Maternal immunization with pneumococcal polysaccharide vaccine in the third trimester of gestation.

In a randomized, double blinded study, 23-valent pneumococcal polysaccharide vaccine (PSV) or conjugate Haemophilus influenzae type b (HbOC) vaccine was administered to 60 healthy women in the third trimester of gestation. Total IgG, IgG1, and IgG2 antibodies to pneumococcal serotypes 6B, 14, 19F and 23F were measured by ELISA in mothers prior to immunization, at delivery and 7 months after delivery, and in infants at birth (cord blood), 2 and 7 months after delivery. IgA was evaluated in breast milk at 2 and 7 months, and opsonophagocytic activity in cord blood. PSV was safe and immunogenic in pregnant women. Transplacental transmission of vaccine-specific antibodies was efficient. Maternal immunization with PSV resulted in significantly higher concentrations of pneumococcal antibodies in infants at birth and at 2 months of age, and greater functional opsonophagocytic activity of passively acquired IgG antibody.

Penetration of trovafloxacin into gynecologic tissues.

BACKGROUND: This randomized open-label study assessed the penetration into gynecologic tissues of trovafloxacin, a new broad-spectrum, fourth-generation fluoroquinolone with in vitro activity against anaerobes, gram-positive, gram-negative, and atypical pathogens. METHODS: Women undergoing hysterectomy or hysterectomy and adnexectomy received 200 mg trovafloxacin orally before surgery as a single dose or as multiple doses. Samples of genital tract tissue and serum were obtained simultaneously during surgery. RESULTS: In the single-dose group, trovafloxacin concentrations in genital tract tissues were measurable for up to 30 hours. Tissue concentrations of trovafloxacin after multiple doses were comparable to those after single doses. Mean tissue: serum concentration ratios after a single dose were greatest in the ovary (1.6 microg/g) and comparable in uterus, myometrium, cervix, and fallopian tubes (0.5 to 0.7 microg/g). Adverse events after a single dose were minor. CONCLUSIONS: A daily dose of 200 mg trovafloxacin produces gynecologic tissue concentrations that persist for up to 30 hours at levels necessary to prevent or treat pelvic infections. This dosing regimen is well tolerated.

Preterm labor and maternal hypoxia in patients with community-acquired pneumonia.

OBJECTIVE: We sought to determine if preterm labor is associated with the degree of maternal hypoxia in pregnant women with community-acquired pneumonia but no other maternal diseases. METHODS: We retrospectively reviewed the medical records of all antepartum patients admitted with a diagnosis of community-acquired pneumonia to an inner-city university hospital between 1983 and 1987. Included in this review were only the patients with radiologically confirmed diagnose of pneumonia and documented arterial blood gases on room air at the time of admission, but no other maternal diseases. RESULTS: A total of 22 cases were identified. There was no maternal mortality, but there were 2 patients (9%) who developed respiratory failure requiring mechanical ventilation. Bacteremia with Streptococcus pneumoniae was documented in 1 patient (5%). Preterm labor complicated 5 cases (23%) and led to preterm delivery in 3 patients (14%). Terbutaline tocolysis was instituted in 3 patients, but was discontinued in 1 patient who was allowed to deliver because of her worsening condition. Preterm labor was associated with the WBC count on admission, usually > 18,000/mm3, but no statistically significant correlation with the severity of maternal hypoxia was noted. Five patients (23%) were incorrectly diagnosed at the time of admission, 4 with an initial diagnosis of pyelonephritis and 1 with an initial diagnosis of cholecystitis. CONCLUSIONS: Community-acquired pneumonia in the antepartum period is responsible for significant maternal and fetal complications even in the absence of other maternal diseases. Preterm labor and delivery remain frequent, and tocolysis should be used cautiously. At the time of admission, the diagnosis may be difficult. The degree of maternal hypoxia on admission does not correlate with the presence of preterm labor.

Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases.

Wound infections are a common surgical complication, often requiring a prolonged hospital stay and leading to increased costs. Over a one-year period, 2,431 patients were followed after cesarean delivery with prompt evaluation and culture of all suspicious wounds. Seventy subjects (2.8%) developed confirmed wound infection, and 42 (1.7%) developed noninfected open surgical wounds. Seven (0.3%) fascial dehiscences were diagnosed, requiring surgical repair. Forty of 63 (64%) infected wounds had positive bacterial cultures, with Staphylococcus epidermidis (29%), Enterococcus faecalis (17%), Staphylococcus aureus (17%), Escherichia coli (11%) and Proteus mirabilis (10%) the most frequent isolates. Only 7 of 42 (17%) noninfected wounds had positive cultures, with only S aureus, S epidermidis and Corynebacterium species isolated. Ninety-five percent of the noninfected wounds had blood or serous collections present. Rupture of membranes lasting longer than six hours, emergency cesarean delivery and morbid obesity were associated with a statistically increased likelihood of the development of infected wounds. Emergency cesarean delivery and morbid obesity, but not prolonged rupture of membranes, were associated with an increased likelihood of the development of noninfected wounds. Therefore, it appears that at least two mechanisms are responsible for the development of postcesarean open wounds: (1) increased amniotic fluid and wound colonization due to prolonged rupture of membranes, resulting in a wound infection containing one or more bacterial species derived from the cervicovaginal flora, and (2) increased exogenous bacterial contamination and flora consistent with skin species or breaks in sterile technique, often accompanying difficult or emergency surgery.

Pneumonia in pregnancy.

Pneumonia complicating pregnancy requires a prompt diagnosis and the institution of adequate supportive and antimicrobial therapy. In a patient with a classic presentation of pneumonia, the most likely pathogens are Streptococcus pneumoniae and Haemophilus influenzae. In a patient with an atypical presentation of pneumonia, Mycoplasma pneumoniae and Chlamydia pneumoniae are frequently encountered. In a patient suffering from acquired immunodeficiency syndrome (AIDS), Pneumocystis carinii is the most frequent pathogen. The antimicrobial therapy, therefore, has to be tailored to the sensitivity patterns of these pathogens in the community. Hospitalization is recommended for the pregnant patient diagnosed with pneumonia to ensure effective supportive care and minimize the risk of preterm labor and delivery.

Prevalence of beta-lactamase enzyme production in bacteria isolated from women with postpartum endometritis.

One hundred eighty-four postpartum patients with the diagnosis of endomyometritis underwent intrauterine culturing. Beta-Lactamase production was tested using nitrocephin-impregnated discs in 278 bacterial isolates from patients with postpartum endometritis. beta-Lactamase production was found to be present in 149 of 278 (54%) isolates tested: 0 of 39 Streptococcus faecalis (0%), 22 of 41 Escherichia coli (54%), 66 of 68 Bacteroides bivius (97%), 0 of 13 Proteus mirabilis (0%) and 15 of 42 Staphylococcus epidermidis (36%). Anaerobes, as a group, had the highest rate of beta-lactamase production, 94 of 102 (93%), followed by gram negatives, 34 of 84 (40%), then gram positives, 21 of 91 (23%). However, it was the beta-lactamase produced by the gram-negative bacteria that was most responsive to the addition of a beta-lactamase inhibitor. The frequent isolation of beta-lactamase-producing bacteria from patients with postpartum endometritis raises concern about the use of antibiotics not resistant to these enzymes. Therefore, antibiotics combined with a beta-lactamase inhibitor may have potential as single-agent therapy in obstetric and gynecologic infections.

Vaginal flora and pelvic inflammatory disease.

Forty-one patients with acute pelvic inflammatory disease were evaluated for the coexistence of bacterial vaginosis. Because all patients had a copious purulent vaginal discharge, microscopic criteria could not be used and microbiologic criteria were employed. The vaginal bacterial flora were not consistent with that of bacterial vaginosis, because Lactobacillus and other gram-positive bacteria dominated with colony counts of 10(3) to 10(5) cfu/ml (colony-forming units per milliliter). Endocervical specimens yielded Neisseria gonorrhoeae from 20 patients and Chlamydia trachomatis from 11 patients. Anaerobes were not dominant in any site sampled. A total of 147 bacteria were isolated from the endometrium, 16 (11%) of which were anaerobes. Thus the endogenous bacterial flora were not consistent with that of the microbiologic definition of bacterial vaginosis. N. gonorrhoeae was the most common isolate from the endocervix and endometrium; it was isolated three times more frequently from the endocervix and two times more frequently from the endometrium than was C. trachomatis.

Ectopic pregnancy with undetectable serum and urine beta-hCG levels and detection of beta-hCG in the ectopic trophoblast by immunocytochemical evaluation.

BACKGROUND: Ectopic pregnancies associated with negative urine or serum pregnancy test by radioimmunoassay usually demonstrate either nonviable trophoblast or absent production of beta-hCG by the ectopic pregnancy. CASE: We report a patient with intra-abdominal hemorrhage caused by a ruptured ampullary ectopic pregnancy who had undetectable serum and urine beta-hCG levels (less than 5 mIU/mL). Immunoperoxidase staining of the ectopic trophoblastic tissue obtained at surgery revealed both beta-hCG and placental alkaline phosphatase. CONCLUSION: Negative serum and urine pregnancy tests can occur even though beta-hCG produced by the viable ectopic trophoblastic tissue can be demonstrated by immunoperoxidase staining.

The microbiology of post-cesarean wound morbidity.

OBJECTIVE: To determine the microbiology of wound morbidity following cesarean deliveries. METHODS: Nine hundred thirty-nine wounds in post-cesarean patients were followed prospectively. Aspirates from the abdominal incision were collected if the wounds developed erythema, induration, or pain and had demonstrable fluid collection noted on ultrasound. Cultures were also obtained of wound exudates when there was spontaneous separation of the skin. Gram stains were performed concomitantly with culture. RESULTS: The cumulative incidence of post-cesarean wound morbidity between September 1990 and June 1991 was 6.9% (65 of 939), and the rate of culture-positive wounds was 72% (47 of 65). Ureaplasma urealyticum was the most frequent isolate at a rate of 62% (29 of 47), followed by coagulase-negative staphylococci at 32% (15 of 47) and Enterococcus faecalis at 28% (13 of 47). Gram stains of the exudates obtained were used to predict microbiologic results. Organisms present on Gram stain yielded a sensitivity of 0.55, specificity of 1.0, positive predictive value of 1.0, and negative predictive value of 0.71 when used to predict positive culture results for bacterial wound infection other than with genital mycoplasmas. White blood cell counts greater than ten per 400x high-power fields yielded a sensitivity of 0.83, specificity of 0.72, positive predictive value of 0.89, and negative predictive value of 0.62 when used to predict wound infection including genital mycoplasmas. CONCLUSIONS: Genital mycoplasmas are the most prevalent bacterium in post-cesarean wound infections in this population. If genital mycoplasmas are pathogenic in this setting, then the Gram stain may be useful in predicting wound microbiology. More research is needed on the pathogenic role of genital mycoplasmas in wound infections.

Treatment of cervical chlamydial infection with amoxicillin/clavulanate potassium.

OBJECTIVE: To determine if amoxicillin/clavulanate potassium is effective in the treatment of Chlamydia trachomatis endocervicitis. METHODS: Thirty-two patients with culture-proven endocervical infection were treated with amoxicillin/clavulanate potassium, 500 mg orally 3 times a day for 10 days. Post-treatment endocervical specimens were obtained at 2, 4, and 6 weeks for culture of C. trachomatis. Male partners were treated with doxycycline, 100 mg orally twice daily for 10 days. The couples were provided condoms and asked to use them throughout the duration of the study. RESULTS: All patients treated with amoxicillin/clavulanate potassium were cured of signs of cervicitis. All were found to be free of C. trachomatis at their follow-up visits. CONCLUSIONS: Amoxicillin/clavulanate potassium is effective in eradicating C. trachomatis.

Cefotetan susceptibility testing against anaerobic bacteria from obstetrical and gynecologic sources: comparison of five different methods.

Five different antibiotic susceptibility methods were utilized to test the effectiveness of cefotetan against 200 anaerobic bacteria recovered from patients with obstetrical or gynecological infections. The object of this study was to determine if a more economical and rapid method for anaerobic susceptibility testing was as acceptable as the reference agar dilution method. The five methods were: 1) broth disk elution, 2) microbroth technique, 3) a commercially available microbroth technique, 4) a commercially available spiral gradient technique, and 5) reference agar dilution. The minimal inhibitory concentrations (MICs) calculated from the spiral gradient technique were equal to or within one doubling dilution of the reference system in 99.5% of cases, while the percentage for the commercially available microbroth system was 96.8%, very similar to the microbroth technique used in our laboratory that yielded a percentage of 96.3. The disk elution method correlated to the reference agar dilution method in 95.3% cases. While the overall agreement between these techniques is good, especially for the spiral gradient system, clustering of certain organisms near the breakpoint of the antibiotic tested results in variability in the labeling of these organisms as susceptible or resistant. This problem appears to be particularly significant for the disk elution method. Therefore, further refinements in these methods of suscleptibility testing are needed in order to provide a more clinically useful assessment of the susceptibility or resistance of certain bacterial isolates.

In Vitro Susceptibility Testing of Clinical Isolates of Chlamydia trachomatis.

Penicillin class antibiotics have demonstrated varying degrees of in vivo and in vitro success when tested against Chlamydia trachomatis. The activity of ampicillin-sulbactam, an agent commonly utilized in the treatment of pelvic infections, was tested to ascertain if any antichlamydial activity is present. Up to six endocervical isolates of C. trachomatis were tested against each of five antibiotics including doxycycline, erythromycin, clindamycin, ampicillin/sulbactam, and sulbactam alone. McCoy cell monolayers were inoculated with high inclusion counts of 10,000-30,000 inclusion-forming units (IFU) per coverslip, and exposed to each antibiotic. Up to nine subsequent antibiotic free culture passes were performed to assess the viability of abnormal inclusions. Doxycycline, erythromycin, and clindamycin achieved 100% eradication of inclusions at concentrations of 4.0, 2.0, and 1.0 microg/mL. Exposure to ampicillin/sulbactam resulted in a greater than 99% reduction in the inclusion count at 32.0 microg/mL, while sulbactam by itself demonstrated considerably less activity. Abnormal inclusions were noted only in the ampicillin/sulbactam exposed cells, and these, plus all inclusions remaining following sublethal exposure to the other antibiotics, resulted in regrowth to control levels in subsequent passes. Doxycycline and erythromycin demonstrated excellent activity. Clindamycin and ampicillin/sulbactam also significantly reduced inclusion formation, and therefore may provide adequate C. trachomatis coverage in patients receiving these antibiotics for pelvic infections.

Intrauterine pressure catheter in labor: associated microbiology.

OBJECTIVE: The purpose of this study was to determine if bacterial growth occurred in the amniotic fluid of laboring women. Twenty patients who required an intrauterine pressure catheter (IUPC) during labor were studied. Amniotic fluid samples were aspirated during labor and at the time of delivery. METHODS: IUPCs were placed in laboring patients for a variety of reasons. Cervical cultures were taken prior to insertion of an IUPC. After the IUPC was placed, amniotic fluid cultures were taken both at the time of placement and 30 minutes prior to delivery. These cultures were sent for aerobic, anaerobic, Mycoplasma, and Ureaplasma cultures. RESULTS: The increase in bacterial concentration from the initial sample to the final sample was statistically significant (P < 0.01) for both aerobes and anaerobes. Amniotic fluid samples demonstrated a median of 0 bacterial species per patient on initial collection and 2 bacterial species per patient in final collection. The mean count of cfu for erobes in the initial amniotic samples was 3.5 x 10(4), compared to that of the second samples, which was 1.4 x 10(5). The mean count of cfu for anaerobes in the initial amniotic fluid samples,.was 4.1 x 10(2), compared to that of the second samples, which was 8.0 x 10(3). Only 3 of 20 patients developed chorioamnionitis, with only 1 patient having an increased number ofbacterial species significantly higher than the median. Although 80% of patients had a colony count > or = 10(2) cfu/cc, only 19% of this group developed chorioamnionitis. CONCLUSIONS: The number of bacterial species and colony counts increased significantly during labor, but this factor alone was not enough to cause chorioamnionitis in a significant number of patients.

Herpes genitalis.

In conclusion, herpes genitalis has become one of the most common sexually transmitted diseases and has reached epidemic proportions. It presents a grave risk to immunocompromised patients and to newborns. The advent of effective therapy with acyclovir has dramatically modified the morbidity and mortality of disseminated herpesvirus infection and has helped in the therapy of primary and recurrent herpes genitalis. Current work has indicated that the disease can be transmitted by asymptomatic patients who are shedding the virus in the absence of visible lesions, which presents a diagnostic and therapeutic problem, especially significant for the pregnant patient, because infection of the neonate leads to serious consequences. Close follow-up of the pregnant woman with genital herpes therefore is imperative to minimize the risk to the newborn. At this time, no vaccines have been demonstrated to be safe and effective; therefore, prevention is of the utmost importance.

Prevalence of active Chlamydia trachomatis infection at the time of exploratory laparotomy for ectopic pregnancy.

Cultures of the fallopian tube, cul-de-sac, and cervix were obtained from 50 patients undergoing exploratory laparotomy for ectopic pregnancy. Chlamydia trachomatis was cultured from the cervix in four patients (8%). All the cultures from the fallopian tube or cul-de-sac were negative. Immunofluorescent stain of deparaffinized cross-sections of fallopian tube at the site of tubal involvement with the ectopic pregnancy failed to reveal any C trachomatis inclusions.

Ciprofloxacin versus gentamicin/clindamycin for postpartum endometritis.

An open, randomized, comparative study of intravenous ciprofloxacin versus gentamicin and clindamycin was performed on women with postpartum endometritis. Ciprofloxacin alone successfully eradicated the infections in 35 of 49 patients (71%), while the combination of gentamicin/clindamycin cured 41 of 48 (85%) (P = .15). The microbiology and antibiotic sensitivity of the endometrial isolates confirmed the poor activity of ciprofloxacin against anaerobic bacteria and less-than-optimal activity against Streptococcus faecalis. Ciprofloxacin, when used alone, may not be suitable for the treatment of postpartum endometritis.

Fungal vulvovaginitis.

Fungal vulvovaginitis remains one of the most frequent conditions affecting the lower genital tract. Recent advances in the understanding of the pathophysiology of the condition have improved our ability to treat recurrent or persistent cases. More clinical data have become available on the optimal duration of treatment with some of the newer antifungal agents.

PIP: Actual incidence of vulvovaginitis is unknown, but apparently about 75% of women experience at least 1 episode of yeast vulvovaginitis during their reproductive years. Candida species causes almost all cases, e.g., Candida albicans causes about 90% of cases. Other species include C. glabrata and C. tropicalis. The spore form of C. albicans spreads the infection and is asymptomatic. The mycelia form induces symptoms. Neither C. glabrata nor C. tropicalis produce mycelia. The 1st step in establishing an infection is bonding to the vaginal mucosa. C. albicans adheres better than do the other 2 species. Proteolytic enzymes help the fungus bind to the mucosa. Research indicates that differences in the composition of normal vaginal bacteria, dearths in site functions that are specific for Candida, or prostaglandin or IgE interference with the cellular mediated immune response specific to Candida may be responsible for recurrent infections. The signs and symptoms of yeast vulvovaginitis are not clear cut so clinicians need to request laboratory tests on samples to confirm diagnosis. The most common symptom is considerable itching. Antifungal medicine is either topical or systemic. The most common yet oldest antifungal agent is 0.5-1% gentian violet applied topically to the affected mucous membranes. There is dome evidence, however, that it causes chromosome damage in some mammal cells. No reported cases of cancer in humans exist though. Imidazoles and polyene compounds constitute the mainstays of candidiasis treatment. Oral ketoconazole has shown promise in preventing recurrence. Colonization and symptomatic vaginitis rates rise during pregnancy. Symptomatic vaginitis is most common during the 3rd trimester. Diabetes mellitus also predisposes women to vaginitis. Women who use high dose oral contraceptives, the contraceptive sponge, and antibiotics also face increased risk of colonization and symptomatic vaginitis. Vaginitis is common among women with AIDS.

Isolation of Kingella denitrificans from amniotic fluid in a woman with chorioamnionitis. A case report.

Kingella denitrificans and Streptococcus agalactiae were isolated from the amniotic fluid of a woman with chorioamnionitis. She was treated with intravenous ampicillin/sulbactam, with a good response.

Ticarcillin/clavulanate for treatment of postpartum endometritis.

Postpartum endometritis continues to be the leading cause of morbidity following cesarean section. This infection is commonly polymicrobial, involving aerobic, facultative, and obligate anaerobic gram-negative bacteria as well as gram-positive bacteria. The major risk factor for the development of post-cesarean section endometritis is duration of labor with ruptured amniotic membranes of greater than 6 hours. The most frequently utilized antibiotic regimen employed for treatment of postpartum endometritis is the combination of clindamycin and gentamicin. The combination ticarcillin/clavulanate has a spectrum of activity resembling that of clindamycin and gentamicin. In the data reported, cure rates among patients treated with ticarcillin/clavulanate were similar to the rates for those treated with clindamycin plus gentamicin as well as those for cefoxitin.