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The approach to cervical cancer prevention has evolved significantly over the past two decades. HPV immunization has decreased the specificity of screening modalities and HPV-based testing has been replacing our previously successful morphology-only approach. Additionally, there is much more emphasis on providing precision prevention, rather than the previously used “one-fits-all” management strategies. A number of new biomarkers are entering clinical practice and being integrated into cervical cancer screening and management in order to enable a more personalized assessment of the risk for precancer/cancer for an individual patient. The 2019 ASCCP Risk-Based Management Consensus Guidelines expand on the concept of “equal management for equal risk”. They consider a patient’s history in addition to current test results to provide recommendations for increased surveillance/treatment in patients at higher risk for CIN3+ while minimizing interventions for lower-risk patients who have new versus persistent HPV infection. Clinical management decisions are based on immediate risk and 5-year risk estimates for CIN3+, which are determined by referencing an extensive risk table compiled by the National Cancer Institute (NCI). The course of action for a given patient is recommended by comparison of the risk in the risk database, to the predetermined clinical action thresholds. These guidelines address the need for simplification and offer some stability for the provider while being conducive to the incorporation of anticipated continued technologic advances in methods for cervical cancer prevention. Their enduring nature will allow for changes needed based on risk reduction as HPV vaccination uptake increases and vaccinated women reach screening age. Similarly, the design allows for the addition of new tests into the risk assessment calculations after their approval by applicable regulatory agencies and review/consensus approval by the ASCCP new technology and enduring guidelines workgroups. As cytopathologists, we must be familiar with the scientific advancements in primary and secondary prevention, evolving screening and management guidelines, and participate actively in the multidisciplinary approach for the prevention of cervical cancer.

Background: Citrobacter, a gram negative bacillus, is emerging as one of the major pathogens in hospital settings, with a potential to cause serious infections. Virulence markers are the factors which enhance the survival ability of the microorganisms. Among the gram negative bacilli, these have been extensively studied in Escherichia coli. To the best of our knowledge as per internet search, we report that this study has been done for the first time in India on Citrobacter. Aims: An investigation was done to determine the ability of Citrobacter in producing virulence markers like the ability to survive the serum bactericidal activity, the resistance to the intracellular killing in the Polymorphonuclear Leucocytes (PMNLs) and the Cell Surface Hydrophobicity (CSH). Settings and Design: This prospective study was conducted in the Department of Microbiology of a tertiary care hospital in Aligarh, India, for a period of one year and six months. Material and Methods: A total of 105 clinical isolates and 20 control isolates from healthy subjects were identified as having Citrobacter spp. by using standard biochemical tests and they were studied for the presence of virulence markers like the ability to survive the serum bactericidal activity, the resistance to the intracellular killing in the Polymorphonuclear Leucocytes (PMNLs) and the cell surface hydrophobicity. The statistical analysis which was used: The standard deviations and the p-values were calculated for comparison. Results: Out of the 105 clinical isolates of Citrobacter which were studied, 86.6% isolates were resistant to 100% serum after 180 minutes of incubation and intracellular killing in PMNL was demonstrated in 17% strains. The Salt Aggregation Test (SAT) for the cell surface hydrophobicity was positive in 17.1% strains at different concentrations of ammonium sulphate. The presence of more than one virulence marker was present in 71.4% of the clinical isolates while in the control isolates. Conclusions: The presence of the virulence markers in Citrobacter demonstrated its pathogenic potential. Its invasiveness and ability to disseminate can be studied by identifying these markers.