INFECTION DIAGNOSTICS :: STIs
vaginal swabs were considered the pre- ferred noninvasive sample type by these investigators.8
ease and preferences for sampling of over 1,000 women across seven North Ameri- can cities, women preferred self-collected vaginal swabs over urine or cervical swab collection during a pelvic exam.9
In a survey of opinions on The vast
majority found vaginal swabs easy to use and agreed they would get tested more regularly if self-collected swabs were an option. Self-collected vaginal swabs were preferred by the majority of college women undergoing STI testing in another survey in upstate New York.10
Availability of this
option might increase testing overall because self-obtained vaginal swabs are a quick, easy way to test for STIs without a pelvic exam, helping those women who avoid STI testing due to anxiety and dis- comfort, or when access to a healthcare provider is not possible. Self-collected vaginal swabs are more
sensitive, less messy, less susceptible to laboratory errors, less expensive, and more cost-effective than urine testing. Finally, the Centers for Disease Control and Pre- vention (CDC) recommends either clini- cian- or self-collected vaginal swabs for CT and NG testing; self-collected vaginal swabs are considered equivalent in sensi- tivity and specificity to those collected by a clinician.11
Self-collected vaginal swabs
have been estimated in mathematical modeling as the most cost-effective sam- pling method for prevention of pelvic inflammatory disease, which suggests benefits to the clinical care providers.12 Additionally, as more point-of-care tests become available, self-collection of swabs immediately following registration has been shown to decrease the wait time for results and improve clinic throughput.13 Regardless of whether the testing will be done on site or sent to a laboratory, self-collection prior to the exam frees up time to allow providers to engage in other activities with their patients.
Beyond CT/NG testing Along with the advantages mentioned above, vaginal swab samples allow the opportunity to test for a broader range of organisms from a single sample com- pared with urine. This is particularly important for symptomatic patients, as many STI and vaginitis symptoms overlap. For example, symptomatic MG infections present similarly to CT, NG, and TV infections, so all tests should be performed.14
with MG and other bacterial STIs have frequently been reported.15, 16, 17
Additionally, co-infections With these
scenarios in mind, healthcare providers
must look beyond CT and NG and con- sider testing women for other genital pathogens, such as MG, TV, or those underlying pathogens causing bacterial vaginitis (BV), to determine the most ap- propriate treatment/s and reduce return visits. For MG and vaginitis, urine has been clearly demonstrated to be a sub- optimal sample type.
Heeding the latest professional guidance The CDC recently released updated STI treatment guidelines to provide guidance for diagnosing and treating infections like TV, BV, and MG. These recommendations further demonstrate the importance of testing for common pathogens beyond CT and NG. TV is estimated to be the most preva- lent nonviral STI worldwide, affecting approximately 3.7 United States.14
million people in the The CDC had previously
recommended diagnostic testing for TV in women seeking care for vaginal discharge. Annual screening should be considered for those in high prevalence settings, such as STI clinics, correctional facilities, and for high-risk asymptomatic women with a history of STIs or incarceration, multiple sex partners, transactional sex, and other identified factors. Asymptomatic women with HIV should be routinely annually screened for TV. Due to a high rate of reinfection, TV retesting within three months of treatment is recommended for sexually active women. Nucleic acid amplification tests (NAATs) for TV were also noted to be more sensitive than wet mount microscopy and culture; both vaginal swabs and urine are considered acceptable samples. The updated recom- mended treatment regimen for women is 500 g metronidazole orally twice daily for 7 days.14
vaginal discharge worldwide, although most women are asymptomatic.14
BV is the most common cause of Tra-
ditional methods of diagnosis such as Amsel’s diagnostic criteria or gram stain are commonly used, although more ac- curate and sensitive NAATs are available. The CDC recommends that symptomatic women should be tested for BV with NAATs using vaginal swab samples, and all women with BV should also be tested for HIV and other STIs. Use of vaginal swabs supports this multi-test approach. MG is another common infection that is difficult to culture and has a low organism load. Infection with MG doubles the risk of cervicitis, pelvic inflammatory disease (PID), preterm delivery, and spontane- ous abortion.14
MG prevalence is also
surprisingly high. Among young adults in the general US population, MG (1%) is more common than NG (0.4%) and less common than CT (2.3%).15
In a study of
515 women seeking healthcare at family medicine, obstetrics and gynecology, family planning, public health, or sexu- ally transmitted disease clinics in the US, MG infections were significantly more prevalent than CT and NG infections, and over 50% of women with MG infec- tions had the macrolide-resistant phe- notype.16
Among 1,737 sexually active
women seeking healthcare at 21 US sites that included clinical research centers, emergency medicine, family planning, public health, STI, and family medicine/ obstetric-gynecologic facilities, 10.1% were infected with M. gen; prevalence was lowest (7.9%) in endocervical and urine samples from asymptomatic women and highest (11.6%) in urine samples and patient-collected vaginal specimens from symptomatic women.18
Overall, MG is
more prevalent in younger, black, non- Hispanic, and symptomatic women.16,18,19 The recent CDC guidelines recom- mend that women with recurrent cer- vicitis be tested for MG using NAATs.14 In Europe, testing is recommended for cervicitis even if it is not a recurrence. Testing for MG should be considered for women with pelvic inflammatory disease. Vaginal swabs are also the specimen of choice for testing for MG.15, 20
due to the increasing resistance of MG to azithromycin, the CDC recommends that any MG patient undergo antimicrobial resistance testing, when available, to guide appropriate treatment.14
Reframing practice patterns to improve women’s sexual health Vaginal swabs are an easy, patient-pre- ferred sample type that allows for self- collection and detection of a broad range of pathogens, yet does not sacrifice clini- cal performance, with sensitivity equal to or better than other sample types. In the past, urine may have been considered a better alternative to endocervical swabs for women, but we now have the best of both worlds — usability and performance — with the vaginal swab. Importantly, detecting multiple pathogens better ad- dresses the needs of symptomatic women, as symptoms from many STIs overlap, and coinfections are not uncommon. CDC recommended treatments are pathogen- specific; therefore, receiving an accurate diagnosis will ensure proper treatment is given, reducing return visits and sup- porting antibiotic stewardship programs. Women deserve more comprehensive, ef-
MLO-ONLINE.COM DECEMBER 2021 19
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