الفهرس 
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Abstract
Vaginitis is an inflammation of the vagina, usually characterized by any of the following: vaginal discharge, vulvar itching, vulvar irritation, vaginal odor, vaginal erythema, dyspareunia, and dysuria. The three most common causes of vulvovaginitis are bacterial vaginosis (BV), being the most prevalent one, followed by candidiasis and trichomoniasis
The aim of this study was to determine the prevalence of Gardnerella vaginalis infection among both pregnant and non-pregnant females, determine the types of candida causing vaginal candidiasis and assessment of their susceptibility to fluconazole, as well asidentification of unconventional pathogens that may be implicated in vaginitis using PCR technique.
The study was conducted among pregnant & nonpregnant females attending
El Shatbi gynecology and obstetrics university hospital as well as other main referral gynecology and obstetrics hospitals during six month period. Females aged twenty to fifty years old complaining of vaginal discharge and/or vaginal odor , dysuria, dyspareunia, pruritus, burning, or vaginal inflammation were included in this study.
During examinations, vaginal specimens were collected aseptically from the study participants using sterile swabs after obtaining their consent.All vaginal swabs were transferred without delay to the microbiology laboratory of the medical research institute.Microscopic examination and Gram-stain were carried out.
For diagnosis of bacterial vaginosis, each slide was graded as per the standardized quantitative morphological classification method developed by Nugent et al.Each vaginal swab was inoculated onto Blood, MacConkey agar, chocolate agar, SD agar before slide preparation for the isolation and characterization of aerobic bacteria and Candida.Swabs were cultured on chromogenic media for detection of group B streptococci.Identification of candida isolates to species level as well as susceptibility to fluconazole wascarried out using candida chrom agar andVitek 2 compact system.
In cases of unidentified etiology using previously mentioned methods, Multiplex Real-time PCR will carried out to identify other etiologies as: Mycoplasma, Chlamydia trachomatis, Herpes simplex virus 1&2.
The majority of cases included in this study were in age group 20 to 30 years representing51.4 % of cases whileonly few caseswere below 20 years (4.5%) and above 50 years (1.9%). Pregnant females in this study were dominant representing60%of cases.
Vaginal discharge (81.7 %) was the commonest presenting symptom followed by itching (58.1%) and dysuria (14.7%) while 12.4 % of cases complained of painful sexual intercourse.Vaginal discharge was the commonest presenting symptom among both non pregnant females and pregnant female with no significant difference in the distribution of symptoms between pregnant and non-pregnant females (<0.05) except in painful sexual intercourse which was significantly higher in non-pregnant females (p=0.042).
Among risk factors reported D.M was the most common (34.7%) followed by frequent sexual intercourse (26.5%), smoking was the least common risk factor reported. However, in (47.6%) no risk factors could be identified. Risk factors were present in 51.3% of pregnant females compared to 54.4% of non-pregnant, this difference between groups is not statistically significant (p=0.0493). Hypertension as a risk factor was more common among pregnant females which was statistically significant p=0.006.
Regarding Amsel’s criteria, all criteria were presented in together (31.4%) of cases. The most reported single criterion of Amsel’s was homogenous discharge (67.4%) of cases followed by Whiff’s test (54.7%) and clue cells (50.2%). However, Majority of cases (68.6%) showed absence of all components of Amsel’s criteria.
Clue cells were statistically higher in non-pregnant group (60.7%) than pregnant group (43.2%) (p < 0.0001) however, all other criteria were not statistically different between both groups p > 0.05. The three criteria together were found statistically to be positive more in non-pregnant than pregnant (p < 0.001). Nugent score categories were not statistically different between pregnant and non-pregnant groups (p=0.115). There is a significant weak agreement between Amsel’s criteria and Nugent Score for bacterial vaginosis (kappa = 0.11, p= 0.01*)
In the present study 211 (40.9%) offemales were negative for both Amsel’s criteria and Nugent’s score compared to 85 (16.5%) females were positive for both Amsel’s criteria and Nugent’s score. However, 77 (14.9%) were positive for Amsel’s criteria while Nugent’s score negative. On other hand, 143 (27.7%) were negative for Amsel’s criteria while Nugent’s score positive. (kappa = 0.11, p= 0.01*).
Using Conventional methods (Gram stain, Amsel’s criteria, Nugent Score, Cultures and Gardnerella vaginalis rapid test): we found that:
• Bacterial Vaginosis was diagnosed in 56% of cases (289/516) followed by Candida species in 50 % of cases (259/516). Gardnerella vaginalis was identified in 52.9% of bacterial vaginosis cases (153/289).
• Mixed infections of Candida species and Bacterial vaginosis (with or without Gardnerella vaginalis) were reported in (60+48)108 cases (21%).
• GBS was detected in 5.6% of cases
Candida and BV were statistically significantly higher in non-pregnant females however Gardenella was statistically significantly higher in pregnant females P = 0.001** . Majority of isolated Candida sp., Gardnerella vaginalis, BV, GBS and Trichomonas vaginalis cases included in this study were in age group 20 to 30 years. Non significant difference was foundbetween different age groups in Candida sp., Gardnerella vaginalis, GBS and Trichomonas vaginalis. However, it is significant in BV.
In the present study confirmatory test was carried out in 148 cases representing intermediate group of Nugent score. These tests included Rapid GV test which was positive in 104/148 (70.27%) and negative in 44 cases (29.72%).PCR was done for Negative cases (44) in which no obvious pathogen could be identified using conventional methods. PCR detected Lactobacilli in 22 cases (50%), Lactobacilli with Gardnerella vaginalis/Prevotella in 6 cases, Gardnerella vaginalis/Prevotella spp, in 7 cases as well as few cases (6.8%) of each Ureaplasma and Mycoplasma. One case showed mixed infection with vaginalis/Prevotella spp Ureaplasma and Mycoplasma hominis.