Milk and Dairy Consumption and Its Relationship With Abundance of Lactobacillus crispatus in the Vaginal Microbiota: Milk Intake and Vaginal Lactobacillus.

OBJECTIVES: Diet habits, such as low milk and dairy intake, have been associated with bacterial vaginosis. Thus, the authors compared vaginal Lactobacillus crispatus abundances in women with different molecularly defined community state types (CSTs) according to the consumption of milk and/or dairy products. METHODS: A total of 516 women from the 5 geographic regions of Brazil were included. Participants were interviewed with a structured questionnaire for assessment of milk and/or dairy intake. Vaginal samples were used for sequencing of V3-V4 regions of the 16S ribosomal RNA gene for further determination of L. crispatus relative abundance (RA) and clustering into 1 of the 5 CSTs (CSTI-CSTV), as firstly described by Ravel et al. (2011). The nonparametric Mann-Whitney test was used to compare L. crispatus RA within the most representative CSTs ( L. crispatus -dominant CSTI, Lactobacillus iners -dominant CSTIII, and Lactobacillus -depleted CSTIV) in this population, according to the frequency of milk and/or dairy intake. RESULTS: The prevalence of CSTI was 33.3% ( n = 172), CSTIII was 39% ( n = 201), and CSTIV was 27.7% ( n = 143). Among the participants with CSTIII, higher L. crispatus RA was observed for those who reported milk/dairy intake (median = 0.02; interquartile range = 0.01-0.09) than those with no consumption (median = 0.01; interquartile range = 0-0.03) ( p = .03). Such difference was not observed for participants with CSTI and CSTIV. CONCLUSIONS: Women with vaginal microbiota dominated by L. iners who consume milk and/or dairy present increased abundances of L. crispatus . Therefore, they could benefit from L. crispatus protective properties conferring greater temporal microbiota stability and, consequently, increased protection against infections.

Vaginal Microbiome Components as Correlates of Cervical Human Papillomavirus Infection.

BACKGROUND: Interplay between vaginal microbiome and human papillomavirus (HPV) remains unclear, partly due to heterogeneity of microbiota. METHODS: We used data from 546 women enrolled in a cross-sectional study in 5 Brazil. We genotyped vaginal samples for HPV and sequenced V3-V4 region of 16S rRNA gene for vaginal microbiome analysis. We used stepwise logistic regression to construct 2 linear scores to predict high-risk HPV (hrHPV) positivity: one based exclusively on presence of individual bacterial taxa (microbiome-based [MB] score) and the other exclusively on participants' sociodemographic, behavioral, and clinical (SBC) characteristics. MB score combined coefficients of 30 (of 116) species. SBC score retained 6 of 25 candidate variables. We constructed receiver operating characteristic curves for scores as hrHPV correlates and compared areas under the curve (AUC) and 95% confidence intervals (CI). RESULTS: Overall, prevalence of hrHPV was 15.8%, and 26.2% had a Lactobacillus-depleted microbiome. AUCs were 0.8022 (95% CI, .7517-.8527) for MB score and 0.7027 (95% CI, .6419-.7636) for SBC score (P = .0163). CONCLUSIONS: The proposed MB score is strongly correlated with hrHPV positivity-exceeding the predictive value of behavioral variables-suggesting its potential as an indicator of infection and possible value for clinical risk stratification.

Characteristics associated with Lactobacillus iners-dominated vaginal microbiota.

OBJECTIVE: The protective role of Lactobacillus iners in the vaginal microbiota has been questioned. Recent studies have shown that L. iners is the dominating taxon in a large subset of women worldwide. The aim of this study was to identify sociodemographic, behavioural and clinical variables associated with L. iners-dominated community state type (CST) III in Brazilian women of reproductive age. PARTICIPANTS AND METHODS: This study leveraged microbiota compositional data generated by sequencing of the V3-V4 16S rRNA gene from vaginal samples collected from 442 participants enrolled in a previous cross-sectional study that included 609 women in five geographical regions of Brazil. A total of 167 (27.4%) participants were excluded from the current study as they did not present a Lactobacillus-dominated vaginal microbiota. Data on sociodemographic and behavioural characteristics of the study population were obtained through face-to-face interviews. Participants were assigned to two study groups: those with L. iners-dominated CST III (n=222) and those with three distinct CSTs (I, II or V) dominated by another Lactobacillus spp. (n=220). Logistic regression analysis using a stepwise method was performed to test association between CST III and participants' characteristics, considering their OR and 95% CIs. RESULTS: Among the population characteristics assessed, L. iners-dominated CST III was independently associated with having two or more sexual partners (OR 3.27; 95% CI 1.50 to 7.11) and microscopic detection of Candida sp. on vaginal smears (OR 2.24; 95% CI 1.02 to 4.89). Other characteristics were inversely associated with CST III, including condom use (OR 0.59; 95% CI 0.38 to 0.91), higher educational level (OR 0.61; 95% CI 0.41 to 0.91) and diet containing milk/dairy intake (OR 0.43; 95% CI 0.20 to 0.90). CONCLUSION: Unprotected sex practices, number of sexual partners and lower educational levels may be useful for identifying women with L. iners-dominated microbiota and its suboptimal protective properties. L. iners microbiota does not seem to provide optimal protection against Candida sp. colonisation, warranting further investigation.

Characterization of the Vaginal Microbiome in Women of Reproductive Age From 5 Regions in Brazil.

BACKGROUND: Composition of the vaginal microbiome is strongly related to a woman's reproductive health and risk of sexually transmitted infections. Ethnoracial, behavioral, and environmental factors can influence microbiome. The Brazilian population is unique in terms of miscegenation of ethnic groups and behavioral characteristics across different regions. We aimed to characterize the vaginal microbiome of women from 5 geographical regions of Brazil. METHODS: We sequenced V3-V4 regions of 16S rRNA gene in vaginal samples of 609 reproductive-aged women. We performed logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between sociodemographic and behavioral factors with Lactobacillus-depleted microbiome (community state type [CST] IV). RESULTS: Vaginal samples were grouped into 5 CST: CST I (L. crispatus predominant, 30.5%), CST II (L. gasseri predominant, 4.4%), CST III (Lactobacillus iners predominant, 36.5%), CST IV (Lactobacillus-depleted, 27.4%), and CST V (L. jensenii predominant, 1.2%). Several factors were independently associated with CST IV, such as smoking (OR, 1.80; 95% CI, 1.02-3.18), number of partners (OR, 2.11; 95% CI, 1.20-3.70), and vaginal douching (OR, 2.24; 95% CI, 1.34-3.74). A protective effect was observed for milk/dairy intake (OR, 0.47; 95% CI, 0.27-0.82) and sitz bathing (OR, 0.43; 95% CI, 0.19-0.98). CONCLUSIONS: Nearly two thirds of Brazilian women may be at an increased risk for adverse outcomes associated with a vaginal microbiota characterized by the depletion of Lactobacillus or dominance by L. iners, whose protective role has been widely questioned. Several factors related to sexual behavior and intimate hygiene were associated with CST IV.

Multicenter study of the epidemiology of Clostridioides difficile infection and recurrence in southern Brazil.

Clostridioides (Clostridium) difficile is the main etiology underlying antibiotic-associated diarrhea (AAD). Still, few Brazilian data are available on this infection. The aims of this multicenter study were to identify the prevalence, clinical characteristics, and outcomes of C. difficile infection (CDI) in patients with antibiotic associated diarrhea at eight hospitals in Curitiba, southern Brazil, during the years 2017-2019. Stool samples were tested using enzyme immunoassay for glutamate dehydrogenase antigen (GDH) and A/B toxins. Positive GDH samples were further evaluated by real-time polymerase chain reaction (PCR) for the presence of genes encoding toxin B (tcdB), binary toxin (cdt), and marker of hypervirulent C. difficile strain (tcdC deletion). The prevalence of CDI in 351 patients with AAD included in the study was 17.7% (n = 62). Among the CDI cases, tcdB was positive in all 62 stool samples, while cdt was positive in 10 samples, and tcdC deletion was positive in only two. Carriage of carbapenem-resistant Gram-negative bacilli, previous hospitalization, and use of broad-spectrum cephalosporin and carbapenem were associated with CDI. Among patients with CDI, 64.5% presented with severe diarrhea, and 8% (5/62) progressed with colitis and required intensive care. The 30-day mortality was 24% (15/62), and the CDI-associated mortality was 4.8% (3/62). Overall, 83.8% (52/62) of the patients achieved primary cure, and 20.8% of the evaluated patients (10/48) presented CDI recurrence. The treatment administered was not significantly associated with the 60-day recurrence or mortality. In conclusion, we reported in this study data of prevalence and recurrence rates of CDI in patients with AAD and evaluated the number of severe cases and infection-related mortality, which were up to now unknown in Southern Brazilian hospitals.

Protein Content of Cervicovaginal Fluid Is Altered During Bacterial Vaginosis.

OBJECTIVES: The aim of the study was to compare, using a proteomic approach, cervicovaginal fluid (CVF) proteins of women with bacterial vaginosis (BV) with those presenting normal microbiota. MATERIALS AND METHODS: A total of 309 reproductive-aged women were cross-sectionally enrolled. Participants were tested for vaginal candidosis, Trichomonas vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae and excluded if positive. Vaginal microbiota was classified microscopically according to Nugent criteria in normal, intermediate, and BV. Randomly selected CVF samples of 29 women with BV and an equal number with normal microbiota were subjected to proteomic analysis. Thus, a total of 58 CVF samples were evaluated using shotgun liquid chromatography-tandem mass spectrometry in a Q-Tof PREMIER API mass spectrometer (MicroMass/Waters) for peptide detection and relative quantification. RESULTS: Of the 309 women enrolled, 63 (20.4%) were excluded after testing positive for at least one of the tested co-infections or because of low-quality samples. Microscopic classification of vaginal microbiota on the remaining 246 samples revealed that 132 women (53.6%) had normal microbiota, 33 (13.4%) had intermediate microbiota, and 81 (33.0%) had BV. Proteomic analysis of CVF of 58 randomly selected women with normal microbiota (n = 29) or BV (n = 29) successfully identified 74 proteins. In addition, the comparison of abundance of those proteins between the groups showed that the following five (6.7%) were enriched in BV: neutrophil elastase, kaliocin-1, neutrophil defensin-1, Ig lambda-2 chain C regions, and protein S100-A7. All of which have a recognized role in host's immunity. CONCLUSIONS: Exclusive finding of BV affects immunity-related CVF components of reproductive-aged women.

Cervicovaginal Levels of Human ß-Defensin 1, 2, 3, and 4 of Reproductive-Aged Women With Chlamydia trachomatis Infection.

OBJECTIVE: This study included women attending primary health care units in Botucatu, São Paulo, Brazil, to assess the cervicovaginal levels of human ß-defensin (hBD) 1, 2, 3, and 4 during Chlamydia trachomatis infection. PATIENTS AND METHODS: Cervicovaginal samples were collected for Pap testing and assessing the presence of infection by C. trachomatis, human papillomavirus, Neisseria gonorrhoeae, and Trichomonas vaginalis. Vaginal smears were taken to evaluate local microbiota. Human ß-defensin levels were determined using enzyme-linked immunosorbent assay in cervicovaginal fluid samples. Seventy-four women with normal vaginal microbiota and no evidence of infection were included in hBD quantification assays; 37 tested positive for C. trachomatis and 37 were negative. Statistical analysis was performed using Mann-Whitney U test. RESULTS: Women positive for C. trachomatis had significantly lower cervicovaginal hBD-1, hBD-2, and hBD-3 compared with those who tested negative (hBD-1: 0 pg/mL [0-2.1] vs 1.6 pg/mL [0-2.4], p < .0001; hBD-2: 0 pg/mL [0-3.9] vs 0.61 pg/mL [0-8.9], p = .0097; and hBD-3: 0 pg/mL [0-4.3] vs 0.28 pg/mL [0-8.4], p = .0076). Human ß-defensin 4 was not detected. CONCLUSIONS: Lower levels of hBD-1, hBD-2, and hBD-3 in cervicovaginal fluid were detected in the presence of C. trachomatis infection.

Effect of short training on vaginal fluid microscopy (wet mount) learning.

OBJECTIVE: Is it feasible to learn the basics of wet mount microscopy of vaginal fluid in 10 hours? MATERIALS AND METHODS: This is a pilot project wherein 6 students with different grades of education were invited for being tested on their ability to read wet mount microscopic slides before and after 10 hours of hands-on training. Microscopy was performed according to a standard protocol (Femicare, Tienen, Belgium). Before and after training, all students had to evaluate a different set of 50 digital slides. Different diagnoses and microscopic patterns had to be scored. κ indices were calculated compared with the expert reading. RESULTS: All readers improved their mean scores significantly, especially for the most important types of altered flora (p < .0001). The mean increase in reading concordance (κ from 0.64 to 0.75) of 1 student with a solid previous experience with microscopy did not reach statistical significance, but the remaining 5 students all improved their scores from poor performance (all κ < 0.20) to moderate (κ = 0.53, n = 1) to good (κ > 0.61, n = 4) concordance. Reading quality improved and reached fair to good concordance on all microscopic items studied, except for the detection of parabasal cells and cytolytic flora. CONCLUSIONS: Although further improvement is still possible, a short training course of 10 hours enables vast improvement on wet mount microscopy accuracy and results in fair to good concordance of the most important variables of the vaginal flora compared to a reference reader.

Streptococcus agalactiae in Brazil: serotype distribution, virulence determinants and antimicrobial susceptibility.

BACKGROUND: Group B Streptococcus (GBS) remains a major cause of neonatal sepsis and is also associated with invasive and noninvasive infections in pregnant women and non-pregnant adults, elderly and patients with underlying medical conditions. Ten capsular serotypes have been recognized, and determination of their distribution within a specific population or geographical region is important as they are major targets for the development of vaccine strategies. We have evaluated the characteristics of GBS isolates recovered from individuals with infections or colonization by this microorganism, living in different geographic regions of Brazil. METHODS: A total of 434 isolates were identified and serotyped by conventional phenotypic tests. The determination of antimicrobial susceptibility was performed by the disk diffusion method. Genes associated with resistance to erythromycin (ermA, ermB, mefA) and tetracycline (tetK, tetL, tetM, tetO) as well as virulence-associated genes (bac, bca, lmb, scpB) were investigated using PCR. Pulsed-field gel electrophoresis (PFGE) was used to examine the genetic diversity of macrolide-resistant and of a number of selected macrolide-susceptible isolates. RESULTS: Overall, serotypes Ia (27.6%), II (19.1%), Ib (18.7%) and V (13.6%) were the most predominant, followed by serotypes IV (8.1%) and III (6.7%). All the isolates were susceptible to the beta-lactam antimicrobials tested and 97% were resistant to tetracycline. Resistance to erythromycin and clindamycin were found in 4.1% and 3% of the isolates, respectively. Among the resistance genes investigated, tetM (99.3%) and tetO (1.8%) were detected among tetracycline-resistant isolates and ermA (39%) and ermB (27.6%) were found among macrolide-resistant isolates. The lmb and scpB virulence genes were detected in all isolates, while bac and bca were detected in 57 (13.1%) and 237 (54.6%) isolates, respectively. Molecular typing by PFGE showed that resistance to erythromycin was associated with a variety of clones. CONCLUSION: These findings indicate that GBS isolates circulating in Brazil have a variety of phenotypic and genotypic characteristics, and suggest that macrolide-resistant isolates may arise by both clonal spread and independent acquisition of resistance genes.

Cervicovaginal levels of proinflammatory cytokines are increased during chlamydial infection in bacterial vaginosis but not in lactobacilli-dominated flora.

OBJECTIVE: The purpose of this study was to assess the cervicovaginal levels of proinflammatory cytokines in women with Chlamydia trachomatis (CT) infection in the presence of bacterial vaginosis (BV) and normal flora and to compare with those negative for CT. MATERIALS AND METHODS: In this cross-sectional study, nonpregnant women were enrolled at 2 outpatient clinics and at 1 primary medical care unit in São Paulo State, Brazil. Cervicovaginal samples from 256 women with BV, of which 68 (26.6%) had concomitant CT infection and 188 (73.4%) were CT-negative, were measured for interleukin-1ß (IL-1ß), IL-6, and IL-8 by enzyme-linked immunosorbent assay. A matching number of samples from women with normal flora, CT-positive (n = 68) and negative (n = 188), were evaluated as control. Cytokine levels were compared by Mann-Whitney test and differences were considered significant at p < .05. RESULTS: In CT-negative women, IL-1ß was increased in BV (p < .001) when compared to normal flora, while the levels of IL-6 and IL8 were unchanged. The presence of CT infection was not associated with differences on cytokine levels in women with normal flora. However, women with BV had higher levels of IL-1ß (p = .02), IL-6 (p = .02), and IL-8 (p = .03) in the presence of CT when compared to those who tested negative for CT. CONCLUSIONS: Detection of endocervical CT is associated with increased cervicovaginal IL-1ß, IL-6, and IL-8 levels in women with concomitant BV but not in those with normal flora.

Do Atopobium vaginae, Megasphaera sp. and Leptotrichia sp. change the local innate immune response and sialidase activity in bacterial vaginosis?

OBJECTIVES: To investigate if the participation of Atopobium vaginae, Megasphaera sp. and Leptotrichia sp. in the bacterial community of bacterial vaginosis (BV) is associated with distinct patterns of this condition. METHODS: In this cross-sectional controlled study, 205 women with BV and 205 women with normal flora were included. Vaginal rinsing samples were obtained for measuring the levels of pro-inflammatory cytokines and bacterial sialidases. Real-time PCR was used to quantify the BV-associated bacteria and to estimate the total bacterial load using the 16S rRNA. Principal component analysis (PCA) using the measured parameters was performed to compare the BV samples with lower and higher loads of the species of interest. RESULTS: Higher bacterial load (p<0.001), levels of interleukin 1-ß (p<0.001) and sialidase activity (p<0.001) were associated with BV. Women with BV and higher relative loads of A vaginae, Megasphaera sp. and Leptotrichia sp. presented increased sialidase activity, but unchanged cytokine levels. PCA analysis did not indicate a different pattern of BV according to the loads of A vaginae, Megasphaera sp. and Leptotrichia sp. CONCLUSIONS: Greater participation of A vaginae, Megasphaera sp. and Leptotrichia sp. in vaginal bacterial community did not indicate a less severe form of BV; moreover, it was associated with increased sialidase activity.

Cervicovaginal Gardnerella sialidase-encoding gene in persistent human papillomavirus infection.

Disturbed vaginal microbiota have a role in the persistence of high-oncogenic-risk human papillomavirus (hrHPV) and Gardnerella spp. is closely related with this condition. Such bacteria are the major source of cervicovaginal sialidases, important for microbiota alterations. The sialidase-encoding gene nanH3 is account for their sialidase activity. Thus, a subset of 212 women positive for hrHPV at the first visit were included in the analysis of the current study aiming to compare the loads of nanH3 in cervicovaginal fluid (CFV) of women with persistent hrHPV infection and with those cleared the infection after a year. Participants were assigned to two study groups named "persistence" (n = 124, 53.22%) or "clearance" (n = 88, 37.77%), according to the HPV status upon enrollment and follow-up. Absolute quantification of nanH3 gene was performed using quantitative real-time PCR (qPCR). Persistence and clearance group did not show statistical difference in the load of nanH3 gene (p = 0.19). When considering the subset of women with HPV16, differences in number of copies of nanh3 gene was observed between the persistent (7.39E+08 copies/µL) and clearance group (2.85E+07 copies/µL) (p = 0.007). Therefore, baseline loads of nanH3 gene is increased in women that persist with cervical HPV16 infection after 12 months.

Factors associated with Trichomonas vaginalis infection in reproductive-aged women attending cervical screening in southeast of Brazil.

BACKGROUND: Sexually Transmitted Infections (STIs) can be caused by viruses, bacteria, and parasites. The World Health Organization estimated more than 300 million new global cases of curable STIs among individuals of reproductive age. Infection by Trichomonas vaginalis is one of the most prevalent curable STI. Despite the current treatments available, the diagnosis of T. vaginalis can be difficult, and the resistance to the treatment increased concern for the healthcare system. OBJECTIVES: The aim of this study was to determine the prevalence and factors associated with Trichomonas vaginalis infection among women of reproductive age attending community-based services for cervical screening. PATIENTS AND METHODS: A total of 1477 reproductive-aged women attending 18 Primary Health Care Units in Botucatu, Brazil, from September to October 2012, were enrolled. A structured questionnaire was used for individual face-to-face interviews for obtaining data on sociodemographic, gynecologic, and obstetrics history, sexual and hygiene practices, among others. Cervicovaginal samples were obtained for detection of T. vaginalis by culture using Diamond's medium and microscopic vaginal microbiota classification according to Nugent. A multivariable logistic regression analysis was carried out to estimate Odds Ratios (OR) and 95% Confidence Intervals (95% CI) for the association between participants' sociodemographic, behavioral factors, and clinical factors with T. vaginalis infection. RESULTS: Median age of study participants was 33 years (ranging from 18 to 50). The overall prevalence of T. vaginalis infection was 1.3% (n = 20). Several factors were independently associated with T. vaginalis infection, such as self-reporting as black or Pardo for ethnicity (OR = 2.70; 95% CI 1.03‒7.08), smoking (OR=3.18; 95% CI 1.23‒8.24) and having bacterial vaginosis (OR = 4.01; 95%CI = 1.55-10.38) upon enrollment. A protective effect of higher educational level (having high school degree) was observed (OR = 0.16; 95% CI 0.05‒0.53). CONCLUSIONS: Our data suggest that screening programs to correctly detect T. vaginalis infection can be helpful to guide prevention strategies to the community. Our study supports an association between abnormal vaginal microbiota and T. vaginalis infection.

Chlamydial infection in a high risk population: association with vaginal flora patterns.

PURPOSE: This study aimed to determine the frequency of Chlamydia trachomatis (CT) infection among high risk Brazilian women and evaluate its association with vaginal flora patterns. METHODS: This was a cross-sectional study, performed in an outpatient clinic of Bauru State Hospital, São Paulo, Brazil. A total of 142 women were included from 2006 to 2008. Inclusion criteria was dyspareunia, pain during bimanual exam, presence of excessive cervical mucus, cervical ectopy or with three or more episodes of abnormal vaginal flora (AVF) in the previous year before enrollment. Endocervical CT testing was performed by PCR. Vaginal swabs were collected for microscopic assessment of the microbial flora pattern. Gram-stained smears were classified in normal, intermediate or bacterial vaginosis (BV), and recognition of Candida sp. morphotypes. Wet mount smears were used for detection of Trichomonas vaginalis and aerobic vaginitis (AV). RESULTS: Thirty-four of 142 women (23.9%) tested positive for CT. AVF was found in 50 (35.2%) cases. The most frequent type of AVF was BV (17.6%). CT was strongly associated with the presence of AV (n = 7, 4.9%, P = 0.018), but not BV (n = 25, 17.6%, P = 0.80) or intermediate flora (n = 18, 12.7%, P = 0.28). CONCLUSIONS: A high rate of chlamydial infection was found in this population. Chlamydia infection is associated with aerobic vaginitis.

Correlation of Atopobium vaginae Amount With Bacterial Vaginosis Markers.

OBJECTIVE: The purpose of this study was to test the correlation of the amount of Atopobium vaginae with the most commonly used markers for bacterial vaginosis (BV). MATERIALS AND METHODS: We enrolled 103 nonpregnant and premenopausal women that were positive for BV by Amsel criteria and with a Nugent score higher than 3. All women were negative for yeast, Chlamydia trachomatis, Trichomonas vaginalis, and Neisseria gonorrhoeae. A. vaginae concentration was determined by quantitative polymerase chain reaction from samples of vaginal rinsings with 2 mL of sterile saline. RESULTS: There was no difference in the median values of A. vaginae concentration when comparing samples with presence or absence of each individual Amsel criterion. In the case of a higher pH cutoff value of 4.9, greater amounts of this microorganism (p = .02) were found. In addition, correlation tests showed that A. vaginae concentration is positively correlated with pH (p < .001) and with Nugent scores (p = .003). CONCLUSIONS: The quantification of A. vaginae is useful for identification of the most severe cases of BV.

Comparison of two microscopic interpretations of vaginal microbiota with molecular profiling.

OBJECTIVE: To compare the diagnosis of bacterial vaginosis (BV) by Nugent scoring criteria (Nugent-BV) and the diagnosis of BV and/or aerobic vaginitis (AV) using Donders criteria (Donders-BV/AV) for identifying Molecular-BV detected by bacterial 16s rRNA profiling. METHODS: We enrolled 512 women of reproductive age in Brazil with data available on Nugent and Donders microscopic analysis and 16S rRNA sequencing. We constructed receiver operating characteristic (ROC) curves of Nugent-BV and Donders-BV/AV and calculated their area under the curves (AUCs) and 95% confidence interval (CI) for matching Molecular-BV. RESULTS: A total of 155 (28.7%) participants were positive for Nugent-BV. Donders-BV and -AV were detected in 90 (17.6%) and 75 (14.6%) participants, respectively, while 28 (5.5%) had concurrent Donders-BV and -AV. Molecular-BV was identified in 139 (27.1%) participants. Analysis of ROC curves showed that diagnosis of Nugent-BV more accurately aligned with presence of Molecular-BV (AUC: 0.88, 95% CI: 0.84-0.91) when compared to Donders-AV/BV (AUC: 0.84; CI: 0.80-0.87) (P = 0.005). CONCLUSION: The use of Nugent-BV is more representative of Molecular-BV than Donders-AV/BV.

Genital Mycoplasmas and Biomarkers of Inflammation and Their Association With Spontaneous Preterm Birth and Preterm Prelabor Rupture of Membranes: A Systematic Review and Meta-Analysis.

Genital mycoplasmas (GM), such as Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma parvum, and Ureaplasma urealyticum are commonly associated with spontaneous preterm labor (SPTL), spontaneous preterm birth (PTB), and preterm prelabor rupture of membranes (PPROM). This study determined the association between GM and such adverse pregnancy outcomes. We searched for studies published 1980-2019 in MEDLINE, EMBASE, and Web of Science. Studies were eligible when GM was detected during pregnancy. We included 93 and 51 studies in determining the prevalence and the inflammatory biomarkers associated with GM, respectively, using the "metafor" package within R. The protocol was registered with PROSPERO (registration no. CRD42016047297). Women with the studied adverse pregnancy outcomes had significantly higher odds of presence with GM compared to women who delivered at term. For PTB, the odds ratios were: M. hominis (OR: 2.25; CI: 1.35-3.75; I 2: 44%), M. genitalium (OR: 2.04; CIL 1.18-3.53; I 2: 20%), U. parvum (OR: 1.75; CI: 1.47-2.07; I 2: 0%), U. urealyticum (OR: 1.50; CI: 1.08-2.07; I 2: 58%). SPTL had significantly higher odds with M. hominis (OR: 1.96; CI: 1.19-3.23; I 2: 1%) or U. urealyticum (OR: 2.37; CI: 1.20-4.70; I 2: 76%) compared to women without SPTL. Women with PPROM had significantly higher odds with M. hominis (OR: 2.09; CI: 1.42-3.08; I 2: 0%) than women without PPROM. However, our subgroup analysis based on the diagnostic test and the sample used for detecting GM showed a higher prevalence of GM in maternal samples than in fetal samples. GM presence of the cervix and vagina was associated with lower odds of PTB and preterm labor (PTL). In contrast, GM presence in the AF, fetal membrane, and placenta was associated with increased odds of PTB and PTL. However, genital mycoplasmas may not elicit the massive inflammation required to trigger PTB. In conclusion, GM presence in the fetal tissues was associated with significantly increased odds of PTB and PTL.

Cervicovaginal loads of Gardnerella spp. are increased in immunocompetent women with persistent high-risk human papillomavirus infection.

Introduction. Two high-oncogenic-risk human papilomavirus (hrHPV) genotypes - HPV16 and HPV18 - cause most of the cases of cervical cancer worldwide. Bacterial vaginosis is associated with increased hrHPV persistence, although the mechanism underlying this association remains unclear. Gardnerella spp. are detected in nearly all cases of bacterial vaginosis and are the major source of cervicovaginal sialidases. The NanH1 gene is present in virtually all Gardnerella sialidase-producing strains and has been proposed as a potential marker for persistent hrHPV infection.Hypothesis. Gardnerella spp. load and the NanH1 gene are associated with hrHPV persistence.Aim. To compare the cervicovaginal load of Gardnerella spp. and the frequency of the NanH1 gene between women with persistent HPV16 and/or HPV18 infection and those who cleared the infection after 11 months.Methodology. Among a population of 1638 HPV screened, we detected 104 with positive HPV16 and/or HPV18 results. Samples were obtained at two time points (baseline and at a median of 11 months at follow-up) and tested using the Linear Array HPV Genotyping kit (Roche Molecular Systems, Pleasanton, CA, USA). Based on their HPV16/HPV18 status at enrolment and follow-up, participants were assigned to 'persistence' or 'clearance' groups. We used cervicovaginal fluid samples obtained upon enrolment to determine the load of the 23 s rRNA gene of Gardnerella spp. and the presence of the NanH1 gene using real-time polymerase chain reaction (PCR). We compared Gardnerella spp. loads and NanH1 frequency between the groups by, respectively, Mann-Whitney and chi-squared tests, with a P-value <0.05 considered to be significant.Results. Of the 104 participants who were positive for HPV16/HPV18, 73 (70.2 %) persisted with at least 1 of the baseline genotypes at follow-up, while 31 (29.8 %) cleared the infection in this time frame. Participants in the persistence group had significantly higher loads of Gardnerella spp. [5.8E+02 (0-3.0E+05) copies µl-1] than those in the clearance group [9.9E+01 (0-7.7E+04) copies µl-1] (P=0.03). The baseline frequency of NanH1 was higher in the persistence' (n=46, 63.0 %) than in the clearance (n=14, 45.2 %) group, although this was not statistically significant (P=0.09).Conclusion. These findings reinforce the negative effect of vaginal microbiota for the clearance of hrHPV and indicate a possible association between sialidase-producing species with hrHPV persistence.

Group B streptococci colonization in pregnant women: risk factors and evaluation of the vaginal flora.

OBJECTIVE: To determine the prevalence of group B streptococci (GBS) in our population, and to assess the association between risk factors and vaginal flora with maternal rectovaginal colonization. METHOD: Samples were obtained from 405 patients between 35 and 37 weeks of gestation. Swabs from the vaginal and perianal regions were cultured in Todd Hewitt and subcultured in blood agar. Colonies suggestive of GBS were submitted to catalase and CAMP test. The vaginal flora was evaluated on Gram stain vaginal smears. Socio-demographic and obstetric data were obtained by designed form. Considering maternal GBS colonization as the response variable, a logistic regression model was fitted by the stepwise method with quantitative and qualitative explanatory variables. RESULTS: The prevalence of GBS colonization was 25.4%. The most frequent vaginal flora abnormalities were cytolytic vaginosis (11.3%), followed by bacterial vaginosis (10.9%), candidosis (8.2%) and intermediate vaginal flora II (8.1%). Logistic regression analysis revealed that maternal age, number of sexual intercourse/week, occurrence of previous spontaneous abortion, presence of candidosis and cytolytic vaginosis were associated with streptococcal colonization. CONCLUSION: The prevalence of GBS is high in pregnant women and is associated with sexual intercourse frequency, previous spontaneous abortion and the presence of candidosis or cytolytic vaginosis.

Microbiological characteristics and inflammatory cytokines associated with preterm labor.

PURPOSE: To evaluate vaginal microflora and interleukin-1ß (IL-ß), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-α) concentrations in the cervicovaginal fluid of a group of pregnant women in preterm labor when compared with a group of full-term pregnant women not yet in labor. METHOD: Case-control study performed in a University tertiary referral maternity in Campinas, Brazil with 45 pregnant women in preterm labor and 45 full-term pregnant women not in labor. All patients underwent speculum examination for the collection of cervicovaginal fluid. Bacterial vaginosis (BV) was diagnosed according to the criteria of Amsel and Nugent. Culture was performed for group B streptococcus (GBS) and lactobacilli, and hybrid capture assay for screening for chlamydial and gonococcal infection. Cytokine concentrations were measured using ELISA technique. Statistical analysis was performed using χ(2), Fisher's exact, and crude and adjusted odds ratios. Significance level was defined at 5%. The main outcome measures were cervicovaginal cytokines in preterm labor. RESULTS: IL-6 and IL-8 were significantly associated with preterm labor. The changes in vaginal microflora, as well as BV and GBS, were more frequent in women in preterm labor, although BV and GBS showed no statistical significance. The presence of Candida sp., absence of lactobacilli, positive screening for chlamydial and gonococcal infection and the presence of IL-1ß and TNF-α were not associated with preterm labor. CONCLUSIONS: IL-6 and IL-8 and the presence of any type of vaginal infection were the factors that were significantly associated with preterm labor.