Usage of antifungal drugs for therapy of genital Candida infections, purchased as over-the-counter products or by prescription: I. Analyses of a unique database.

OBJECTIVES: To present sales figures of antifungal drugs for treatment of genital Candida infections in females, which had been purchased in the Swedish county of Skåne (with approximately 1.2 million inhabitants) during the 1990s. To study the relative proportions of the drugs sold by prescription and as over-the-counter (OTC) products. METHODS: Sales figures of antifungal drugs for therapy of vulvovaginal candidiasis (VVC) and such recurrent infections (RVVC), for the years 1990--99, were collected from the 'ACS' database of the National Corporation of Swedish Pharmacies. RESULTS: The study showed an increase in sales of the type of drugs studied from 45,000 packages in 1990 until mid-93/94, when approximately 70,000 packages were sold (mainly azoles for topical use and fluconazole for oral intake). Thereafter there was a decrease until the end of November 1999, when 54,000 packages were purchased. Of the total sales, 93% were OTC products. Sales of clotrimazole and econazole (for vaginal installation) in 1993--1994 were equal to 85-90 packages/1000 women in the age group 15-45 years. Extremely high sales volumes of fluconazole and itraconazole, for one single year each, could be explained by marketing-related activities directed to the medical community. CONCLUSIONS: As many women with RVVC are not cured by iatrogenic initiatives and women consider themselves able to diagnose episodes of genital Candida infection, affected women generally turn to self-medication with antifungal OTC products. This stresses the role of pharmacy counseling. Short-term marked alterations in sales volumes may be due to marketing factors rather than changes in the epidemiology of genital Candida infections

Leukocyte Esterase Activity in Vaginal Fluid of Pregnant and Non-Pregnant Women With Vaginitis/Vaginosis and in Controls

Objectives: To determine the leukocyte esterase (LE) activity in vaginal lavage fluid of women with acute and recurrent vulvovaginal candidosis (VVC and RVVC respectively), bacterial vaginosis (BV), and in pregnant and non-pregnant women without evidence of the three conditions. Also to compare the result of LE tests in women consulting at different weeks in the cycle and trimesters of pregnancy.The LE activity was correlated to vaginal pH, number of inflammatory cells in stained vaginal smears, type of predominating vaginal bacteria and presence of yeast morphotypes. Methods: One hundred and thirteen women with a history of RVVC, i.e. with at least four attacks of the condition during the previous year and who had consulted with an assumed new attack of the condition, were studied. Furthermore, we studied 16 women with VVC, 15 women with BV, and 27 women attending for control of cytological abnormalities, who all presented without evidence of either vaginitis or vaginosis. Finally, 73 pregnant women were investigated. The LE activity in vaginal fluid during different weeks in the cycle of 53 of the women was measured. Results: In the non-pregnant women, an increased LE activity was found in 96, 88, 73 and 56% of those with RVVC, VVC and BV and in the non-VVC/BV cases, respectively. In 73% of pregnant women in the second trimester, and 76% of those in the third, the LE test was positive. In all groups of non-pregnant women tested, the LE activity correlated with the number of leukocytes in vaginal smears, but it did not in those who were pregnant. There was no correlation between LE activity and week in cycle. The vaginal pH showed no correlation to LE activity in any of the groups studied. Conclusions: The use of commercial LE dipsticks has a limited value in the differential diagnosis of RVVC, VVCand BV. There is no correlation between the LE activity in vaginal secretion on one hand and vaginal pH, week in the menstrual cycle and trimester in pregnancy on the other. Women with BV often have signs of inflammation as evidenced by a positive LE test and inflammatory cells in genital smears

Characterization of women with a history of recurrent vulvovaginal candidosis.

Background. To characterize history, signs, and symptoms in women with a history of recurrent vulvovaginal candidosis (RVVC) and who had consulted with symptoms generally associated with the condition. Methods. Eighty-three women with a history consistent with RVVC were interviewed regarding 32 parameters and 10 signs found at the clinical examination were noted. Candida cultures were made from the introitus and the posterior vaginal fornix. Results. Only in a few of the 43 women with and the 40 without a positive yeast culture could any of the many etiological factors that have been associated with RVVC be traced. Only two factors differed between the groups, namely yogurt intake, which was reported by 28 (68%) and 38 (95%) women in these groups, respectively. Vaginal douching was performed by 10 (23%) women in the Candida-positive group and by 17 (42%) women in the Candida-negative group. Pruritis and burning occurred in 31 (72%) and 22 (51%) of culture-positive patients, which was less frequent than in the culture-negative group, i.e. reported by 19 (47%) and 9 (22%) patients, respectively (p = 0.022 and p = 0.007). Edema (p = 0.026) of the vulva as well as erythema (p = 0.019) and edema (p = 0.008) of the vaginal mucosa, caseous discharge (p = 0.016), were found more often in the Candida culture-positive cases. Conclusions. History and results of clinical examination of patients with RVVC are not enough to distinguish those who are culture-positive from those who are culture-negative for Candida from the genital tract

Aetiology, diagnosis and therapyof sexually transmitted and allied infections-reflections on novel observations and current trends.

The present communication highlights aspects on the aetiology, diagnosis and therapy of sexually transmitted infections (STIs) and some allied infections in which sexual transmission is regarded as possible. The aetiology of many genital infections is still unknown or rather, an aetiological relationship between a given agent and a clinical manifestation is in some infections still debated. The paper will discuss some shortcomings in the current surveillance systems for STIs, if these systems exist at an. Thus, the paper considers their value in estimating the extent of the problem on a general population basis. It also focuses on the discrepancy between the current high prevalence of diagnosed cases of some STIs, such as of genital chlamydia infections, and the relatively low number of complications and sequelae presently seen, in contrast to the comparatively high prevalence more commonly reported in the past. Recent discoveries of novel aetiological agents of STIs, including mycoplasmas, may explain a lack of recovery from infections, due to the common use of antibiotic drugs to which these agents have a natural resistance. The observation of a synergistic effect of a commonly used anti-inflammatory drug, which may overcome antifungal resistance in vulvovaginal candidiasis, will also be reviewed. Furthermore, other reflections concern some of the classic STIs, e.g. lymphogranuloma verenerium, syphilis, gonorrhoea, herpes and condyloma

Chlamydia screening--yes, but of whom, when, by whom, and with what?

The importance of screening programs in reducing the prevalence of genital chlamydial infections is stressed by the fact that the majority of infected persons are more or less asymptomatic. The use of oral contraceptives may mask infections affecting the upper genital tract. This imposes selective screening and rescreening of women with a history of pelvic inflammatory disease. The recent knowledge that vaginal introital samples will provide a detection rate equal to or even higher than that of cervical samples collected in the same women opens up the possibility of screening women in health units lacking a gynecological examination chair. It also opens up the possibility of outpatient screening programs, for example, home sampling and mailing samples to laboratories that will perform analyses. The use of nucleic acid-based assays means increased sensitivity and specificity compared with earlier used techniques such as ELISA. These former methods can also be used in low-prevalence populations with acceptable positive predictable value, but may be misleading if used in post-therapy check-ups because the antigen may persist in microbiologically cured cases

Bacterial vaginosis: a threat to reproductive health? Historical perspectives, current knowledge, controversies and research demands

Bacterial vaginosis is a change in flora, the cause of which is still unknown in the vast majority of instances. Bacterial vaginosis has generally been used to represent any change in vaginal flora resulting in an assumed loss of lactobacilli. However, whether such a flora represents the genetically normal state of some women is poorly defined. The present 'crude' diagnosis of bacterial vaginosis ought to be refined. The proposed impact of bacterial vaginosis on adverse pregnancy outcome is contradicted by therapeutic studies involving pregnant women that result in a change in flora to a lactobacillus-dominated vaginal flora, but have no influence on the course ofpregnancy. Most therapies recommended for bacterial vaginosis in non-pregnant women are often successful in the short term, but usually unsuccessful if the follow-up period after finishing therapy is prolonged. Although bacterial vaginosis is generally believed to be an endogenous condition, a number of behavioral factors are involved, such as the use of contraceptive and intimate hygiene products and smoking habits. Although bacterial vaginosis is not considered a true sexually transmitted infection, it is correlated to sexual activities. The current review elaborates on these matters and on the vaginal microbial ecology