The antimicrobial treatment of subacute endometritis: a proof of concept study.

OBJECTIVE: Our purpose was to evaluate the antimicrobial therapy effect on clinical and laboratory findings among women at risk for endometritis. STUDY DESIGN: A prospective antimicrobial treatment trial of 153 women was performed to characterize subacute endometritis and to determine the treatment effect on endometritis resolution. RESULTS: After antimicrobial treatment, significant reductions occurred in abnormal bleeding (60% vs 29%), mucopurulent cervicitis (20% vs 6%), uterine tenderness (20% vs 6%), and histologic endometritis (38% vs 4%), all P<.001. In women with prior pelvic inflammatory disease (PID), endometritis was present in 43% with and 28% without current Chlamydia trachomatis or Neisseria gonorrhoeae. In women without prior PID, endometritis was present in 23% with and 12% without current C trachomatis or N gonorrhoeae (P=.002 for trend). CONCLUSIONS: In women without a clinical diagnosis of PID, antimicrobial therapy decreased abnormal clinical findings and histologic endometritis. Prior PID is additive with current cervical infection as a risk for endometritis.

Histologic endometritis in asymptomatic human immunodeficiency virus-infected women: characterization and effect of antimicrobial therapy.

OBJECTIVE: To estimate the prevalence, risk factors, clinical symptoms and signs, and response to antimicrobial therapy of histologic endometritis in human immunodeficiency virus (HIV)-infected women without clinical salpingitis. METHODS: This was a cross-sectional study of 42 HIV-infected women enrolled from a single clinic. Subjects underwent standardized history, examination, and laboratory determinations, including endometrial biopsy. Women with suspected pelvic inflammatory disease were excluded. All women were given antibiotics and repeat evaluation in 5-7 weeks. Histologic endometritis was defined by at least one stromal plasma cell per 120x field and five or more surface polymorphonuclear leukocytes per 400x field. Chi-square and Fisher exact tests were used as appropriate. RESULTS: Histologic endometritis was present among 16 (38%) of 42 evaluable HIV-infected women, none of whom had Chlamydia trachomatis or Neisseria gonorrhoeae. Douching three or more times per month, history of ectopic pregnancy, and two or more prior urinary tract infections were associated with endometritis, as was elevated erythrocyte sedimentation rate (P < or = .05). Physical examination findings and mean CD4+ lymphocyte count were similar among those with and without endometritis. In the nine HIV-infected women with a repeat biopsy, endometritis decreased from four (44%) to two (22%) after treatment (P = .30). CONCLUSION: The prevalence of histologic endometritis in HIV-infected women was high despite few examination findings and no demonstrated pathogens. Endometritis in HIV-infected women might be related to pathogens not evaluated, to prior infection, or to reduced immunity from HIV.

Comparison of clindamycin phosphate vaginal cream with triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.

BACKGROUND: Triple sulfonamide vaginal cream has been used to treat bacterial vaginosis for many years. There are few studies in which triple sulfonamide cream has been compared with newer regimens. GOAL: To compare the efficacy and safety of clindamycin phosphate vaginal cream with that of triple sulfonamide vaginal cream in the treatment of bacterial vaginosis. STUDY DESIGN: In this double-blind, randomized multicenter study, nonpregnant women 16 years of age or older with symptomatic bacterial vaginosis were assigned to receive either 2% clindamycin phosphate vaginal cream or triple sulfonamide vaginal cream for 7 days. Follow-up visits were conducted 5 to 10 days and 25 to 39 days after completion of treatment. RESULTS: Clinical cure or improvement at 25 to 39 days was noted in 55 (69.6%) of 79 assessable participants who received clindamycin vaginal cream and in 33 (41.8%) of 79 women who received triple sulfonamide vaginal cream (P < 0.0001). Most of the difference between the treatment groups was noted in women with a history of bacterial vaginosis. Among women without a history of bacterial vaginosis, clindamycin and triple sulfonamide creams had similar efficacy. Evaluation of Gram-stained vaginal smears correlated with clinical outcome. Most patients in both treatment groups reported an improvement in symptoms. No significant difference was observed between the treatment groups in the incidence of adverse events. CONCLUSION: Clindamycin 2% vaginal cream is more effective than triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.

Increased tumor necrosis factor-alpha production after lipopolysaccharide stimulation of whole blood in patients with previous preterm delivery complicated by intra-amniotic infection or inflammation.

OBJECTIVE: To compare cytokine production after lipopolysaccharide stimulation of whole blood from women who were delivered of infants at term compared with women who were delivered of preterm infants with intra-amniotic evidence of infection or inflammation. STUDY DESIGN: Whole blood samples from 12 women who were not pregnant and who had previously had preterm deliveries before 32 weeks complicated by intra-amniotic infection or inflammation and samples from 12 age- and race-matched control subjects were stimulated with Escherichia coli lipopolysaccharide. Tumor necrosis factor-alpha and interleukin-6 levels were quantified at 6 hours and interleukin-10 at 24 hours by enzyme immunoassay. Results were compared with use of the Wilcoxon rank sum test. RESULTS: Tumor necrosis factor-alpha production was significantly higher in whole blood from women with histories of a preterm birth and intra-amniotic infection or inflammation (11,243 +/- 1030 pg/mL [mean +/- SEM]) compared with control subjects (3649 +/- 349 pg/mL) at a lipopolysaccharide concentration of 1 microg/mL (P =.002). There were no significant differences in interleukin-6 or interleukin-10 production. CONCLUSION: Women with previous early preterm deliveries who had evidence of intra-amniotic infection or inflammation had significantly higher tumor necrosis factor-alpha production after lipopolysaccharide stimulation of whole blood compared with women with previous term deliveries.

Effects of vaginal intercourse with and without a condom on vaginal flora and vaginal epithelium.

Effects of a single episode of intercourse on vaginal flora and epithelium were examined in subjects randomly assigned to groups that used no condom or lubricated nonspermicide condoms. Subjects were evaluated at visits before (1 month and 1-2 days) and after (8-12 h, 2-3 days, and 6-8 days) an index episode of sexual intercourse. The 22 subjects who used no condoms had significantly more Escherichia coli and a high concentration (> or =10(5) cfu/mL) of E. coli in the vagina (both, P<.001) and urine (all <10(5) cfu/mL; P=.004) at visit 3 than at visits 1 and 2. The 20 subjects who used condoms had a trend toward more vaginal E. coli (P=.06) and a significant increase in other enteric gram-negative rods (P=.001) after intercourse. Intercourse was not associated with gross, colposcopic, or histologic vaginal epithelial abnormalities.

Vaginal indicators of amniotic fluid infection in preterm labor.

OBJECTIVE: To determine whether vaginal interleukin-6, interleukin-8, neutrophils, bacterial vaginosis, and selected vaginal bacteria are predictors of amniotic fluid (AF) infection among women in preterm labor. METHODS: One hundred ninety-seven afebrile women in preterm labor with intact membranes had vaginal and AF samples collected for Gram stain, culture, and interleukin-8 and interleukin-6 determinations. Vaginal interleukin-6, interleukin-8, neutrophils, and vaginal flora were compared in women with positive and negative AF cultures. The negative AF culture group was subdivided according to AF interleukin-6 concentration. Logistic regression was used to examine the associations between vaginal cytokines and flora and AF infection or elevated AF interleukin-6. RESULTS: The vaginal interleukin-8 concentration and neutrophil count were significantly higher with both AF infection and elevated concentrations of AF interleukin-6 and interleukin-8. The vaginal interleukin-6 concentration was not associated with AF infection or high concentration of AF cytokines. Amniotic fluid infection was associated with bacterial vaginosis or intermediate vaginal flora by Gram stain, absence of hydrogen peroxide-producing Lactobacillus, and presence of vaginal Bacteroides ureolyticus and Fusobacterium. Vaginal interleukin-8 levels greater than 30 ng/mL had 80% sensitivity and a positive predictive value of 35%, and an abnormal vaginal Gram stain (more than five neutrophils per 400x field, bacterial vaginosis species, or intermediate flora) had 90% sensitivity and a positive predictive value of 27% to detect AF infection or elevated AF interleukin-6. CONCLUSION: A high vaginal interleukin-8 concentration, abnormal vaginal Gram stain, absent hydrogen peroxide-producing Lactobacillus, and anaerobic vaginal flora were strongly associated with AF infection among women in preterm labor.

Amniotic fluid infection, cytokines, and adverse outcome among infants at 34 weeks' gestation or less.

OBJECTIVE: We examined the hypothesis that amniotic fluid (AF) infection and elevated cytokine concentrations may cause neonatal injury beyond that expected solely from prematurity. METHODS: The effects of exposure to AF infection and elevated cytokine concentrations were measured in 151 infants born to afebrile women in preterm labor with intact membranes at less than or equal to 34 weeks' gestation. Amniotic fluid was collected by amniocentesis for culture and determination of tumor necrosis factor-alpha and interleukin-6. Cytokine concentrations, stratified by AF infection, were compared for three gestational age groups. We then examined the associations between a positive AF culture or elevated AF tumor necrosis factor-alpha concentration and adverse neonatal outcomes, adjusted for birth weight. RESULTS: Amniotic fluid from 45 (30%) of 151 pregnancies had microorganisms, an elevated tumor necrosis factor-alpha concentration, or both. Amniotic fluid cytokine concentrations were significantly higher among women in preterm labor at less than or equal to 30 weeks, compared with 31-34 weeks. Nine of 11 infants who died at less than or equal to 24 hours of age had AF infection or elevated AF tumor necrosis factor-alpha. For the 140 surviving infants, AF infection and/or an elevated AF tumor necrosis factor-alpha was associated with respiratory distress syndrome (adjusted odds ratio [OR] 1.7), grade 3-4 intraventricular hemorrhage (adjusted OR 2.2), necrotizing enterocolitis (adjusted OR 1.8), and multiple organ dysfunction (adjusted OR 3.0). CONCLUSION: Among infants born at less than or equal to 34 weeks to women who have intact membranes and are initially afebrile, those exposed to AF bacteria or cytokines have more adverse neonatal outcomes than unexposed infants of similar birth weight.

Effects of oral contraceptive pill use on vaginal flora and vaginal epithelium.

The objective of this study was to examine the effect of oral contraceptive (OC) use on vaginal discharge, epithelium, and flora. Thirty women who planned to use OC for contraception were evaluated before and 2 months after the start of OC use. At both visits, genital symptoms and exposures were assessed by questionnaire; vaginal signs were assessed by speculum examination and colposcopy; vaginal microflora was evaluated by quantitative culture; and a vaginal biopsy was obtained for histopathologic evaluation. Variables were compared between the initial visit and after 2 months of OC use. It was found that OC use did not change the gross, colposcopic, or histologic appearance of the vaginal epithelium or characteristics of vaginal or cervical discharge. Vaginal flora essentially remained unchanged after 2 months of OC use, except that a small decrease occurred in the number of subjects with > or =10(5) colony forming units/mL of H(2)O(2) producing Lactobacillus from 16 at baseline to 9 (p = 0.04) and in the total number of subjects with Ureaplasma urealyticum from 17 at baseline to 10 of 29 (p = 0.04). The results indicate minimal effect of OC use on the vaginal epithelium and vaginal and cervical discharge, and a small effect on vaginal flora.

Bacteria in the transfer catheter tip influence the live-birth rate after in vitro fertilization.

OBJECTIVE: To assess the impact of individual bacteria isolated from the vagina and tip of the embryo transfer catheter on live-birth rates. DESIGN: Prospective clinical study. SETTING: Infertility outpatient clinic of a university hospital. PATIENT(S): Ninety-one women undergoing IVF-ET. INTERVENTION(S): Cultures were obtained from the vagina for aerobic and anaerobic bacteria at the time of both sonographic egg retrieval and embryo transfer and from the tip of the embryo transfer catheter. Doxycycline treatment was started after egg retrieval. MAIN OUTCOME MEASURE(S): The live birth of one or more neonates. RESULT(S): Doxycycline had no substantial impact on the recovery of individual vaginal bacteria or on bacterial vaginosis. An increase in live-birth rate was associated with the recovery of hydrogen peroxide-producing Lactobacillus from the vagina (P=0.01) and from the embryo transfer catheter (P=0.01). In contrast, a reduction in live-birth rate was associated with recovery of Streptococcus viridans (S. viridans) from the embryo transfer catheter tip (P=0.04). CONCLUSION(S): In the setting of IVF-ET, prophylactic doxycycline had little effect on vaginal bacteria. Specific bacteria recovered from the embryo transfer catheter appear associated with a detrimental or beneficial effect or with no effect on live-birth rates.

Metronidazole for bacterial vaginosis. A comparison of vaginal gel vs. oral therapy.

OBJECTIVE: To compare the efficacy and safety of 0.75% metronidazole vaginal gel with oral metronidazole for the treatment of bacterial vaginosis (BV). STUDY DESIGN: Nonpregnant women with BV were enrolled in a multicenter, randomized, investigator-blind treatment trial. Patients were randomly assigned to either 0.75% metronidazole vaginal gel (5 g twice daily for five days) or oral metronidazole (500 mg twice daily for seven days). Follow-up visits occurred approximately two and five weeks after initiation of therapy. RESULTS: BV was clinically eliminated at the first follow-up visit in 83.7% (36/43, 95% CI 72.3-95.1%) of the intravaginal group and 85.1% (40/47, 95% CI 74.6-95.6%) of the oral group. At the final visit, BV was eliminated in 70.7% (29/41, 95% CI 56.3-85.1%) of the intravaginal group and 71.1% (32/45, 95% CI 57.4-84.8%) of the oral group. Significantly more patients in the oral treatment group (51.8%) reported gastrointestinal complaints as compared to the intravaginal treatment group (32.7%, P = .04). CONCLUSION: The efficacy of 0.75% metronidazole vaginal gel twice daily for five days in treating BV was similar to that of standard oral metronidazole treatment and was associated with fewer gastrointestinal complaints.

Epithelial cell layer thickness and immune cell populations in the normal human vagina at different stages of the menstrual cycle.

OBJECTIVE: The aim of our study was to examine vaginal tissue during 3 phases of the menstrual cycle for the number of cell layers and epithelial immune cells. STUDY DESIGN: Vaginal biopsies were performed during 3 phases of the normal menstrual cycle (menstrual, days 1-5; preovulatory, days 7-12; and postovulatory, days 19-24) in 74 subjects. A subset of women had vaginal tissues stained with specific monoclonal antibody markers for Langerhans cells (CD1a), macrophages (KP1), T and B lymphocytes (CD4, CD8, CD21) and neutrophils (CD15). The number of cell layers and the number of immune cells in the vaginal tissue biopsy specimen were determined by a single observer who was blinded to clinical data. RESULTS: At 3 phases of the normal menstrual cycle, the mean number of epithelial cell layers underwent a small but statistically significant decrease from 27.8 +/- 0.7 on days 1-5 and 28.1 +/- 0.6 on days 7-12 to 26.0 +/- 0.7 on days 19-24 of the cycle (P =.01). Nonovulating women had a reduced mean epithelial cell layer count on days 7-12 (23.7 +/- 1. 4) compared with the epithelial cell layer count in ovulating women (28.8 +/- 0.7; P =.005). No significant changes were observed in the mean number per high-power field of Langerhans cells, macrophages, CD4 or CD8 lymphocytes, and neutrophil cell populations during the 3 phases of the cycle. B lymphocytes were not observed in the vaginal tissues. CONCLUSION: A small but statistically significant reduction in the number of vaginal epithelial cells was observed over the menstrual cycle. This reduction is not likely to be clinically significant. Immune cell populations in the vaginal tissues appeared stable throughout the menstrual cycle.

Depomedroxyprogesterone-induced hypoestrogenism and changes in vaginal flora and epithelium.

OBJECTIVE: To identify the effects of depomedroxyprogesterone acetate (DMPA) on vaginal microbial flora and epithelium. METHODS: Women who desired DMPA for contraception were evaluated before and at 3 and 6 months after initiation of 150-mg DMPA injections every 3 months. At each visit, we assessed genital symptoms, vaginal signs, vaginal microflora, and histopathology by vaginal biopsies. RESULTS: Among 38 women observed for 6 months, there was significant reduction in mean serum estradiol level (99.9 +/- 9.3 pg/mL to 26.6 +/- 1.6 pg/mL, P <.001). The number of subjects with any Lactobacillus did not change, but the number with hydrogen peroxide (H(2)O(2))-positive Lactobacillus decreased from 20% before to 12% after 6 months of DMPA (P =.005). The log concentration in colony-forming units per milliliter of vaginal fluid of H(2)O(2)-positive Lactobacillus decreased in a linear manner from 4. 0 +/- 0.6 at baseline to 2.5 +/- 0.6 after 6 months of DMPA use (P =. 006). The mean number of cell layers in the epithelium was reduced slightly from 28.1 +/- 0.7 to 25.9 +/- 0.9 (P =.05), epithelial thickness decreased from 1.02 +/- 0.04 mm to 0.89 +/- 0.05 mm (P =. 005), and the glycogen-positive thickness decreased from 0.81 +/- 0. 04 mm at baseline to 0.66 +/- 0.05 after 6 months of DMPA use (P =. 005). CONCLUSION: Depomedroxyprogesterone acetate produced a systemic hypoestrogenic state associated with decreased H(2)O(2)-positive Lactobacillus colonization and slight thinning of the glycogen vaginal epithelial layer. Such changes possibly compromise the vaginal barrier to infection.

Influence of the normal menstrual cycle on vaginal tissue, discharge, and microflora.

The objective of this study was to examine genital tissue, vaginal fluid, and vaginal microbial flora at 3 phases of the menstrual cycle in asymptomatic women. Vaginal examinations were performed 3 times in 74 women: at the menstrual phase (days 1-5), the preovulatory phase (days 7-12), and the postovulatory phase (days 19-24). Flora of 50 women without bacterial vaginosis (BV) was analyzed separately from flora of 24 women with BV. The volume of vaginal discharge increased and the amount of cervical mucus decreased over the menstrual cycle. Among subjects without BV, the rate of recovery of any Lactobacillus changed little (range, 82% to 98%; P = .2); however, a small increase occurred in the rate of recovery of heavy (3+ to 4+ semiquantitative) growth of Lactobacillus over the menstrual cycle (P = .04). A linear decrease occurred in the rate of recovery of heavy growth of any non-Lactobacillus species, from 72% at days 1-5 to 40% at days 19-24 (P = .002). A linear decrease also occurred in the rate of recovery of Prevotella species, from 56% on days 1-5 to 28% on days 19-24 (P =. 007), while a small linear increase occurred in the rate of recovery of Bacteroides fragilis (P=.05). Among subjects with BV, the only significant change was an increase in the rate of recovery of Lactobacillus, from 33% at days 1-5 to 54% at days 19-24 (P = .008). Among all subjects, the rate of recovery of heavy growth of Lactobacillus increased over the menstrual cycle and, in contrast, the concentration of non-Lactobacillus species tended to be higher at menses, which is evidence that the vaginal flora becomes less stable at this time.

Intrauterine infection and preterm delivery: evidence for activation of the fetal hypothalamic-pituitary-adrenal axis.

OBJECTIVE: We studied pregnant women in preterm labor with and without intrauterine infection to determine whether fetal hypothalamic-pituitary-adrenal axis activation occurs in the setting of infection-induced preterm parturition. STUDY DESIGN: Amniotic fluid collected by amniocentesis and maternal blood from patients in preterm labor with intact membranes at 24 to 34 weeks' gestation were analyzed by radioimmunoassay for the steroid hormones estrone, estradiol, progesterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate, and cortisol. Amniotic fluid was also obtained for microbial culture and for interleukin 6 measurements by enzyme immunoassay. RESULTS: Patients with intrauterine infection (n = 11) had significantly higher amniotic fluid concentrations of dehydroepiandrosterone (539 +/- 79 pg/mL) and of cortisol (5.28 +/- 1.0 microg/dL) than did patients with preterm labor and preterm delivery without infection (n = 11; 273 +/- 82 pg/mL and 1.61 +/- 1.05 microg/dL, respectively) or patients with preterm labor and subsequent term delivery (n = 11; 202 +/- 79 pg/mL and 1.82 +/- 1.0 microg/dL, respectively). Furthermore those patients who were delivered within 7 days after enrollment (who were also more likely to have intrauterine infection) had higher amniotic fluid concentrations than did those who were not delivered within 7 days of both estrone (586 +/- 101 pg/mL vs 314 +/- 98 pg/mL) and estradiol (238 +/- 44 pg/mL vs 91 +/- 43 pg/mL). CONCLUSION: Intrauterine infection was associated with increased fetal adrenal androgen and cortisol biosynthesis, and delivery within 7 days after the onset of preterm labor was associated with increased placental estrogen synthesis. These data are consistent with fetal hypothalamic-pituitary-adrenal axis activation in the setting of infection-associated preterm delivery.

Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on efficacy of ambulatory oral therapy.

OBJECTIVE: This study was undertaken to determine the effects of human immunodeficiency virus 1 infection on the clinical presentation, severity, causal organisms, and response to ambulatory therapy of pelvic inflammatory disease. STUDY DESIGN: Women 18 to 40 years old with lower abdominal pain for <1 month were recruited. Participants underwent a standardized questionnaire, physical examination, screening for human immunodeficiency virus 1 and other sexually transmitted infections, and endometrial biopsy to detect plasma cell endometritis. Reevaluations were performed at 1 and 4 weeks to assess response to therapy. RESULTS: Among 162 women with adequate endometrial biopsy specimens 63 (39%) had histologically confirmed endometritis. Endometritis was more frequent among women who were seropositive for human immunodeficiency virus 1 than among women who were seronegative (odds ratio, 3.0; 95% confidence interval, 1.5-5.9). Infections with either Neisseria gonorrhoeae or Chlamydia trachomatis, or both, were least common and bacterial vaginosis was most common among human immunodeficiency virus 1-infected women with CD4 T-lymphocyte counts <400 cells/microL (P <. 04, P <.03, respectively). After oral antibiotic therapy, similar proportions of both women who were seropositive and women who were seronegative for human immuno-deficiency virus 1 had a >/=75% reduction in clinical severity score (81% vs 86%). CONCLUSION: Outpatient treatment of pelvic inflammatory disease was successful regardless of human immunodeficiency virus 1 serostatus.

Infertility following pelvic inflammatory disease.

OBJECTIVE: To assess the frequency of infertility after pelvic inflammatory disease (PID) and factors important in postinfectious tubal damage in an urban population at high risk for sexually transmitted diseases. METHODS: From a cohort of 213 women with PID documented by laparoscopy and/or endometrial biopsy, 58 women (27% of the initial cohort) were interviewed by phone 2 to 9 years after an index episode of PID. Data regarding the initial history, physical examination, microbiology, laparoscopic, and serologic findings, and data concerning interval contraception, subsequent pregnancy, subsequent infection, and chronic pelvic pain were compared among those with and without infertility at follow up. RESULTS: Nineteen (40%) of the 48 women not using contraception were involuntarily infertile after the index episode of PID. Compared with those who had an interval pregnancy, infertile women were older (P = 0.02), more likely to have a history of infertility prior to the index episode of PID (P = 0.001), and were more likely to have occluded or partially occluded fallopian tubes (P = 0.03), peritubal adhesions (P = 0.007), or perihepatic adhesions (P = 0.02) seen by laparoscopy performed during the index episode. Surprisingly, recovery of Chlamydia trachomatis was negatively related to infertility (P = 0.001), although a similar proportion of both groups had chlamydia immunoglobulin M antibody (40% vs. 31%). Chlamydia heat shock protein was weakly related to infertility (P = 0.08). The isolation of Neisseria gonorrhoeae was not significantly different between groups (53% vs. 57%). CONCLUSIONS: The high rate of postinfection infertility found was probably related to a combination of tubal damage before and during the index episode of PID. Prevention of recurrent PID and better understanding of the pathophysiology of postinfection tubal damage (which may differ between chlamydia and gonorrhea) is needed to develop more effective strategies to reduce permanent tubal damage.

Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm.

OBJECTIVE: To correlate symptoms, signs, and risk factors with positive wet mounts or cultures for Candida albicans and to develop an algorithm to diagnose vulvovaginal candidiasis. METHODS: This cross-sectional study of 774 randomly selected women from an urban sexually transmitted disease (STD) clinic evaluated symptoms, signs, and risk factors associated with C albicans, detected by wet mount and culture, and constructed an algorithm. RESULTS: C albicans, recovered from 186 (24%) of the 774 women, was associated with chief complaints of vulvar pruritus or burning. Elicited symptoms were vulvar pruritus, pain or burning, and external dysuria; signs were vulvar erythema, edema, fissures, vaginal erythema, and thick, curdy vaginal discharge. Among 545 women with symptoms of either increased vaginal discharge or vulvar pruritus or burning, only 155 (28%) had positive C albicans cultures, whereas bacterial vaginosis or other sexually transmitted infections were found in 288 (53%). In multivariate analysis, risk factors for positive C albicans culture included condom use, presentation after the 14th menstrual cycle day, sexual intercourse more than four times per month, recent antibiotic use, young age, past gonococcal infection, and absence of current gonorrhea or bacterial vaginosis. A clinical algorithm based on symptoms, signs, and selective use of wet mounts and cultures would have provided prompt treatment to 150 of 167 (90%) women with vulvovaginal candidiasis while minimizing the number of cultures performed. CONCLUSION: A simple algorithm using symptoms, signs, wet mounts, and selective cultures can identify 90% of women with vulvovaginal candidiasis. In this STD clinic, vulvovaginal symptoms also require assessment for bacterial vaginosis, trichomoniasis, and cervical infection.