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Holding the culture longer than two days may allow the diagnosis and appropriate therapy buy valacyclovir 500 mg amex symptoms hiv infection first week. The value of sputum gram stain and culture in the diagnosis of community-acquired pneumonia is another area of considerable debate generic valacyclovir 1000mg visa hiv infection of the mouth. Moreover buy valacyclovir 1000mg line symptoms of hiv infection in babies, empiric therapy with newer cephalosporins generally has proven effective in situ- ations in which clinicians suspect a bacterial cause of community-acquired pneumonia in a child cheap valacyclovir 500mg online antiviral medication side effects. Malaria evaluation is another case in which the fail- ure to submit a suitable microbiology specimen may be problematic. Peripheral blood examinations performed using automated equipment may be inadequate. The number of felds scanned by a technologist on these smears using automated equipment is quite low, and thus failure to pick up a light malarial parasitemia is not unusual. More extensive scanning of the blood felds stored in automated blood equipment by a patholo- gist is, however, an excellent way to make a diagnosis of malaria. Thin and thick smears for malaria should be ordered as the parasitemia may be missed with routine complete blood counts done on automated instruments. Thrombocytopenia is the most common laboratory abnormality encountered with malaria, seen in approximately 60% of cases regardless of the type of malaria, and should also prompt a blood smear. Hyperbilirubinemia is also seen in approximately 40% of malaria cases, and anemia is seen in approxi- mately 30%. The presence of thrombocytopenia and hyperbilirubinemia alone has a positive predictive value of 95% in the presumptive diagnosis of malaria in the febrile traveler returning from a part of the world where malaria is endemic. Mycotic infections provide yet another example of the importance of collecting suitable specimens. Chromoblastomycosis is a chronic mycotic infec- tion caused by pigmented saprophytic molds of the Dermatiaceae family ubiquitous in the environment. The members of the Dermatiaceae family aredimorphic flamentous fungi with melanic-type pigment in the cell wall. Clinically, the infection usually follows trau- matic inoculation through penetrating thorn or splin- ter wounds and is characterized by the development of chronic verrucose lesions at the inoculation site. Phialophora richardsiae is a recognized cause of chromo- blastomycosis in humans and can cause osteomyeli- tis. Puncture wounds of the foot can result in serious complications such as osteomyelitis. For this reason, 206206 ■■ CliniCal DiagnosTiC TesTsCliniCal DiagnosTiC TesTs puncture wounds may require wound enlargement and a search for a retained foreign body. Biopsy with appropriate cultures should be done initially rather than relying on empiric antimicrobial therapy. However, other microorgan- isms including fungi or mycobacteria can also cause osteomyelitis of the calcaneus secondary to a puncture wound. The frst solu- tion is to recut the formalin-fxed, paraffn-embedded tissue for additional acid-fast staining. Molecular testing is a reasonable adjunct test when mycobacterial cultures have not been done or are negative. Attention to detail and electronic bar code labeling can assist with this problem. This solution may not be possible, however, if antimicrobial agents have been initiated. Consider a case, for instance, in which there is more than one unlabeled set of blood culture bottles, each set from two separate patients. Properly labeling these two sets of blood culture bottles would become a major problem. The preanalytic phase of laboratory testing is man- ually intensive and thus prone to having the highest error rate. Blood collection is a particularly error-prone portion of the total laboratory testing process. Clearly the preanalytic phase of laboratory testing is vulnerable to errors; most of these errors result from system faws and insuffcient audit and control of the operators involved in specimen collection. The frst factor to consider is prediction of accidental events, which is accomplished by the following processes: (a) exhaus- tive process analysis, (b) reassessment and rearrange- ment of quality requirements, (c) dissemination of operating guidelines and best-practice recommenda- tions, (d) reduction of complexity and error-prone activities, (e) introduction of error-tracking systems, (f) continuous monitoring of performance, and (g) root cause analysis of any errors identifed to ensure that any systems faws can be addressed. The next factor to consider is an increase in and diversifcation of defenses, which is accomplished by the application of multiple and heterogeneous systems to identify nonconformities. The fnal factor to consider is a decrease in vulnerability, which is accomplished by implementation of reliable and objective detection sys- tems, causal relation charts, and education/training. These factors taken together constitute a systems approach for solving the problem of preanalytic errors. This does not mean that the analytic phase of testing in the clinical microbiology laboratory is error- free. The Cumitech series is designed to provide consensus rec- ommendations regarding the judicious use of clini- cal microbiology and immunology laboratories; each series is written by a team of clinicians, laboratorians, and other knowledgeable stakeholders to provide a broad overview of various important aspects of infec- tious diseases testing. The discussion of analytic error that follows is based on the medical literature as well as the personal experience of the author and illustrates common medical errors that may occur in the clinical microbiology laboratory. The well-recognized diffculty of diagnosing cryptococcal meningitis provides a useful example 5: CliniCal MiCroBiology ■ 211 of cases where a misread gram stain of the CsF may contribute to diagnostic confusion. The gram stain of CsF is recognized as critical in the diagnostic evalua- tion of a patient with suspected meningitis, and posi- tive gram stains revealing microorganisms are used to direct initial therapy. Clinicians and laboratory person- nel usually do not consider a false-positive gram stain from CsF to be a potential problem. Clearly, the rapid and accurate detection and char- acterization of microorganisms encountered in puru- lent CsF from patients with meningitis are important. Quality assessment programs in the clinical microbi- ology laboratory include both internal and external profciency testing as well as the testing of microbiol- ogy technologists for colorblindness. Factitious meningitis due to nonviable bacteria in commercial lumbar puncture trays was frst reported in the mid-1970s and still occurs. The medical 212212 ■■ CliniCal DiagnosTiC TesTsCliniCal DiagnosTiC TesTs products industry has effectively ensured the sterility of commercial medical devices, but the procedures used to sterilize these products do not prevent the pres- ence of nonviable microorganisms. Therefore, physi- cians and laboratory personnel must be aware that such false-positive gram stains may occur. The laboratory must review any specimen showing micro- organisms on direct smears that fail to grow. Streptococcuss pneumoniae is a common cause of community-acquired meningitis in pediatric patients, but Acinetobacter baumannii, which is a short, plump, gram-negative rod that is diffcult to destain, may also be misidentifed as a gram-positive Diplococcus. Bacillus species includ- ing Bacillus cereus are known to be gram-variable and can stain as gram-negative bacilli as well as gram-positive flamentous forms that show beading and can be confused with Nocardia species. These beta-lactamases are 5: CliniCal MiCroBiology ■ 213 very potent against beta-lactam agents, including the third-generation cephalosporins. Morphologic changes can sometimes be seen in gram-negative bacilli that are exposed to certain beta-lactam agents; for example, piperacillin interact- ing with penicillin-binding proteins may result in cell elongation without division.
In the treatment of leukemias buy generic valacyclovir 1000mg on-line lemon antiviral, only limited guidance is available on prophylactic platelet transfusion trig- gers for minor procedures such as central venous line placement buy valacyclovir 1000mg on-line hiv infection rate in south africa. The response to a platelet transfusion is best assessed by obtain- ing a posttransfusion platelet count order cheapest valacyclovir hiv infection via kissing. This should be obtained between 15 and 60 minutes after com- pletion of the transfusion discount valacyclovir 500 mg without prescription hiv infection period. Delayed haemolytic transfusion reaction initially presenting as serum sickness like syndrome. Jackson: a recurring dilemma for health care providers in the treatment of Jehovah’s Witnesses. Primary chronic cold agglutinin disease: an update on pathogenesis, clinical features and therapy. The expanding role of apheresis platelet support in neonatal alloim- mune thrombocytopenia: current status and future trends. Stability of coagulation factors in thawed, solvent/detergent-treated plasma during storage at 4 degrees C for 6 days. Streptococcus pneumonia– associated hemolytic uremic syndrome: classifca- tion and the emergence of serotype 19a. Preoperative autologous donation decreased allogeneic transfusion but increases exposure to all red blood cell transfusion: results of a meta-analysis. Fresh-Frozen Plasma, Cryoprecipitate, and Platelets admin- istration Practice guidelines Development Task Force of the College. Practice parameter for the use of fresh- frozen plasma, cryoprecipitate, and platelets. Drug induced immune haemolytic anaemia in the Berlin case-control surveillance study. How to approach major surgery where patients refuse blood transfusion (including Jehovah’s Witnesses). Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials group. Safety of lumbar puncture for children with acute lympho- blastic leukemia and thrombocytopenia. Signifcant numbers of apheresis-derived group o plate- let units have “high-titer” anti-a/a,B: implications for transfusion policy. Coagulation abnormali- ties produced by plasma exchange on the cell separator with special reference to fbrinogen and platelet levels. Toward an under- standing of transfusion-related acute lung injury: statement on the consensus panel. Pretransfusion testing without serologic crossmatch: approaches to ensure patient safety. Incidence of transfusion risk factors for transfusion-associated circulatory over- load among medical intensive care unit patients. Comparison of graft- versus-host-disease and survival after Hla-identical sibling bone marrow transplantation in ethnic popula- tions. Hemolysis of red blood cells after cell washing with different automated technologies: clinical implications in a neonatal cardiac surgery population. Phenotype matching of donor red blood cell units for nonalloimmunized sickle cell disease patients: a survey of 1182 North american laboratories. How I manage patients suspected of having had an Iga anaphylactic transfusion reaction. Factors affecting post- transfusion platelet increments, platelet refractoriness, and platelet transfusion intervals in thrombocytopenic patients. Cardiac arrests asso- ciated with hyperkalemia during red blood cell transfu- sion: a case series. Practice guidelines for blood component therapy: a report by the american Society of anesthesiologists Task Force on Blood Com- ponent Therapy. The differentiation of delayed hemolytic and delayed serologic transfusion reactions: incidence and predictors of hemolysis. Inhibition of erythroid progenitor cells by anti-Kell antibodies in fetal alloimmune anemia. Physiologic strate- gies to prevent fainting responses during or after whole blood donation. Paroxysmal cold hemoglobinuria of childhood: a review of the man- agement and unusual presenting features of six cases. Such errors can result in cata- strophic bleeding or thrombosis that is preventable. Importantly, home- monitored patients with more frequent testing experience less bleeding and less thrombosis. This often happens when one physician is cross covering the patients of another physician and is unaware of the clinical status of the warfarin- treated patient for whom he or she has assumed temporary responsibility. Bleeding that does not appear to be life threatening can be treated with oral vitamin K. Warfarin dose adjustment should not occur until the patient has received two to three doses of warfarin and monitoring should occur at least once per month. Values that are substantially outside the therapeutic range require immediate attention to prevent a potentially lethal outcome. However, many clinical laborato- ries monitoring heparin-treated patients are now using an assay for anti-factor Xa. As with all antico- agulants, errors surrounding anticoagulation therapy have become highly visible because they can result in catastrophic bleeding or thrombosis, and they are often preventable. Monitoring the platelet count in a hospitalized patient on intravenous unfractionated heparin therapy is essential to reduce the incidence of this potentially lethal thrombotic condition by discontinuing heparin therapy and introducing an anticoagulant unrelated to heparin. The laboratory uses unfractionated heparin to calibrate the assay when the anticoagulant effect of unfractionated heparin is being assessed; and it uses low molecular weight heparin when the anticoagulant effect of low molec- ular weight heparin is being assessed. The labora- tory must know, therefore, whether the test request is for the assessment of anticoagulation with unfrac- tionated heparin or low molecular weight heparin. Providing a thrombotic patient with an inadequate dose of unfractionated heparin can result in clinically signifcant thrombosis. Activation of even a small percentage of the platelets in whole blood results in the release of a substance from the acti- vated platelets that neutralize heparin. The clinical impact of either of the situations is incorrect heparin dosing of the patient. A standard recommendation is that a whole-blood specimen is processed to separate blood cells from plasma within 4 hours of sample collection. An anti-factor Xa assay must be used in these cases, with careful attention to use the therapeutic range associated with unfractionated heparin and not low molecular weight heparin. For those patients who do need monitoring (see section Result Interpretation Mistakes for indica- tions), the appropriate test is the anti-factor Xa assay. As with all anticoagulants, errors surrounding antico- agulation therapy have become highly visible, because such errors can result in catastrophic bleeding or thrombosis, and they are often preventable.
These urinary antigen tests have sensitivities in the range of 70% to 100% but are only able to detect L purchase valacyclovir online from canada stages of hiv infection wiki. False-positive results for the Legionella urinary antigen have been reported as well order valacyclovir 500 mg with visa antiviral influenza drugs. Clearly cheap valacyclovir express hiv infection rate in zimbabwe, there remains a role for Legionella cultures obtained by bronchoscopy or pulmonary biopsy purchase discount valacyclovir on-line hiv infection one night stand. Consultation with the clinical microbiology laboratory regarding suitable specimens is the best way to avoid this error. The increasing inci- dence of community-associated methicillin-resistant staphylococcus aureus (Ca-Mrsa) has intensifed this debate. Nocardia species, for instance, often take fve days or longer to grow on sheep blood agar, so a “no growth” culture result after 48 hours would not assist in the care of such a patient. Prompt gram staining of positive blood cultures is recognized as an important factor in directing antimi- crobial therapy and has been shown to decrease mor- tality. Underdecolorization and overdecolorization of the gram stain are related to the use of acetone and isopropanol in the decolorization step. Therefore, most gram stain kits use a mixture of one part acetone to three parts of isopropanol. The decol- orization step should be done until the solvent run- ning from the slide is colorless. Prolonged application may cause gram-positive microorganisms to appear gram nega- tive, while short application may cause gram-negative microorganisms to appear gram positive. The timing and the acetone/isopropanol ratio as well as the spe- cies of microorganism all are important factors in the gram stain. For gram stains of clinical specimens that include polymorphonuclear cells in the background, a good quality-control indicator is that occasionally the nucleus of a polymorphonuclear cell should stain pur- ple. Pathologists and microbiologists must assess the tis- sue infammatory response when fungal elements are seen; if the cellular response is inconsistent, fungal contamination during slide preparation must be con- sidered. This mimic is russell bodies, which are intracytoplas- mic immunoglobulin bodies in plasma cells. Morphologic identifcation can be a useful tool for the preliminary diagnosis of fungal infection, but culture remains the gold standard for speciation. For example, lack of budding in a frozen section stain can make Blastomyces dermatitidis diffcult to distin- guish from Coccidioides. Moreover, empty, overlap- ping spherules in Coccidioides can mimic budding yeast and be mistaken for B. The alcian blue or an acid-fast stain can be used to distinguish between Coccidioides and Blastomyces; Coccidioides is nega- tive and Blastomyces is weakly positive. Cryptococcus usually will stain strongly with mucicar- mine; the occasional capsule-defcient forms of cryp- tococci stain with melanin. Correction of the misidentifcation in the medical record and timely communication of the mis identifcation are important. Burkholderia pseudomallei is the cause of melioi- dosis, a serious infection common in southwest asia. The limitations of automated systems must be understood by clinical microbiologists in order to avoid this type of identifcation error. Many clinical microbiology laboratories presumptively identify beta- hemolytic streptococci on the basis of lancefeld group- ing. This type of sentinel result has been termed a “vital value”; alerting clinicians regarding such a result can promote patient safety by preventing a medical error and is an example of “enhanced clinical consulting. Conventional diagnosis of mycobacterial infec- tion uses acid-fast staining, culture, and phenotypic characterization of culture isolates; cultures may require weeks or months before results are available. These molecular methods have greatly reduced the time to diagnosis of tuberculosis. However, molecular methods have their own set of problems, such as the potential for misidentifcation of a microorganism owing to a false-positive result from a molecular amplifcation test for tuberculosis. False-positive results may lead to a misdiagnosis of tuberculosis and weeks of unnecessary antituberculous therapy. The menu of this system includes selected members of the Mycobacterium family, including M. Clinical microbiologists should be aware of this poten- tial for this type of misidentifcation of M. Unfortunately, the exquisite sensitivity of these assays makes them vulnerable to contamina- tion. Potential sources of contamination include large numbers of target microorganisms/virions in clinical specimens as well as repeated amplifcation of the same target sequence, leading to accumulation of amplifca- tion product in the laboratory environment. The accu- mulation of amplifcation product is a critical issue and, 220220 ■■ CliniCal DiagnosTiC TesTsCliniCal DiagnosTiC TesTs if uncontrolled, will lead to contamination of laboratory reagents, equipment, and even the ventilation system. Often there is a technical reason for such errors; automated susceptibility testing systems have been involved in such errors. Most clinical microbiology laboratories today rely on automated systems such as the Phoenix automated Microbiology system for identifcation and suscepti- bility testing. The performance of susceptibility testing in a clinical microbiology laboratory depends on robust methodology, good laboratory practices, and clearly delineated antimicrobial breakpoints. Moreover, rou- tine susceptibility testing must be checked with both internal and external quality control programs. Both clinicians and the clinical microbiology laboratory face uncertainty when the results of a sus- ceptibility test are not consistent with the established susceptibility patterns for a particular species. The availability and refex use of a confrmation test may be critical for directing proper antimicrobial therapy. Clinical microbiology laboratories must take an aggressive approach to detecting carbapen- emases in order to provide clinicians with clinically relevant susceptibility results. Many of the test results from the clinical microbiology laboratory logi- cally can be defned as vital values. Microbiology test results that are of vital value require timely notifca- tion of the health care provider; most microbiology laboratories call nurses or physicians for such results. Timely communi- cation of important laboratory data has long been rec- ognized as essential for providing optimal health care. The responsibility for interpretation of laboratory data has not been as clear as the reporting of these data. However, similar interpretation of laboratory data by the clinical pathologist has been less clear, and this concept is only recently coming to the forefront. The responsibilities of clinical pathologists, like the surgical pathologist, should extend into the postanalytic phase of the laboratory testing to assist clinicians in reviewing and understanding the results, and often providing an interpretation and/or recommending a future course of action. The discussion of post- analytic error that follows is based on the medical lit- erature as well as the personal experience of the author and includes common postanalytic medical errors from the perspective of the clinical microbiology laboratory. Consultation with infec tious disease clinicians and/or the clinical microbiology labo ratory director can help avoid such errors. The diagnosis of lyme disease can be diffcult; overdiagnosis and overtreatment of lyme disease is a recognized problem. The chronic symptoms of this patient were nonspecifc, and the results of her diagnostic evaluation for lyme disease did not support this diagnosis. Contradictory results warrant antimicrobial therapy with oral sulfamethoxazole/trimethoprim or oral tetracycline as this therapy can result in rapid improvement of the clinical status.
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Results to date have been contradictory or ing of the mechanisms responsible for the makeup fragmentary due buy cheap valacyclovir online natural anti viral foods, at least in large part discount valacyclovir 1000 mg amex antiviral serum, to an incom- of the vaginal microbiome in individual women at plete understanding of what constitutes a normal different lifetime stages cheap valacyclovir 1000 mg overnight delivery hiv zero infection, and in various environ- vaginal microbiota buy 1000mg valacyclovir with amex acute hiv yeast infection. Before we can utilize exogenous ments, and the triggers that induce pathological bacteria, either natural strains or experimentally changes in bacterial composition at this site remains redesigned microorganisms, or other products to fragmentary. In this chapter, we will summarize the correct purported defciencies and promote vaginal current state of knowledge of the composition of health, we frst need to more completely understand the bacterial microbiome in the lower female genital the composition and functions of the endogenous tract under different conditions and attempt to ana- bacteria, factors contributing to variability of the lyze the biological signifcance of the observations. The infu- Further analysis and interpretation of the vaginal ence of host genetic, immune, and environmental microbiome in women with defned pathological factors on bacteria–host interactions must also be conditions such as vulvovaginal candidiasis, bacte- considered. This is probably relationships between the microorganisms that colo- a simplistic and inaccurate view, at least for many nize different body sites and human physiology. Nonpregnant women may be positive is estimated that there are 10 times more bacterial for bacteria in their endometrium,3 and bacteria cells in our body than there are human cells, and have been recovered from almost 25% of placentas Vulvovaginal Infections 2 that were obtained from women who were deliv- a clinical diagnosis on the basis of analyzing only ered by cesarean section in the absence of labor. The following discussion Bacteria, as well as viruses, have been consistently highlights the predominant fndings from vagi- identifed in amniotic fuid during the midtrimester nal samples obtained from women in the United (reviewed in Reference 5). Variations in predomi- certainly becomes infected with the mother’s vagi- nant Lactobacillus species as well as the detection nal bacteria during delivery, and the female infant’s of unique bacterial genera at different frequencies vagina is similar to the bacterial composition of might be expected in the analysis of comparable her mother. In babies born by cesarean section to samples from women in other parts of the world women who were not in labor, the baby’s vaginal and depending on economic status and cultural microbiota more closely resembles the mother’s skin norms. Estrogen promotes glycogen deposition in their vagina by one or a combination of four on vaginal epithelial cells. It is important to emphasize that tion of the vagina reverts back to one dominated by other bacteria, such as Atopobium, Megasphaera, lactic acid–producing bacteria. The absence of a vaginal It has become abundantly clear that the vaginal microbiota dominated by Lactobacilli is more com- bacterial population in apparently healthy repro- mon in Hispanic or African-American women than ductive age women can be quite diverse as well as in women of European or Asian origin. Sexual activities Semen, saliva, and foreign objects in the vagina alter vaginal pH and immune functions and introduce foreign microbes. Contraception Oral contraceptives alter estrogen levels, diaphragms and condoms associated with increased enterobacteria levels, and intrauterine devices increase Bacteroides and Group B Streptococci. Vaginal products Douches, deodorants, pads, and tampons can alter vaginal ecosystem. Immune status Allergy or tolerance to specifc microbes alters the magnitude and direction of local innate and acquired immunity. Genetics Individual variations in production of immune activators or inhibitors infuence the capacity of the host to tolerate commensal bacteria and prevent overgrowth of pathogens. During the later gestational microbiota was stable throughout the cycle and even stages, the microbiome began to revert back to that during menstruation, while in other women, large present prior to conception. Preterm birth remains the major unresolved It must be emphasized that regardless of whether problem in obstetrics, and ascending infection from or not alterations in the vaginal microbiota were the lower to the upper genital tract is a major cause observed, all subjects remained in good health. Two studies investigated whether Therefore, the apparent stability or instability of a preterm birth could be predicted by analysis of the woman’s bacterial population is not predictive of vaginal microbiome during pregnancy. The most frequent changes in com- investigation evaluated the vaginal microbiome in position of the vaginal microbiota in the majority women undergoing assisted reproduction (in vitro of women were observed during menstruation and fertilization and embryo transfer) to determine following sexual intercourse. It should be noted that the microbiome observed, in women who either conceived natu- of the human ejaculate has been characterized in rally or following in vitro fertilization, that there a recent study, and there were more bacteria than was a greater species diversity in the microbiome there were spermatozoa in a semen sample. It has of women who did not have a term birth than in been suggested that the vaginal and seminal micro- women who delivered at term. Owing most likely to the Further investigations are certainly required to ver- increase in estrogen, and thus glycogen deposition, ify these discordant observations. A complication during gestation, the presence of a Lactobacillus- is that a specifc bacterium may be a pathogen in dominated vaginal microbiota appears to increase one woman and a commensal in a second woman. In addition to the lactobacillus species ria present in the same microbiome as well as host that predominate in nonpregnant women, one study genetic, immune, and environmental factors, will of pregnant women found that L. In each of these scenarios, the human vagina at these extravaginal locations strongly refected the may require unique and enhanced mechanisms of composition present in the corresponding vagina. It protection against infection as compared to other thus appears that bacteria present in secretions fow- mammals. It is ronment, and not other related acidic compounds, not surprising, therefore, that lactic acid–producing inhibits the growth of a multitude of bacteria asso- bacteria decline in concentration in the vagina in ciated with bacterial vaginosis as well as being toxic many postmenopausal women. Swidsinski A, Verstraelen H, Loening-Baucke clinical implications of this observation remain to be V et al. However, several studies have indicated trial bioflm in patients with bacterial vagino- that L. Am J Obstet Gynecol explore the relationship between d-lactic acid and 2008;199:52. Delivery mode shapes the acquisition methods of bacterial identification, that there is and structure of the initial microbiota across not one single human vaginal microbiome that multiple body habitats in newborns. Microbiology of the vagina in children: Normal and potentially pathogenic organisms. Temporal related the findings with various disorders may, dynamics of the human vaginal microbiota. Differences in vaginal microbi- an’s unique vaginal ecosystem and increase her ome in African American women versus susceptibility to growth of microorganisms that women of European ancestry. Microbiota mal for each individual patient before initiating of the seminal fuid from healthy and infertile a course of treatment to alter her vaginal micro- men. A metage- microbiome and the presence of unique microbial nomic approach to characterization of the vag- metabolites in the vagina may lead to development inal microbiome signature in pregnancy. The and l-lactic acid isomers, in maintaining optimal vaginal microbiota of pregnant women who health in reproductive age women. Tumor-derived lactic acid modulates lar samples from women with vulvar vestibulitis dendritic cell activation and antigen expres- syndrome. Inhibitory Association between the vaginal microbiota, effect of tumor cell-derived lactic acid on menopause status, and signs of vaginal atro- human T cells. The for protection against upper genital tract infec- primate vaginal microbiome: Comparative tions. Temporal shifts in nonpregnant African- Vaginal pH and microbicidal lactic acid when American women with and without bacterial lactobacilli dominate the microbiota. This process of specifc antigen recog- (masturbation, sexual intercourse, receptive oral nition by lymphocytes requires several days and is sex), nonsexual touching, contamination from the long lasting. Once sensitized to a specifc antigen, rectum, and environmental exposures all result in the lymphocytes retain an immunological memory deposition of various microorganisms in the vulvo- and rapidly recognize the antigen upon subsequent vaginal region. The prevention of clinical are probably the most important link between innate symptom development in response to this constant and acquired immunity. These cells are potent anti- microbial incursion and the continued presence of gen-presenting cells. The keratin prevents microbial adhe- antigens, and then transport these antigens to their sion to the epithelium, while vaginal mucus traps cell surface. Maturation also involves the concomi- microorganisms and prevents them from coming tant reorganization of the dendritic cell cytoskel- into contact with vaginal cells. In addition, the top eton and facilitates migration of the dendritic cells layer of epithelial cells in the vagina is exfoliated at to regional lymph nodes. There, the dendritic cells regular intervals, and microbes that adhere to these then come into intimate contact with T lymphocytes cells are released into the vaginal lumen.