title: Telephone triage:  diagnosis of candidiasis based upon self-reported vulvovaginal symptoms.
abstract: OBJECTIVE
  The study aimed to determine which self-reported vulvovaginal symptoms are most consistent with candidiasis confirmed by yeast culture and to establish guidelines to determine who can be appropriately treated by telephone triage versus office examination for women with vulvovaginal symptoms.
  
  
  METHODS
  A retrospective chart review of 105 patients seen in the Saint Louis University Vulvar and Vaginal Disorders Specialty Center during a 14-month period was performed after institutional review board approval. Patient's age, medication use, symptom scores on a Likert rating scale for vaginal/vulvar pain, burning, itching, dyspareunia, wet-mount results, and yeast culture results were recorded. Differences in the occurrence of vaginal/vulvar symptoms of any severity between women with positive and with negative yeast culture results were calculated using χ2 and Fisher exact tests. Differences in symptom scores of any severity were compared between women with positive and with negative yeast culture results using nonparametric Kolmogorov-Smirnov test, owing to a lack of normality of the distributions. Sensitivity of 75% or greater and specificity of 67% or greater were sought for all 9 recorded symptoms. Multiple logistic regression analysis was used to determine which symptoms and their cutoff values were significant independent predictors of a positive yeast culture result. Receiver operating characteristic curve analysis was used to determine the efficacy of individual symptoms and combinations of symptoms for predicting a positive yeast culture result. A value of p < 0.05 was used to denote statistical significance.
  
  
  RESULTS
  Four vulvovaginal symptoms met cutoff criteria for analysis to predict a positive yeast culture result: vaginal burning, vulvar burning, vulvar itching, and clitoral pain. Vaginal burning with a score of 6 or greater (p < 0.001) and vulvar itching with a score of 5 or greater (p < 0.05) were significant independent predictors of a positive yeast culture result. Women with both a vaginal burning score of 6 or greater and a vulvar itching score 5 or greater had a positive predictive value of 91.7% (22/24). Vaginal discharge was not shown to be predictive of candidiasis.
  
  
  CONCLUSIONS
  Diagnosis of candidiasis using self-reported vulvovaginal symptoms by telephone triage is difficult. Self-reported scores for vaginal burning of 6 or greater and for vulvar itching of 5 or greater are significant indicators of a positive yeast culture result. Vaginal discharge was not predictive of a diagnosis of candidiasis. A symptom chart can aid office staff in telephone triage of symptomatic women.
authors.affiliation: Department of Obstetrics, Gynecology, and Women's Health, School of Medicine, Saint Louis University, Saint Louis, MO 63117, USA. hoffstes@slu.edu
authors.forename: Susan
authors.initials: S
authors.lastname: Hoffstetter
authors.forename: Susan
authors.initials: S
authors.lastname: Barr
authors.forename: Cherie
authors.initials: C
authors.lastname: LeFevre
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Gavard
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use; D002176:Candida albicans / Q000302:isolation & purification; D002181:Candidiasis, Vulvovaginal / Q000175:diagnosis* / Q000188:drug therapy; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004414:Dyspareunia / Q000175:diagnosis; D005260:Female; D006801:Humans; D016015:Logistic Models; D015999:Multivariate Analysis; D009819:Office Visits; D010808:Physical Examination / Q000379:methods*; D011539:Pruritus Vulvae / Q000175:diagnosis; D012372:ROC Curve; D012189:Retrospective Studies; D057566:Self Report; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013685:Telecommunications; D014218:Triage; D019522:Vaginal Discharge / Q000175:diagnosis
chemical_list: D000935:Antifungal Agents