{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,11]],"date-time":"2026-09-11T10:55:32Z","timestamp":1789124132414,"version":"build-2803163510"},"reference-count":38,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2022,1,13]],"date-time":"2022-01-13T00:00:00Z","timestamp":1642032000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Wet-mount microscopy aerobic vaginitis (AV) diagnostic criteria need phase-contrast microscopy and keen microscopists, and the preservation of saline smears is less common in clinical practice. This research work developed new AV diagnostic criteria that combine Gram stain with clinical features. We enrolled 325 AV patients and 325 controls as a study population to develop new AV diagnostic criteria. Then, an independent group, which included 500 women, was used as a validation population. AV-related microscopic findings on Gram-stained and wet-mount smears from the same participants were compared. The accuracy of bacterial indicators from the two methods was verified by bacterial 16S rRNA V4 sequencing (n = 240). Logistic regression was used to analyse AV-related clinical features. The screened clinical features were combined with Gram-stain microscopic indicators to establish new AV diagnostic criteria. There were no significant differences in the leukocyte counts or the parabasal epitheliocytes (PBC) proportion between the Gram-stain and wet-mount methods (400\u00d7). Gram stain (1000\u00d7) satisfied the ability to identify bacteria as verified by 16S rRNA sequencing but failed to identify toxic leukocytes. The new criteria included: Lactobacillary grades (LBG) and background flora (Gram stain, 1000\u00d7), leukocytes count and PBC proportion (Gram stain, 400\u00d7), and clinical features (vaginal pH &gt; 4.5, vagina hyperemia, and yellow discharge). These criteria satisfied the accuracy and reliability for AV diagnosis (Se = 86.79%, Sp = 95.97%, and Kendall\u2019s W value = 0.899) in perspective validation. In summary, we proposed an alternative and valuable AV diagnostic criteria based on the Gram stain, which can make it possible to diagnose common vaginitis like AV, BV, VVC, and mixed infections on the same smear and can be available for artificial intelligence diagnosis in the future.<\/jats:p>","DOI":"10.3390\/diagnostics12010185","type":"journal-article","created":{"date-parts":[[2022,1,13]],"date-time":"2022-01-13T10:57:37Z","timestamp":1642071457000},"page":"185","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":19,"title":["Aerobic Vaginitis Diagnosis Criteria Combining Gram Stain with Clinical Features: An Establishment and Prospective Validation Study"],"prefix":"10.3390","volume":"12","author":[{"given":"Mengting","family":"Dong","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3995-4242","authenticated-orcid":false,"given":"Chen","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huiyang","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7921-0101","authenticated-orcid":false,"given":"Ye","family":"Yan","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaotong","family":"Ma","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huanrong","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xingshuo","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Huihui","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yixuan","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4872-6957","authenticated-orcid":false,"given":"Wenhui","family":"Qi","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ke","family":"Meng","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenyan","family":"Tian","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingmei","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aiping","family":"Fan","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cha","family":"Han","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9890-6254","authenticated-orcid":false,"given":"Gilbert G. G.","family":"Donders","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, University of Antwerp, 2550 Antwerp-Edegem, Belgium"},{"name":"Femicare Clinical Research for Women, 3300 Tienen, Belgium"},{"name":"Department of Obstetrics and Gynecology, Regional Hospital, 3300 Tienen, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fengxia","family":"Xue","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Tianjin Medical University General Hospital, 154 Anshan Road, He Ping District, Tianjin 300052, China"},{"name":"Tianjin Key Laboratory of Female Reproductive Health and Eugenics, 154 Anshan Road, He Ping District, Tianjin 300052, China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,1,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1111\/j.1471-0528.2002.00432.x","article-title":"Definition of a type of abnormal vaginal flora that is distinct from bacterial vaginosis: Aerobic vaginitis","volume":"109","author":"Donders","year":"2002","journal-title":"BJOG"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1007\/s00404-012-2571-4","article-title":"Aerobic vaginitis and mixed infections: Comparison of clinical and laboratory findings","volume":"287","author":"Fan","year":"2013","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1016\/j.resmic.2017.04.004","article-title":"Aerobic vaginitis: No longer a stranger","volume":"168","author":"Donders","year":"2017","journal-title":"Res. Microbiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1007\/s10096-018-3416-2","article-title":"Aerobic vaginitis in late pregnancy and outcomes of pregnancy","volume":"38","author":"Han","year":"2019","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Serretiello, E., Santella, B., Folliero, V., Iervolino, D., Santoro, E., Manente, R., Dell\u2019Annunziata, F., Sperlongano, R., Crudele, V., and De Filippis, A. (2021). Prevalence and Antibiotic Resistance Profile of Bacterial Pathogens in Aerobic Vaginitis: A Retrospective Study in Italy. Antibiotics, 10.","DOI":"10.3390\/antibiotics10091133"},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Oerlemans, E.F.M., Wuyts, S., Bellen, G., Wittouck, S., De Boeck, I., Ruban, K., Allonsius, C.N., van den Broek, M.F.L., Donders, G.G.G., and Lebeer, S. (2020). The Dwindling Microbiota of Aerobic Vaginitis, an Inflammatory State Enriched in Pathobionts with Limited TLR Stimulation. Diagnostics, 10.","DOI":"10.3390\/diagnostics10110879"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1007\/s00404-015-4007-4","article-title":"Diagnosis of aerobic vaginitis by quantitative real-time PCR","volume":"294","author":"Rumyantseva","year":"2016","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"114981","DOI":"10.1016\/j.diagmicrobio.2019.114981","article-title":"Vaginal bacterial profiles of aerobic vaginitis: A case-control study","volume":"96","author":"Wang","year":"2020","journal-title":"Diagn. Microbiol. Infect. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"677648","DOI":"10.3389\/fcimb.2021.677648","article-title":"Composition of Vaginal Microbiota in Pregnant Women with Aerobic Vaginitis","volume":"11","author":"Oh","year":"2021","journal-title":"Front. Cell. Infect. Microbiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1315","DOI":"10.1111\/j.1471-0528.2009.02237.x","article-title":"Predictive value for preterm birth of abnormal vaginal flora, bacterial vaginosis and aerobic vaginitis during the first trimester of pregnancy","volume":"116","author":"Donders","year":"2009","journal-title":"BJOG"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1007\/s00404-014-3525-9","article-title":"Diagnostic and therapeutic advancements for aerobic vaginitis","volume":"291","author":"Han","year":"2015","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1007\/s00404-011-2085-5","article-title":"Chlamydial infection in a high risk population: Association with vaginal flora patterns","volume":"285","author":"Marconi","year":"2012","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1007\/s10096-016-2584-1","article-title":"Bacterial vaginosis, aerobic vaginitis, vaginal inflammation and major Pap smear abnormalities","volume":"35","author":"Pinto","year":"2016","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Sherrard, J., Wilson, J., Donders, G.G.G., Mendling, W., and Jensen, J.S. (2018, July 27). 2018 European (IUSTI\/WHO) International Union Against Sexually Transmitted Infections (IUSTI) World Health Organization (WHO) Guideline on the Management of Vaginal Discharge. Available online: https:\/\/journals.sagepub.com\/doi\/10.1177\/0956462418785451.","DOI":"10.1177\/0956462418785451"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1016\/j.diagmicrobio.2015.12.018","article-title":"Screening for abnormal vaginal microflora by self-assessed vaginal pH does not enable detection of sexually transmitted infections in Ugandan women","volume":"85","author":"Donders","year":"2016","journal-title":"Diagn. Microbiol. Infect. Dis."},{"key":"ref_16","first-page":"727","article-title":"Enumeration of clue cells in rehydrated air-dried vaginal wet smears for the diagnosis of bacterial vaginosis","volume":"76","author":"Larsson","year":"1990","journal-title":"Obstet. Gynecol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e00300-19","DOI":"10.1128\/JCM.00300-19","article-title":"Molecular Diagnosis of Vaginitis: Comparing Quantitative PCR and Microbiome Profiling Approaches to Current Microscopy Scoring","volume":"5","author":"Lynch","year":"2019","journal-title":"J. Clin. Microbiol."},{"key":"ref_18","first-page":"352","article-title":"Bacterial infections of the lower genital tract in fertile and infertile women from the southeastern Poland","volume":"84","author":"Tomusiak","year":"2013","journal-title":"Ginekol. Pol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"48","DOI":"10.3855\/jidc.11940","article-title":"Commensal and virulent Escherichia coli strains of vaginal origin are reservoirs of resistance cassettes in class 1 integrons","volume":"14","year":"2020","journal-title":"J Infect. Dev. Ctries"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1016\/j.tjog.2015.06.012","article-title":"Diagnosis and microecological characteristics of aerobic vaginitis in outpatients based on preformed enzymes","volume":"55","author":"Wang","year":"2016","journal-title":"Taiwan. J. Obstet. Gynecol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.ijantimicag.2003.12.013","article-title":"Microbiological\/clinical characteristics and validation of topical therapy with kanamycin in aerobic vaginitis: A pilot study","volume":"24","author":"Tempera","year":"2004","journal-title":"Int. J. Antimicrob. Agents"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Boccella, M., Santella, B., Pagliano, P., De Filippis, A., Casolaro, V., Galdiero, M., Borrelli, A., Capunzo, M., Boccia, G., and Franci, G. (2021). Enterococcus Prevalence and Antimicrobial Resistance of Species: A Retrospective Cohort Study in Italy. Antibiotics, 12.","DOI":"10.3390\/antibiotics10121552"},{"key":"ref_23","first-page":"1","article-title":"Centers for Disease Control and Prevention, Sexually transmitted diseases treatment guidelines","volume":"64","author":"Workowski","year":"2015","journal-title":"MMWR Recomm. Rep."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1113","DOI":"10.1128\/JCM.02523-06","article-title":"First notification of positive blood cultures and the high accuracy of the gram stain report","volume":"45","year":"2007","journal-title":"J. Clin. Microbiol."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Wang, Z., Zhang, L., Zhao, M., Wang, Y., Bai, H., and Wang, Y. (2020). Deep Neural Networks Offer Morphologic Classification and Diagnosis of Bacterial Vaginosis. J. Clin. Microbiol., 59.","DOI":"10.1128\/JCM.02236-20"},{"key":"ref_26","unstructured":"Berek, J.S. (2012). Berek, & Novak\u2019s Gynecology, Lippincott Williams & Wilkins. [15th ed.]."},{"key":"ref_27","unstructured":"Holt, G.J., Krieg, N.R., Sneath, H.P., Staley, J.T., and Williams, S.T. (1994). Bergey\u2019s Manual of Determinative Bacteriology, Williams & Wilkins. [9th ed.]."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Sonthalia, S., Aggarwal, P., Das, S., Sharma, P., Sharma, R., and Singh, S. (2020). Aerobic vaginitis\u2014An underdiagnosed cause of vaginal discharge\u2014Narrative review. Int. J. STD AIDS, 1018\u20131027.","DOI":"10.1177\/0956462420913435"},{"key":"ref_29","first-page":"352","article-title":"Normal flora and bacterial vaginosis in pregnancy: An overview","volume":"42","author":"Redelinghuys","year":"2016","journal-title":"Crit. Rev. Microbiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1297","DOI":"10.1007\/s10096-016-2664-2","article-title":"Increased vaginal pH in Ugandan women: What does it indicate?","volume":"35","author":"Donders","year":"2016","journal-title":"Eur. J. Clin. Microbiol. Infect. Dis."},{"key":"ref_31","unstructured":"Clinical & Laboratory Standards Institute (CLSI) (2008, November 24). Abbreviated Identification of Bacteria and Yeast; Approved Guideline\u2014Second Edition. 24 November 2008. Available online: https:\/\/www.clsi.org\/standards\/products\/microbiology\/documents\/m35\/."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1136\/sextrans-2015-052406","article-title":"How to diagnose and treat aerobic and desquamative inflammatory vaginitis","volume":"93","author":"Mason","year":"2017","journal-title":"Sex. Transm. Infect."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1002\/(SICI)1098-0997(1996)4:1<2::AID-IDOG2>3.0.CO;2-5","article-title":"Assessment of vaginal lactobacillary flora in wet mount and fresh or delayed gram\u2019s stain","volume":"4","author":"Donders","year":"1996","journal-title":"Infect. Dis. Obstet. Gynecol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1136\/jcp.53.4.308","article-title":"Wet mount microscopy reflects functional vaginal lactobacillary flora better than Gram stain","volume":"53","author":"Donders","year":"2000","journal-title":"J. Clin. Pathol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"482","DOI":"10.1097\/00006250-200103000-00031","article-title":"Wet smear compared with Gram stain diagnosis in asymptomatic pregnant women","volume":"97","author":"Donders","year":"2001","journal-title":"Obstet. Gynecol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Kim, H., Kim, T., Kang, J., Kim, Y., and Kim, H. (2020). Is Lactobacillus Gram-Positive? A Case Study of lactobacillus iners. Microorganisms, 7.","DOI":"10.3390\/microorganisms8070969"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1016\/S0020-7292(01)00388-5","article-title":"Efficacy of 7-day treatment with metronidazole + miconazole (Neo-Penotran)\u2014A triple-active pessary for the treatment of single and mixed vaginal infections","volume":"74","author":"Ozyurt","year":"2001","journal-title":"Int. J. Gynaecol. Obstet."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1318","DOI":"10.1016\/j.cmi.2020.03.012","article-title":"Image analysis and artificial intelligence in infectious disease diagnostics","volume":"26","author":"Smith","year":"2020","journal-title":"Clin. Microbiol. Infect."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/12\/1\/185\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,13]],"date-time":"2025-10-13T14:14:53Z","timestamp":1760364893000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/12\/1\/185"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,1,13]]},"references-count":38,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,1]]}},"alternative-id":["diagnostics12010185"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics12010185","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,1,13]]}}}