Professional Documents
Culture Documents
Des Moines UniversityOsteopathic Medical Center, Des Moines; and 2Creighton University School of Medicine, Omaha
QUALITATIVE MICROBIOLOGY
The microbiological flora of the lower female genital
tract is a dynamic, complex example of microbial colonization, the regulation of which is not fully understood. Much of what we know about the bacterial composition of the female genital tract is derived from
qualitative, descriptive studies [110]. The fund of information that such studies have provided with regard
to the microbial flora of the lower female genital tract
is weakened by the intrinsic technical limitations that
are inherent in the studies. Often, even the usefulness
of qualitative data is negatively affected by inappropriate or suboptimal methods of data collection, failure
to use appropriate transport systems or enriched media,
or a lack of stringent anaerobic technique in the processing and culture of specimens.
The importance of using specialized media is illustrated in a study of Clostridium difficile by Bramley et
al. [11]. These investigators evaluated cultures of vaginal specimens obtained from 522 women who made
a total of 902 visits to a family planning clinic, and they
found this organism in only 1 patient. However, when
a specialized medium that contained 0.2% para cresol
was used, a higher rate of isolation (11%) was obtained.
One can only speculate as to how many more microbial species would have been recovered if truly optimal media and methods had been used for all studies
reported in the literature prior to the 1970s. Isolation
techniques used prior to the 1970s resulted in a gross
underestimation of the importance of anaerobic bacteria as major constituents of the normal flora of the
female genital tract. Failure to use appropriate transport
systems as well as failure to use optimal media and
anaerobic culture techniques have compromised the results of many studies with regard to the delineation of
the bacterial constituents present.
Although anaerobic bacteria had been identified previously, it was not until publication of the work of
Gorbach et al. [2] and, soon afterward, that of Ohm
and Galask [3], Galask et al. [5], and Hill [7], that the
role of anaerobic bacteria both in maintaining health
The microbiological flora of the lower female genital tract provides a dynamic, complex example of microbial
colonization, the regulation of which is not fully understood. When an exogenous bacterial species, with its
array of virulence factors, is introduced into the host, disease does not always occur. Conversely, under selected
conditions, commensal endogenous bacteriafor example, Gardnerella vaginalis and group B streptococcican participate in disease processes. Disease caused by both exogenous and endogenous bacteria correlates positively with a markedly increased level of bacterial replication. The key question is what determines
the quantity of a given bacterium at any given time. For disease to occur, exogenous or endogenous bacteria
that possess pathogenic prerequisites must attain replicative dominance. Their ability to do so is potentially
governed by inhibitory or synergistic interrelationships with other microbes.
Low
Mean
High
Gram-positive rods
Diphtheroids
Lactobacilli
40
80
18
60
90
Gram-positive cocci
Staphylococcus aureus
25
Staphylococcus epidermidis
50
95
Streptococcus species
a-Hemolytic
20
38
b-Hemolytic
15
22
Nonhemolytic
20
32
Group D
28
45
Escherichia coli
18
33
10
20
Proteus species
10
Pseudomonas species
0.1
Gram-negative rods
NOTE.
QUANTITATIVE MICROBIOLOGY
[20]
[21]
[22]
[23]
[4]
B. biviusa
12
B. fragilis
17
40
12
16
Bacteroides species
B. melaninogenicusb
33
Other
40
18
46
10
Bifidobacterium species
Clostridium species
C. perfringens
13
Any
Eubacterium species
31
Fusobacterium species
28
13
Gaffkya speciesc
Lactobacillus species
10
46
52
P. asaccharolyticus
48
12
P. magnus
11
17
P. prevotii
17
21
Other
11
33
64
65
P. anaerobius
34
15
P. intermedius
10
P. micros
Peptococcus speciesd
Any
Peptostreptococcus species
P. productus
Any
33
76
35
15
Proprionibacterium species
Veillonella species
27
11
NOTE.
a
b
c
d
Prevotella bivia.
Prevotella melaninogenica.
Aerococcus species.
Peptostreptococcus species.
Flora of the Female Genital Tract CID 2001:32 (15 February) e71
Other
defined, one is confronted with having to explain why apparently commensal bacteria (e.g., G. vaginalis, group B streptococci and Escherichia coli) can cause disease.
More than a century after Pasteur introduced the idea of
monoetiological disease (the idea that 1 pathogen causes 1 disease), we still struggle with the definition of the term pathogen [24]. In the middle of the 19th century, Pasteur provided
evidence that the presence of an organism, such as the anthrax
bacillus, in a host is associated with disease; however, there
frequently has been a tendency to think that the mere presence
of certain organisms is synonymous with disease. It was not
until the early part of the 20th century that Theobald Smith
introduced the idea that disease was the result of the interplay
between microbial virulence, dominance of the organism in
terms of numbers, and the innate defenses of the host [25].
Because Kochs postulates stated that monoetiological disease
could be demonstrated through production of infections in
animals, many studies were done in which animals could be
successfully infected with microbial pathogens. Often, however,
these infections eventuated only when a change in the microenvironment was created as part of the experimental model of
infection. For example, peritonitis might be more efficiently
induced when blood is added to the inoculum. Gangrene has
been known to develop when calcium chloride is implanted
into muscle along with the Clostridium species. In rodents,
vaginal infection with Candida albicans requires estrogen replacement therapy for the animal host. Bacteria that are normal
constituents of the vaginal flora of the host have the potential
to cause symptoms of disease, but they apparently require some
alteration in the microenvironment to do so. C. albicans, group
B Streptococcus (GBS), G. vaginalis, and Escherichia coli, which
are organisms that are commonly isolated from the lower female genital tract, can, under select circumstances, cause disease.
Although they are not indigenous to the microflora of the
genital tract, organisms that are commonly termed pathogens, such as H. influenzae, S. pneumoniae, S. pyogenes, and
T. vaginalis, may also be present without causing symptoms,
much in the way that organisms that are part of the normal
flora of the genital tract are typically present. These seeming
inconsistencies focus on a critical question regarding the pathogenesis of infectious diseases: what enables a given organism
to produce disease?
For endogenous bacteria of the female genital tract, the microbiological environment may supersede selected inherent virulence factors in terms of importance; at the very least, the
microbiological environment may affect the bacterial expression of virulence factors [26]. Theoretically, if a virulence factor
is constitutive, the number of organisms present will determine
the amount of the virulence factor available to promote infec-
Lactobacillus species and G. vaginalis. By inference, those bacteria that were not present were presumed to be susceptible to
bacterial interference by the target bacteria or its subsequent
isolates.
Certainly, confirmation of this hypothesis will require additional in vitro evaluation. Lactobacillus species appeared to
be the major regulator of both G. vaginalis and selected anaerobic bacteria. Lactobacillus species were identified in 131
cultures of vaginal specimens. When Lactobacillus species were
present, G. vaginalis was a co-isolate in 7 cultures. In only 1
of these 7 cases were fewer than 5 isolates observed, including
the anaerobic bacteria present. In this study, inhibitory organisms appeared to include coagulase-negative staphylococci,
which appeared to suppress S. aureus and the group B streptococci, and other b-hemolytic streptococci.
References
1. Weinstein L. The bacterial flora of the human vagina. Yale J Biol Med
1938; 10:24760.
Flora of the Female Genital Tract CID 2001:32 (15 February) e75
55.
56.
57.
58.
59.
60.
61.
62.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
Flora of the Female Genital Tract CID 2001:32 (15 February) e77
63.
teriuria during pregnancy with special reference to group B streptococci. Scand J Infect Dis 1985; 17:1959.
Persson K, Bjerre B, Elfstrom L, et al. Group B streptococci at delivery:
high count in urine increases risk for neonatal colonization. Scand J
Infect Dis 1986; 18:52531.
Helmig R, Halaburt JT, Uldbjert M, et al. Increased cell adherence of
group B streptococci from preterm infants with neonatal sepsis. Obstet
Gynecol 1990; 76:8257.
Chaisilwattana P, Monif GRG. In vitro ability of the group B streptococci to inhibit gram-positive and gram-variable constituents of the
bacterial flora of the female genital tract. Infect Dis Obstet Gynecol
1995; 3:917.
Carson HM, LaPoint PG, Monif GRG. Interrelationships within the
bacterial flora of the female genital tract. Infect Dis Obstet Gynecol
1997; 5:3059.
De Klerk HC, Cortzec JM. Antibiosis among lactobacilli. Nature
1961; 192:3401.
Brock TD, Peacher B, Pierson D. Survey of the bacteriocins of enterococci. J Bacteriol 1963; 86:7027.
Reves R. The bacteriocins. Bacteriol Rev 1965; 29:2545.
Holmberg K, Hallander HO. Interference between gram-positive microorganisms in dental plaque. J Dent Res 1972; 51:58895.
Tagg JR, Dajami AS, Wannamaker LW. Bacteriocin of gram-positive
bacteria. Bacteriol Rev 1976; 40:72256.
Rogosa M, Shape ME. Species differentiation of human vaginal lactobacilli. J Gen Microbiol 1960; 23:19720l.
Skarin A, Sylwan J. Vaginal lactobacilli inhibit growth of Gardnerella
vaginalis, Mobiluncus, and other bacterial species cultured from vaginal
content of women with bacterial vaginosis. Acta Pathol Microbiol Immunol Scand [B] 1986; 94:399403.
Reid G, Servin AL, Bruce AW, Busscher HJ. Adhesion of three Lactobacillus strains to human urinary and intestinal epithelial cells. Microbios 1993; 75:5765.
Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J
Med 1993; 329:7536.
Larsen B, Markovetz AJ, Galask RP. Quantitative alterations of the
genital microflora of female rats in relation to the estrous cycle. J Infect
Dis 1976; 134:4869.
Weinsten L, Howard JH. The effect of estrogenic hormone on the Hion concentration and the bacterial content of the human vagina, with