Abstract
Summary
The purpose of this case-note review was to examine the clinical features and management of women with either vulval or vaginal swabs culturing positive for streptococci. Group B haemolytic streptococcus was isolated in all cases. The majority of women with vulval streptococci presented with irritation or soreness. Candidal infection was found in 43% and a dermatosis in 27%. All women with positive vaginal culture had vaginal soreness and/or discharge. Candida was isolated in 27% and there were features of desquamative vaginitis in 20%. Women treated with erythromycin failed to improve symptomatically. The findings of this study suggest that streptococci mostly play a secondary role and colonize an already damaged genital epithelium.
Keywords
INTRODUCTION
Genital disease caused by streptococcal infection is well recognized but uncommon. Group A streptococcus (Streptococcus pyogenes) is a cause of cellulitis, necrotizing fasciitis, erysipelas and impetigo and has also been reported to cause a balano-posthitis in prepubertal and adult men. 1 –3 An association between group A streptococcal infection and vulvo-vaginitis in adult women has also been reported. 4,5
Group B streptococcus is considered non-pathogenic in the vagina, 6,7 although one non-controlled study reported an association with vaginal symptoms. 8 The organism has the well-reported potential to cause neonatal morbidity and mortality as a result of vaginal carriage during labour. Group B streptococcus has also been reported to cause balano-posthitis in men. 9
The objective of this retrospective study was to review the clinical presentation, clinical features and management of women with streptococci isolated from vulval or vaginal genital swabs.
METHODS
This was a retrospective case-note review from December 2011 of 100 female patients attending the Department of GU Medicine and Sexual Health at Addenbrooke's Hospital, Cambridge, UK and who were found to be streptococcus positive on vulval or vaginal swab culture. Patients had been seen by doctors trained or training in GU medicine and swabs taken if considered clinically appropriate by the practitioner. All patients were reviewed 2–4 weeks after initial presentation and examination performed only if symptoms persisted or an abnormality had been detected at the initial consultation. The duration of follow-up was variable and dependent upon response to treatment.
RESULTS
Following clinical-note review, patients were categorized into two groups according to the site from where swabs were taken. One group of 70 women had streptococci isolated from a vulval swab (mean age 32 years; median 29 years; range 19–62 years) and a separate second group of 30 women were streptococcus positive on vaginal swab culture (mean age 34 years; median 29 years; range 18–61 years). Swabs were taken because of symptoms or clinical findings at the time of examination. Group B haemolytic streptococcus was isolated in all cases.
Vulval swab positive group
Considering the 70 women positive for streptococci on vulval swab culture, 65 (93%) presented with symptoms of vulval irritation or soreness, 10 (14%) of whom also had vaginal soreness. Examination revealed vulval fissuring in 49 (70%). Candida species were isolated from 30 (43%) women and herpes simplex virus detected in eight (11%), two of these in conjunction with candida.
Microscopy of a Gram-stained vaginal smear showed a lactobacillus morphotype predominance in 53 (76%), bacterial vaginosis in five (7%) and the presence of cocci-form bacteria in 10 (14%), of which six (9%) also showed lactobacilli morphotypes and one (1%) with basal cells but no other bacterial types. Eight (27%) patients were thought to have a vulval dermatosis (four dermatitis, three lichen simplex and one lichen sclerosus) and symptomatically improved with the use of topical steroids. Diagnosis was made on clinical appearance with no patient proceeding to vulval biopsy.
Of the 30 women found to have candida on culture, 27 improved with oral or topical antifungals. Two women had Candida glabrata infection and improved partially to itraconazole and one woman was also considered to have dermatitis that responded to a steroid/antifungal cream. Ten women received erythromycin, of whom four improved after treatment; however one of these responders also received an oral antifungal and two had been prescribed a topical steroid/antibiotic cream. Erythromycin was used in preference to penicillin as this is available within the department.
Vaginal swab positive group
Considering the 30 women positive for streptococci on vaginal swab culture, all presented with vaginal soreness and/or discharge, of whom nine (30%) also had vulval irritation and 14 (47%) evidence of vaginitis on examination. Eight women (27%) were positive for Candida on culture.
Microscopy of a Gram-stained vaginal smear showed a lactobacillus morphotype predominance in 11 (37%) and bacterial vaginosis in two (7%). Cocci-form bacteria were seen in 11 (37%), of which three (10%) also showed lactobacilli morphotypes, two (7%) lactobacillus morphotypes and basal cells, and four (13%) with basal cells but no other bacterial types. Six (20%) women were treated with intravaginal clindamycin cream for desquamative or macular vaginitis, of whom five improved. One woman symptomatically improved following treatment for atrophic vaginitis with topical oestrogen. Five women received erythromycin, to which the organism was sensitive, all without clinical benefit. There was symptomatic improvement of women found to be candida culture positive and treated with antifungals.
DISCUSSION
Although Group A streptococcal infection has been reported to cause vulvo-vaginitis in adult women, 4,5 no cases were reported in this study. Group B streptococcus is generally considered to be non-pathogenic in the vagina. 6,7 The findings of this retrospective case-note study support this view. Of the 30 women positive for streptococci on vaginal swab culture, five were treated with erythromycin, to which the organism was sensitive, without clinical benefit. Just over one-quarter of these women were candida culture positive and responded to antifungals, again suggesting a non-pathogenic role of the co-existent streptococci. Desquamative vaginitis was diagnosed in 20% of women, based on the findings of a vaginitis, in some cases macular, in addition to the presence of cocci-form bacteria with or without basal cells on vaginal smear Gram stain. 10 –12 Sobel 12 found Group B streptococci and other streptococcal species in 44% and 29%, respectively, in a group of 34 women with desquamative vaginitis. Although there was an excellent response to intravaginal clindamycin, the author considered streptococci to have a secondary colonizing role. In a more recent review of 98 patients with desquamative vaginitis, an abnormal vaginal bacterial flora was noted in 97% but the presence, and relevance, of streptococci was not determined. 13 As clindamycin is recognized as an appropriate first line treatment, other antistreptococcal agents, such as penicillin or erythromycin were not used in Sobel et al.'s study nor in the current study. It has been suggested that clindamycin may be successful in this condition because of an anti-inflammatory rather than antibacterial action; however further study, possibly multicentre in view of the numbers required, directly comparing clindamycin with an alternative antistreptococcal antibiotic is warranted.
Just under a half of women with streptococci isolated on vulval swab culture also cultured positive for candida species. Considering this group of 30 women, all except one had symptoms of vulval irritation and 80% had evidence of vulval fissuring, clinical features in keeping with candidiasis. Symptoms improved with antifungal medication suggesting a non-pathogenic role for streptococci. Of the 10 women receiving treatment with erythromycin, four reported symptomatic improvement, however, one also had candida isolated and received an antifungal and two were treated with a topical steroid/antibacterial cream for a dermatosis. These findings on a small number of women make it difficult to determine the clinical significance of the presence of streptococci.
As this study included only symptomatic women or those with abnormal clinical findings, the prevalence of asymptomatic streptococcal carriage was not determined. A further disadvantage of this study was the lack of a comparison control group of patients.
In conclusion, the current study of women presenting with vulval irritation, vulval or vaginal soreness, vulval fissuring, vaginal discharge or vaginal erythema suggests that streptococci play a secondary role and probably colonize an already damaged epithelium, for example from candidal infection or a dermatosis.