Clinical Microbiology Procedures Handbook (3 Volume Set)-ASM Press (2016)
 SWABS TO SLIDES
(FOR GRAM AND KOH)

Specimens on swabs:
• Roll the swab gently across the slide to
avoid destruction of cellular elements
and disruption of bacterial arrangements.

https://www.researchgate.net/fig
Amy L. Leber - Clinical Microbiology Procedures ure/Preparing-a-bacterial-smear-
Handbook (3 Volume Set)-ASM Press (2016) using-a-swab_fig6_259467300
 IF CAN NOT PERFORM SWABS TO SLIDE
FOR GRAM STAIN→ SPECIMEN TRANSPORT
Transport medium
• Submit swab in Amies transport tube.
• Label specimens.
• Indicate the pathogens sought on
requisition → example: BV (Nugent
Score).
✓Send to lab in < 2 hour (room
temperature, 15-25ºC).
Amies transport medium
✓If delay, store in room temperature
and send in < 24 hour.

• How to store unused Amies

transport media?
• In refrigerator or 5-25 ºC.

Amy L. Leber - Clinical Microbiology Procedures Handbook (3 Volume Set)-ASM Press (2016)
AMIES SWAB
 NUGENT SCORING FOR BV

GOLD STANDARD “TRANSPORT MEDIUM” METHOD

air-dried smear of vaginal secretions,
slides prepared from swabs in transport medium two days
promptly heat- or alcohol-fixed, Gram-
stained after collection

VS

• sensitivity of 90.2% (95% CI 85.3% to 95.1%)

• specificity of 97.2% (95% CI 94.5% to 99.9%).

Eason E, Toye B, Wells GA, Senterman M. Assessment of two alternative sample transport and fixation methods in the
microbiological diagnosis of bacterial vaginosis. Can J Infect Dis. 2003;14(6):322-326. doi:10.1155/2003/312429
 WHEN TO CULTURE?

Vaginal cultures are necessary when the microscopic evaluation

does not provide a clear etiology.
Sparks JM. Vaginitis. J Reprod Med. 1991 Oct;36(10):745-52. PMID: 1956016.
 WHEN TO CULTURE?
• If microscopy (saline wet mount and KOH wet mount) is negative but yeast is
suspected, additional testing by culture or molecular test (NAAT)
for Candida species.
• Bacterial cultures→ rarely indicated in women with vaginal discharge.
• Indication for culture:
• Treatment failure (co-infections or resistant isolates)
• Suspect Sexual Transmitted Infection (STI) → N. gonorrhoeae.
• Any woman with new or multiple sexual partners, a symptomatic sexual partner, or
an otherwise unexplained cervical or vaginal discharge that contains a high
number of PMNs → should be tested for N. gonorrhoeae by culture or an
alternative sensitive test (example: PCR).
• NOTE: For N. gonorrhoeae → Endocervical swab is better than vaginal swab.

1. Muthusamy, Swapna, and Selvi Elangovan. "Comparison of Amsel’s Criteria, Nugent Score and Culture for the Diagnosis of Bacterial
Vaginosis." National Journal of Laboratory Medicine 5.1 (2016): 37-40.
2. https://www.uptodate.com/contents/approach-to-females-with-symptoms-of-vaginitis#H6
 FOR N. gonorrhoeae CULTURE

→
OR

Amies charcoal Transport media → Thayer Martin or Chocolate Agar → bedside

send in room temperature (15-25C) streak → send in candle jar in room
in 6 hour, better in < 2 hour. temperature (15-25C) in 2 hour.
Amy L. Leber - Clinical Microbiology Procedures Handbook (3 Volume Set)-ASM Press (2016)
 • Difference → not statistically significant (p-value
> 0.05).
• Amsel’s criteria can be used in resource poor
settings, with care to rule out false positives.
• Nugent score is specific but needs microbiology
expertise and culture has its role in treatment failure
cases.
Muthusamy, Swapna, and Selvi Elangovan. "Comparison of Amsel’s Criteria, Nugent Score and Culture for the Diagnosis of Bacterial
Vaginosis." National Journal of Laboratory Medicine 5.1 (2016): 37-40.
 MEDIUM TRANSPORT LAB PK RSCM

• Cotton-tipped swabs contain

unsaturated fatty acids →may
inhibit N. gonorrhoeae.
• Calcium alginate swabs should not
be used due to their toxicity.
• Dacron (polyethylene terephthalate)
or rayon (viscose)-tipped swabs are
preferred for culture-based isolation
of GC.

Price:
@ Rp. 5000. Amy L. Leber - Clinical Microbiology Procedures
Handbook (3 Volume Set)-ASM Press (2016)
 MICROSCOPIC EXAMINATION
OF VAGINAL SAMPLES
A. Normal saline wetmount showing a
clump of 3 normal vaginal epithelial
cells (original magnification X 600).
B. Normal saline wet mount showing 2
clue cells (X 400). Inset, Gram stain
demonstrating how coccobaccilli on the
surface of vaginal epithelial cells create
the characteristic granular appearance
and indistinct borders of clue cells (X
1000).
C. Normal saline wet mount showing
numerous Candida hyphae and buds (X
400).
D. Normal saline wet mount showing 4
trichomonads. Trichomonads can often
be identified easily because of their
characteristic jerky motility (X 600).

Anderson, Matthew R. (2004). Evaluation of Vaginal Complaints. JAMA, 291(11), 1368

KOH (JAMUR)
Pseudohifa
 KOH (JAMUR)

Yeast (400X)
Yeast (400X)
 GRAM
Bacterial Vaginosis intermediate Yeast/Ragi

1000x 1000x
BIAYA PEMERIKSAAN MIKROSKOPIK
SK TGL 8 FEB 2021
 PROM (PREMATURE RUPTURE OF
MEMBRANE)
AND NEONATAL SEPSIS

• In PROM → risk of neonatal sepsis is

higher in longer duration of prolonged
rupture of membrane as well as preterm
pregnancy.
• Neonatal sepsis
• gestational age of ≥ 37 weeks (0.5%)
• gestational age of < 37 weeks (9.1%).
• New Question: Do we need to perform
vaginal swab for culture in pregnant
women with PROM?

Ocviyanti D, Wahono WT. Risk factors for neonatal sepsis in pregnant women with premature rupture of the membrane.
Journal of pregnancy. 2018 Oct 1;2018.
 VAGINAL INFECTIONS AND ITS
RELATION TO PRETERM LABOUR,
PPROM, PROM AND ITS OUTCOME

• In resource limited settings (microbiological

evaluation of amniotic fluid is not feasible) →
identification of bacteria in high vaginal swab →
can guide antibiotic therapy in women with
PPROM (Preterm PROM).
• Previous studies have shown good correlation
between genital tract flora and organism
grown in amniotic fluid or blood of neonates
with early onset sepsis.
• Antibiotic therapy in PPROM → associated with
significant reduction in incidence of
chorioamnionitis and improved neonatal
outcomes.

Shivaraju, Pradeep, et al. "Vaginal infections and its relation to preterm labour, PPROM, PROM and its outcome." International Journal of Reproductive
Contraception, Obstetrics and Gynecology 4.5 (2015): 1422-6.
 VAGINAL SWAB IN PROM
(PREMATURE RUPTURE OF MEMBRANE)
= KPD (KETUBAN PECAH DINI)

• Jadi apakah diperlukan kultur swab vagina pada KPD?

• Pada kondisi risiko infeksi yang meningkat: KPD prematur
(Preterm PROM) dan KPD memanjang (Prolonged PROM) ≥ 18
jam → dapat dipertimbangkan (dapat menjadi data pendukung bila
terdapat sepsis neonatus, dan untuk data penelitian).
• Adanya data tentang patogen dan pola kepekaan dari swab vagina
wanita hamil dengan KPD ini→ di tingkat RS, regional maupun
nasional → untuk memandu pemilihan antibiotik terutama pada
KPD prematur (Preterm PROM) dan KPD memanjang (Prolonged
PROM).
 BIAYA DI LMK FKUI
PER SK TGL 8 FEB 2021
Pemeriksaan Kultur/Biakan, Identifikasi dan Uji Resistensi (AST) → @ Rp. 550.000

Pemeriksaan Molekular → @ Rp. 700.000

TERIMA KASIH