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Comparative performance of vulvovaginal swab sampling versus endocervical sampling for the detection of Chlamydia, Gonorrhea, Mycoplasma genitalium, and Trichomoniasis: a cross-sectional study in Spain
Rendimiento comparativo del exudado vulvovaginal frente al endocervical para la detección de Chlamydia, Gonorrhea, Mycoplasma genitalium y tricomoniasis: un estudio transversal en España
M. Linaresa,1, P. Galiciaa,b,
,1, A. Rojasa, A. Miguel-Benitoc, J. Cuadros-Gonzáleza,d, J.M. Ramos-Rincóne
a Servicio de Microbiología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain
b Centro de Salud Segovia, Madrid, Spain
c Subdirección General de Vigilancia en Salud Pública, Madrid, Spain
d Departamento de Microbiología, Facultad de Medicina, Universidad Alcalá de Henares, Spain
e Departamento de Medicina Clínica, Facultad de Medicina Clínica, Universidad Miguel Hernández, Elche, Spain
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Women with symptoms often undergo laboratory testing depending on the specific standards of care for each facility. Thus, women seen in a family practice office might receive only vaginitis testing, while those seen in a sexually transmitted disease office might be more likely to receive only sexually transmitted infection (STI) testing. This is evidence of the importance of adequate diagnosis and screening in primary care settings.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Moreover, evidence suggests that women with bacterial vaginosis alone or with concurrent <span class="elsevierStyleItalic">Candida</span> spp. infections had significantly higher rates of STI coinfection compared to those negative for vaginitis, underscoring the importance of comprehensive screening where indicated.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain, the most frequent notifiable STIs are those caused by <span class="elsevierStyleItalic">Chlamydia trachomatis</span> and <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> while <span class="elsevierStyleItalic">Trichomonas vaginalis</span> remains the most prevalent non-viral infection worldwide, with around 156 million cases reported in 2016.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Moreover, the progressive incorporation of molecular diagnostic techniques for resistance has led to the detection of increased antimicrobial resistance of <span class="elsevierStyleItalic">Mycoplasma genitalium</span>, underscoring the urgent need to review and possibly modify empirical treatment strategies.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Despite this, routine screening for <span class="elsevierStyleItalic">M. genitalium</span> (MG) and <span class="elsevierStyleItalic">T. vaginalis</span> (TV) is not included in primary STI screening protocols in many countries, which may result in a significant gap in the epidemiological comprehension of MG and TV prevalence among the general population.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain, the diagnosis of STIs in women often depends on the collection of endocervical samples, which sometimes hinders and delays diagnosis and adequate treatment.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This type of sample can also displace the advantages of self-sample collection in asymptomatic patients, which is in contrast to the recommendations of the most recent literature, according to which the use of vaginal exudate to collect STI samples is preferred.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of our study was to evaluate the concordance between vaginal and endocervical samples for the diagnosis of STIs in female patients attended in the referral area of the Hospital Universitario Principe de Asturias between April 2022 and December 2023. This study forms part of Project Aproxima, a broader initiative aimed at improving STI diagnostic protocols and patient management strategies within primary care settings.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective cross-sectional study was carried out on vaginal and endocervical samples from women attended in the reference area of the Principe de Asturias Hospital with symptoms suggestive of vulvovaginitis or for STI screening during the study period.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During the study period, 7260 vaginal and 3994 endocervical samples were processed. Of the vaginal samples analyzed, 23.8% (n = 1727) were processed for molecular biology with a percentage of positivity for any of the pathogens studied of 15.28%. Of the endocervical samples, 55.65% (n = 2223) were processed for molecular biology, with a positivity percentage for STI of 14.88% (n = 331). Of all these samples, 130 paired samples (vaginal + endocervical) were analyzed for our study.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following variables were collected: a) sociodemographic b) variables related to the sample (endocervical and vaginal, result of STI diagnosis and CT index in case of positive samples) and c) clinical variables (symptomatology and reason for request).</p><p id="par0045" class="elsevierStylePara elsevierViewall">Vaginal and endocervical samples were collected by health professionals (nursing, medicine or midwifery) using Abbott swabs®. Following collection, samples were transported at room temperature to the Department of Clinical Microbiology at Principe de Asturias University Hospital and processed within 24 h of receipt.</p><p id="par0050" class="elsevierStylePara elsevierViewall">On arrival, the vulvovaginal and endocervical swabs were subjected to nucleic acid amplification testing (NAAT) using the Abbott Alinity® systems and the Abbott RealTime CT/NG (<span class="elsevierStyleItalic">M. genitalium</span>/<span class="elsevierStyleItalic">T. vaginalis</span>) kit. The assays were carried out in strict accordance with the manufacturer's protocol.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">A description of STI cases diagnosed was carried out using measures of central tendency and dispersion for quantitative variables, as well as frequency distributions and percentages for qualitative variables, respectively. The median age of women of positive endocervical sample was compared by Mann–Whitney <span class="elsevierStyleItalic">U</span> test.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A Kappa index as measure of concordance of endocervical and endovaginal samples were performed. The sensitivity, specificity, and predictive value (positive and negative) of the vaginal sample was calculated, as well as the likelihood ratios (positive and negative) with 95% of coefficient interval. The gold standard was the endocervical sample. The statistical analysis was performed by EpiData Software.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This work was approved by the Institutional Research Ethics of Principe de Asturias University Hospital (IE ITS OE 41/2021). The requirement to obtain informed consent from participants was waived by the Institutional Research Ethics of Principe de Asturias University Hospital. The study was conducted in accordance with the principles of the latest revision of the Helsinki Declaration.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">A total of one hundred and thirty paired samples (endocervical and vaginal were analyzed during the study period (April 2022 to December 2023). The patients median age was 29 years (IQR: 15–42). A total of 57 (43.8%) endocervical samples tested positive for sexual transmitted pathogens. The distribution of microorganisms was as follows: <span class="elsevierStyleItalic">M. genitalium</span> (n = 19; 14.6%), <span class="elsevierStyleItalic">C. trachomatis</span> (n = 18; 13.8%), <span class="elsevierStyleItalic">N. gonorrhoeae</span> (n = 12; 9.2%), and <span class="elsevierStyleItalic">T. vaginalis</span> (n = 10; 7.7%).</p><p id="par0075" class="elsevierStylePara elsevierViewall">Of the vaginal and endocervical samples analyzed, 57 and 59 respectively were positive for any of the pathogens tested. The Kappa concordance index was 0.969: IC95%:0.926−1.012; standard error = 0.022. One vaginal sample of <span class="elsevierStyleItalic">C. trachomatis</span> and other of N. <span class="elsevierStyleItalic">gonorrhoeae</span> were negative. The sensitivity of vaginal samples was 96.5% with specificity of 100%. The sensitivity for <span class="elsevierStyleItalic">N. gonorrhoeae</span> was 91.6% with specificity of 100%, and <span class="elsevierStyleItalic">M. genitalium</span> 94.7%% with also a specificity of 100%. The sensitivity and specificity for vaginal samples for diagnosis of <span class="elsevierStyleItalic">C. trachomatis</span> and <span class="elsevierStyleItalic">T. vaginalis</span> was 100% in both cases. The details of predictive values in global and in each microorganism is in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The cycle thresholds (Ct) of the positive samples for any of the microorganisms were also analyzed and their distribution is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The findings of our study allow us to affirm that the diagnosis of STI can be carried out in vaginal samples. This finding aligns with recommendations in the literature, which suggest that vaginal samples are suitable for women undergoing STI testing.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In Spain, according to recent studies, there has been a significant increase in STIs, especially among women and in patients under 30 years old.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Additionally, healthcare regarding STIs varies greatly depending on the region, making it necessary to search for effective diagnostic and public health tools that can be implemented in actual clinical practice.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The introduction of STI screening in vaginal samples in our environment can promote early detection, especially in Primary Care, facilitating diagnosis in asymptomatic women and also allowing accurate treatment and avoiding comorbidity due to late STI diagnosis (infertility, coinfections, etc.). These findings highlight the need to implement point of care services, especially in high-prevalence STI areas.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The standardization of STI diagnosis is crucial, facilitating less invasive samples as well as self-collection of samples if possible, especially in populations with less access to health resources and in areas with a high prevalence of STIs. Allowing the patient to collect her own vaginal swab for STI testing reduce the demands on resources and personnel since a traditional pelvic exam for obtaining an endocervical sample is time and resource intensive.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The strength of this research is pioneering in evaluating vulvovaginal exudate samples for STI testing within the Spanish healthcare context, offering an insightful precedent for future public health strategies in STI management.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our study has limitations, such as the small sample size as well as the lack of knowledge of clinical factors, such as treatments received and symptoms duration, since it is not recorded in the clinical history of some patients.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The vaginal panel RT-PCR kit is a simple and fast tool for microbiological diagnosis of this type of infection compared to endocervical panel RT-PCR kit. Clinical adoption of vaginal samples into primary care clinics and doctors' offices could reduce underdiagnosis and undertreatment of STIs. If integrated efficiently into the clinical workflow, the test would have minimal impact on staff time and visit duration for patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Transparency declaration</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have nothing to disclose.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare no potential conflicts of interest.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0125" class="elsevierStylePara elsevierViewall">This study has no received any funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2162646" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1834687" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2162645" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1834686" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Transparency declaration" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "xack750559" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1834687" "palabras" => array:7 [ 0 => "Sexually transmitted infections" 1 => "Vulvovaginal swab" 2 => "<span class="elsevierStyleItalic">Chlamydia trachomatis</span>" 3 => "<span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>" 4 => "<span class="elsevierStyleItalic">Trichomonas vaginalis</span>" 5 => "<span class="elsevierStyleItalic">Mycoplasma genitalium</span>" 6 => "Endocervical swab" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1834686" "palabras" => array:7 [ 0 => "Infecciones de transmisión sexual" 1 => "Exudado vaginal" 2 => "<span class="elsevierStyleItalic">Chlamydia trachomatis</span>" 3 => "<span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>" 4 => "<span class="elsevierStyleItalic">Trichomonas vaginalis</span>" 5 => "<span class="elsevierStyleItalic">Mycoplasma genitalium</span>" 6 => "Exudado endocervical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The global increase in sexual transmitted infections (STI) makes it necessary to seek public health strategies that facilitate rapid and minimally invasive diagnosis. The objective was to evaluate the concordance between vaginal and endocervical samples for STI diagnosis.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A retrospective cross-sectional study was carried out on vaginal and endocervical samples from women attended in our reference area with symptoms suggestive of vulvovaginitis or for STI screening during the study period.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 130 paired samples were analyzed; fifty-seven and 59 samples were positive for vaginal and endocervical specimens (Kappa index of 0.969 (Standard error = 0.022). The sensitivity of the vaginal samples was 96.5% (IC95%: 87.2–99.4), with a specificity of 100% (IC95%: 93.0–100).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The introduction of STI screening in vaginal samples in our environment can facilitate rapid and effective diagnosis and allow early treatment of STI. Additionally, it facilitates sample collection and diagnosis in the community setting, essential for optimal screening.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1050">Introducción</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El aumento de infecciones de transmisión sexual (ITS) subraya la necesidad de herramientas de diagnóstico rápido y mínimamente invasivas. El objetivo fue evaluar la concordancia entre muestras vaginales y endocervicales para el diagnóstico de ITS.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio transversal retrospectivo de muestras vaginales y endocervicales de mujeres atendidas en nuestra área de referencia con síntomas de vulvovaginitis o cribado de ITS.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 130 muestras pareadas. Cincuenta y siete muestras vaginales y 59 endocervicales fueron positivas para alguno de los patógenos analizados (índice Kappa 0.969 (error estándar = 0,022). La sensibilidad de las muestras vaginales fue del 96,5% (IC95%: 87,2–99,4), con una especificidad del 100% (IC95%: 93,0–100).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discusión</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La introducción del cribado de ITS en muestras vaginales en nuestro medio puede facilitar un diagnóstico rápido y permitir el tratamiento precoz de las ITS, incluso en pacientes asintomáticas. Además, facilita la recogida de muestras y el diagnóstico en el ámbito comunitario.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Equal contribution.</p>" "identificador" => "fn0005" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 814 "Ancho" => 1455 "Tamanyo" => 69501 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distribution of the cycle thresholds (CT) of positive samples for each microorganism.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">NA, not applicable; PPV, positive predictive value, NPV, negative predictive value; PLR, positive likelihood ratios; NLR, negative likelihood ratios; 95% confidence interval.</p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gold standard—endocervical sample</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Vagina sample \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Positive \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Negative \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Total</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">130 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3563661.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="6" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Values (95% confident intervals)</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Overall \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Mycoplasma genitalium</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Chlamydia trachomatis</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Trichomonas vaginalis</span> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensitivity (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">96.6 (87.2−99.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.7 (71.8−89.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (78.1−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">91.6 (59.7−99.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (65.5−100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specificity (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (93.0−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(93.1−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (93.6−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (93.6−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (93.6−100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PPV (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (92.1−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (78.1−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (78.1−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (67.8−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (65.5−100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NPV (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">97.2 (89.5−99.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">98.6 (91.4−99.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (93.6−100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">98.6 (91.4−99.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (93.6−100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NLR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03(0,01−0.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05 (0.08−0.54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.08 (0.01−0.54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3563662.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratios (PLR), and negative likelihood ratios (NLR) of comparison the diagnosis of sexual transmitted diseases by vaginal samples, endocervical sample as a gold standard.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sexually transmitted infections in Spain: current status" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. 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