Genital bacteriology: A comparative study of premenopausal women with postmenopausal women

Genital bacteriology: A comparative study of premenopausal women with postmenopausal women

Genital bacteriology: A comptiative study of premendpausal women with postmenopausal women NEWTON G. OSBORNE, RALPH C. WRIGHT, LOUIS GRUBIN, Far...

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Genital bacteriology: A comptiative study of premendpausal women with postmenopausal women NEWTON

G. OSBORNE,

RALPH

C. WRIGHT,

LOUIS

GRUBIN,

Farmington,

M.D., M.D.,

PH.D.,

F.A.C.O.G.

F.A.C.O.G.

M.S.

Connecticut

Premenopausal women are reportedly at 9 higher risk than postmenopausal women of postoperative infection following iegiinal h.yst?rectomy. A study was de@gned to determine whether a relationship exists between bacterial flora and patient age that may explain the differe&e in the risk of postoperative infectibn. No statistically significant differevce was fdund in the number or type of bacterial species isolated from the cervix or vagina of premenopausal and postmeno@ausal women. Postmenopausal women on a regimen of conjugated estrogens had genital flora similar to that of the other women studied. (AM. J. OBSTET. GYNECOL. 135195, 1979.)

SEVERAL AUTHORS'-4 have reported a high risk of infectious morbidity when vaginal hysterectomy is performed in preinenopausal women. In contrast, a low incidence of morbidity following vaginal hysterectomy in postmenopausal women has been observed.lm3 Several methods for lowering the risk of postoperative morbidity in premenopausal women have been developed. 4-7 The objective of most methods is to reduce the number of bacteria capable of contaminating the operative site.4-7 However, it has not been shown that postmenopausal women harbor fewer or different genital organisms than premenopausal women. Our purpose was to determine the relationship between bacterial flora and age in these two groups.

A study was designed to compare the genitzil flora of premenopausal women less than 36 years of age with that of postmenopausal women over 55 years of age. All women admitted to the study were healthy and free of any genital symptoms. The patients were from a From the Department of Obstetrics and Gynecology, University of Connecticut School of Medicine and New Britain General Hospital.

Revised Accepted

October October

August

1, 1978.

17, 1978. 23, 1978.

Reprint requests: Dr. Newton G. Osborne, Department Obstetrics and Gynecology, University of Connecticut, School of Medicine, Farmington, Connecticut 06032. 0002-9378/79/180195+04$00.40/0

of patients species of organisms

Organism

Lactobacillus sp. Staphylococm Staphylococcus

albus aureus streptococcus virid.an.s

Beta-hemolytic streptococcus Gamma streptococcus Escherichia coli Candida albicans

Corynebacteeum

sp.

Haophilus vaginalis Proteus @vbili.s

Klebsiella sp. Total species/50

Material and methods

Received for publication

Table I. Number aerobic

0

1979

The

C. V. Mosby

Co.

of

from whom given were isolated

Premerwpausai

Postmeno@Lual

Vagina

Vagina

29 17

Cer&

Cenk

18 14 5

26 18 3

11 8

10

11

9

10

8

6 4

7 10 8 7 1

7 f

0 0 118

0 0 76

3 14 4 6 2 1

2 4 1 2 0 1

1 97

40

1.52

1.94

0.8

16 14

4 1

1

0

patients

Mean No. of species/

2.36

culture

private clinic population and were seen between September ,l, 1977, and April 30, 1978. Premenopausal wonien had an age distribution between 19 and 36 with a mean of 25.3. Postmenopausal women had an age distribution between 55 and 73 with a mean of 63.7. Fourteen postmenopausal women were using conjugated estrogens and 36 were not using any type of medication at the time they were seen. Cultures were taken from premenopausal and postmenopausal patient pairs who were scheduled to be

196

Osborne, Wright, and Grubin

September Am. J. Obstet.

Table II. Number of patients from whom given anaerobic species of organisms were isolated Premenopausal Organism Bacteroides sp. Peptostreptococcus Peptococcus Lactobacillus Fusobacterium SD. Bifidobacterium’sp. Veillonella Clostridium

Vagina

Cetvix

Vagina

Cervix

25 16

25 15

19 12

15 14 6 9 3 1 5 2 3 1 1

sp

Eubacterium

sp.

Actinomyces

sp.

7

9

9

6 5 5 5 4 1

7 4 3 4 2 2 0

0

0

6 5 0 8 3 2 1 1

0

Sarcina sp. Total

species/50

Postmenofkwsal

74

71

66

60

1.48

1.42

1.32

1.20

patients Mean No. of’speciesl culture

Table III. Number of patients Mycoplasmas were isolated

from

PrenwnDpausal Myco$asmu

Vagina

Cervix

whom Postmen@aural Vagina

Cervix

T-strain M. huminis

14

9

8

7

11

6

6

2

Total

species/50

25

15

14

9

patients Mean No. of species/

0.5

0.3

0.28

0.18

culture

Table

IV. Number

Species Aerobes Anaerobes

Mycoplasmas Subtotal Cervix and vagina

of different

species per culture

11 2.36 1.84 0.50 4.70

1.52 1.42 0.30 3.24 7.94

1.94 1.32 0.28 3.54

0.80 1.20 0.18 2.18 5.72

seen consecutively in the private office. A sterile warm metal speculum was inserted into the vagina, and cultures were obtained separately from the posterior third of the vagina and from the endocervix with a sterile cotton-tipped applicator and placed in Ames’ transport medium and in mycoplasma media as described by Kundsin.8 The samples were streaked within 30 minutes of collection onto prereduced sheep blood agar, trypticase soy broth, MacConkey agar Thayer-Martin, and Sabouraud’s agar plates. One set of sheep blood agar plates was incubated at

15, 1979 Gynecol.

36” C under anaerobic conditions in a Gas-Pak jar immediately after inoculation. Anaerobic isolates were identified according to the criteria described in the Anaerobe Luboratory Manual from the Virginia Polytechnic Institute.g Aerobic organisms were identified by standard microbiologic techniques.‘” The number of species cultured from premenopausal women was compared with the number cultured from postmenopausal women and the results were submitted for statistical analysis.

Results Analysis of the results obtained suggested that the Kolmogorov-Smirnov two-sample testto was the appropriate method for evaluating the significance of the data. Tables I, II, and III show the species of organisms cultured from both groups of patients. There was no group of organisms found to be significantly predominant in any set of patients. Table IV indicates the distribution of aerobes, anaerobes, and mycoplasma in the study population. Table V shows a comparison of the flora between postmenopausal women taking conjugated estrogens and those using no medications. The difference in the mean number of species per culture from the cervix and vagina outlined in Tables IV and V is not significant. No statistically significant differences could be found in the number of species of microorganisms isolated from the cervix and vagina of premenopausal and postmenopausal women (p > 0.5). The bacterial flora of postmenopausal patients using conjugated estrogens was not significantly different from that of premenopausal women or the other postmenopausal women. Neisseria gonorrhoeae and Trkhomonus q$udis were not identified in any of the patients studied.

Comment Reports on premenopausal women without preoperative evidence of infection who underwent vaginal hysterectomy for benign disease** indicate that this group is at high risk for postoperative infection. It has been suggested that hormone-induced changes in the cervical-vaginal epithelium may be associated with variations in the genital flora. Our findings suggest that the genital flora may not account for the reported increased morbidity risk in premenopausal women undergoing the same procedure. In a study of the genital flora of women with gynecologic malignancies I6 no difference was found in bacterial growth or in type of bacteria between patients who had temperature elevation during cesium application

Volume Number

135 2

Table

V. Number

Genital

of species per culture

in postmenopausal

Conjugated Vagina

Cemix

Aerobes Anaerobes Mycoplasmas Subtotal Cervix and vagina

29114 21/14 5114 55114 (3.93)

12114 19/14 4114 35/14 (2.5)

REFERENCES 1. Taylor, vaginal 2.

3. 4.

5.

No medication

Species

and those who did not experience a temperature elevation. Furthermore, the flora of the cervix in patients with cervical carcinoma was found to be the same as that of healthy women, although a number of specific bacteria could vary. Several factors have been proposed to account for the difference in the risk of postoperative infection in premenopausal and postmenopausal patients. Among these are increased blood loss in the premenopausal women,13 reduced vascularity’3 in the postmenopausal women, and possible undiagnosed subclinical pelvic inflammation in some premenopausal women.14 Ohm and associates15 studied the genital flora of immunosuppressed renal transplant patients and found an increased number of anaerobes, particularly the gram-positive cocci. They concluded that the cervicalvaginal flora is a dynamic entity which may change under a variety of influences. The fact that the risk of postoperative infection in the premenopausal woman can be significantly diminished by reducing the number of genital bacterial species has been well documented.*-7. I2 None of these factors, however, has been shown to explain the difference in the incidence of postoperative infection in premenopausal and postmenopausal women. These findings suggest that there are factors in addition to bacteria which influence the rate of postoperative infection.

E. S., and Hansen, R. R.: Morbidity following hysterectomy and colpoplasty, Obstet. Gynecol. 17:346, 1961. Pratt, J. H., and Galloway, J. R.: Vaginal hysterectomy in patients less than 36 or more than 60 years of age, AM. J. OBSTET. GYNECOL. 93:812, 1965. Chehab, H. E.: Decreasing the morbidity of vaginal hysterectomy, Obstet. Gynecol. 31:198, 1968. Ledger, W. J.. Sweet, R. L., and Headington, J. T.: Prophylactic cephaloridine in the prevention of postoperative pelvic infections in premenopausal women undergoing vaginal hysterectomy, AM. J.-OBSTET. GYNECOL. 115:766, 1973. Swartz, W. H., and Tanaree, P.: Suction drainage as an alternative to prophylactic antibiotics for hysterectomy, Obstet. Gynecol. 45:305, 1975.

197

women

estrogens (14)

6.43

bacteriology

CtYliX

Vagim 68136 45136 9136 122/36

(36)

28136 41136 5136 74/36 (2.05)

(3.39) 5.44

We recognize that the host defense system is complex. It is known that the first line of defense includes the normal skin, mucous membranes, and some body secretions. Leukocytes, immunoglobulins, and complement are known to be indispensable parts of this system. The question is whether the effectiveness of the known humoral, phagocytic, and cell-mediated immunity systems varies among normal individuals to the extent that some are at a higher risk of infection when stressed or whether other mechanisms are necessary to explain these differences. It is possible :hat a tissue or humoral factor protects some patients from invasion by indigenous flora while others are not adequately protected and develop sepsis following the stress of an operation. This protective entity may be age related. Borderline deficiencies in the generation of chemotactic and/or opsonization factors as well as the presence of inhibitors of these factors may be fruitful subjects for investigation. A mechanism that explains why the postmenopausal woman is apparently at a lower risk of posthysterectomy infection could suggest alternate ways to reduce the risk of postoperative sepsis. A better understanding of normal host defense and host-parasite interaction may provide a clue to one of the fundamental principles governing health and disease.

6. Osborne, N. G., and Wright, R. C.: Effect of preoperative scrub on the bacterial flora of the endocervix and vagina, Obstet. Gynecol. 50: 148, 1977. 7. Ohm, J. J., and Galask, R. P.: The effect of antibiotic prophylaxis on patients undergoing vaginal operations. II. Alterations of microbial flora, AM. J. OBSTET. GYNECOL. 123:597, 1975. 8. Kundsin, R. B.: Mycoplasma infections of the female genital tract, Prog. Gynecol. 6~291, 1975, 9. Holdeman, L. V., and Moore, W. E. C.: Anaerobe Laboratory Manual, Blacksburg, Virginia, 1972, Virginia Polytechnic Institute. IO. Buchanan, R. E., and Gibbons, N. E.: Bergey’s Manual of Determinative Bacteriology, ed. 8, Baltimore, 1974, The Williams & Wilkins Co. Il. Siegel, S.: Non-parametric Statistics, New York, 1956, McGraw-Hill Book Company, Inc., pp. 127-136,278-279.

198

Osborne, Wright, and Grubin

12. Osborne, N. G., Wright, R. C., and Dubay, M.: Preoperative hot conization of the cervix: A possible method to reduce postoperative febrile morbidity following vaginal hysterectomy, AM. J. OBSTET. GYNECOL. 133:374. 1979. 13. Goosenberg, J., Emich, J. P., and Schwarz, R. M.: Prophylactic antibiotics in vaginal hysterectomy, AM. J. OBSTET. GYNECOL. 105:503, 1969. 14. Ledger, W. J., and Child, M. A.: The hospital care of patients undergoing hysterectomy: An analysis of 12,026

September 15, 1979 Am. J. Obstet. Gyn~ol.

patients OBSTET.

from

the

Professional

Activity

Study.

AM.

J.

117:423, 1973. 15. Ohm, J. J., Scott, J. R., and Galask, R. P.: Cervical-vaginal flora of immunosuppressed renal transplant patients, AM. J. OBSTET. GYNECOL. 130:49, 1978. 16. Blythe, J. G.: Cervical bacterial flora in patients with gynecologic malignancies, AM. J. OBSTET. GYNECOL. 131: 438, 1978. GYNECOL.

lnfortmtion for authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore, all manuscripts must be accompanied by the following written statement, signed by one author: “The undersigned author transfers all copyright ownership of the manuscript (title of article) to The C. V. Mosby Company in the event the work is published. The undersigned author warrants that the article is original, is not under consideration by another journal, and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all co-authors.” Authors will be consulted, when possible, regarding republication of their material.