Impact of nurse-delivered community-based CD4 services on facilitating pre-ART care in rural South Africa.

BACKGROUND: HIV testing, diagnosis and treatment programs have expanded globally, particularly in resource-limited settings. Diagnosis must be followed by determination of treatment eligibility and referral to care prior to initiation of antiretroviral treatment (ART). However, barriers and delays along these early steps in the treatment cascade may impede successful ART initiation. New strategies are needed to facilitate the treatment cascade. We evaluated the role of on site CD4+ T cell count phlebotomy services by nurses in facilitating pre-ART care in a community-based voluntary counseling and testing program (CBVCT) in rural South Africa. METHODS: We retrospectively evaluated CBVCT services during five continuous time periods over three years: three periods when a nurse was present on site, and two periods when the nurse was absent. When a nurse was present, CD4 count phlebotomy was performed immediately after HIV testing to determine ART eligibility. When a nurse was absent, patients were referred to their local primary care clinic for CD4 testing. For each period, we determined the proportion of HIV-positive community members who completed CD4 testing, received notification of CD4 count results, as well as the time to test completion and result notification. RESULTS: Between 2010 and 2013, 7213 individuals accessed CBVCT services; of these, 620 (8.6 %) individuals were HIV-positive, 205 (33.1 %) were eligible for ART according to South African national CD4 count criteria, and 78 (38.0 % of those eligible) initiated ART. During the periods when a professional nurse was available to provide CD4 phlebotomy services, HIV-positive clients were significantly more likely to complete CD4 testing than during periods when these services were not available (85.5 % vs. 37.3 %, p < 0.001). Additionally, when nurses were present, individuals were significantly more likely to be notified of CD4 results (60.6 % vs. 26.7 %, p <0.001). The time from HIV screening to CD4 test completion was also significantly shorter during nurse presence than nurse absence (median 8 days (IQR 4-19) vs. 35 days (IQR 15-131), p < 0.001). CONCLUSIONS: These findings indicate that in addition to CBVCT, availability of on site CD4 phlebotomy may reduce loss along the pre-ART care cascade and facilitate timely entry into HIV care.

Characteristics of HIV-1-associated Kaposi's sarcoma among women and men in South Africa.

Despite the increase of HIV-1-associated Kaposi's sarcoma (KS), little is known about HIV-associated KS in the African setting, particularly among women. A descriptive study of the demographic, clinical, immunological and virological features of AIDS-associated KS from KwaZulu-Natal, South Africa was undertaken. Consecutively, recruited patients were clinically staged; CD4/CD8 cell counts, HIV-1 viral loads and clinical parameters were evaluated. Of the 152 patients (77 male and 75 female) 99% were black. Females were significantly younger (P = 0.02) and had poorer disease prognosis (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.4-5.4, P = 0.003) and were more likely to have extensive cutaneous KS when compared with males (OR = 3.1, 95% CI = 1.4-6.7, P = 0.003). One-third of patients had coexisting HIV-related disease, most commonly tuberculosis, and these were more frequent in females (56.7 vs. 43.3%). In conclusion, HIV-associated KS in South Africans has an equal female-to-male ratio. Females are younger and have more severe disease than males.

The treatment of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome.

Forty-four episodes of Pneumocystis carinii pneumonia (PCP) occurred in 36 of 70 patients with the acquired immunodeficiency syndrome. Thirty-four patients with 40 episodes of PCP were treated with trimethoprim-sulfamethoxazole. Therapy was successful in 18 episodes (45%), but was unsuccessful in 15 episodes (37.5%). In the latter cases, two patients died within 72 hours; 13, of whom nine died, had therapy changed to pentamidine. In seven additional episodes (17.5%), trimethoprim-sulfamethoxazole was changed to pentamidine due to adverse reactions; all patients survived. Seven patients (26% of survivors) developed recurrent PCP. Twenty-two patients (65%) developed adverse reactions to trimethoprim-sulfamethoxazole, including leukopenia (20), hepatotoxicity (12), fever (eight), rash (six), and immediate reactions (two). Reactions were most common during the second week of therapy. Patients with the acquired immunodeficiency syndrome who have PCP have a high trimethoprim-sulfamethoxazole failure rate, due either to adverse reactions or unresponsive infection. Late recurrence is common.

Intravenous drug abusers and the acquired immunodeficiency syndrome (AIDS). Demographic, drug use, and needle-sharing patterns.

We studied the demographic characteristics, drug use patterns, and sexual habits of intravenous (IV) drug abusers to further define this population at risk for acquired immunodeficiency syndrome (AIDS). Sixteen IV drug abuser patients with AIDS, 24 IV drug abuser patients with AIDS-related complex (ARC), and 14 IV drug abuser controls without evidence of AIDS or ARC were evaluated. The subjects in each group were similar demographically, in drug use practice, and in sexual orientation and experience. Of the AIDS and ARC patients, 34 (88%) of 40, including all seven homosexual men, shared needles, as did all drug abusers without AIDS or ARC. Seventy-four percent of patients, including all homosexual men, attended "shooting galleries," where anonymous multiple-partner needle sharing took place. Needle sharing supports the hypothesis of AIDS transmission by a blood-borne route, can explain the spread of AIDS and the high rate of seropositivity to the putative AIDS agent among IV drug abusers, and is a logical link between IV drug abusers and male homosexuals, the two largest groups with AIDS.

Attaining higher goals in HIV treatment: the central importance of adherence.

In recent years, advances in HIV therapeutics have changed the nature of HIV/AIDS disease, so that it has now assumed some of the characteristics of a 'chronic' disease. Several factors have, however, qualified these advances. Social, economic, and clinical variables have confounded universal therapeutic success. Access to the highly active antiretroviral therapy is limited among marginalized populations, such as the homeless, or absent in many nations that have poor resources. In addition, study populations are often not fully representative of those actually cared for in clinical practice, who may respond differently to the study medications. Moreover, physiologic differences between patients may alter drug plasma levels, resulting in varying efficacy levels in different patients. Finally, and crucial among determinants of effective therapy, is a patient's level of adherence to the antiretroviral regimen. The magnitude of 'error-prone' viral replication makes resistance to antiretroviral agents invariable. In the presence of partially suppressive therapy, viral replication will select for viral variants with resistance mutations. Therefore, potent and continuous suppressive therapy for the duration of viral replicative capability is necessary for therapy to be effective. Factors that have an impact on adherence include characteristics of the treatment regimen, of patients and clinicians, and of the clinical setting. Successful adherence to therapeutic regimens is the responsibility of clinicians as well as patients. Many patient- and clinician-focused strategies and interventions that can improve adherence exist. The simplification of current antiviral regimens, without the loss of potency, is essential to achieving the goal of complete adherence. Maximizing the long-term benefit of highly active antiretroviral therapy requires knowledge of the technical and biologic aspects of HIV therapeutics, but necessitates an understanding of the behavioral aspects of therapeutics as well.

Nevirapine induced opiate withdrawal among injection drug users with HIV infection receiving methadone.

BACKGROUND: Pharmacokinetic interactions complicate and potentially compromise the use of antiretroviral and other HIV therapeutic agents in patients with HIV disease. This may be particularly so among those receiving treatment for substance abuse. OBJECTIVE: We describe seven cases of opiate withdrawal among patients receiving chronic methadone maintenance therapy following initiation of therapy with the non-nucleoside reverse transcriptase inhibitor, nevirapine. DESIGN: Retrospective chart review. RESULTS: In all seven patients, due to the lack of prior information regarding a significant pharmacokinetic interaction between these agents, the possibility of opiate withdrawal was not anticipated. Three patients, for whom methadone levels were available at the time of development of opiate withdrawal symptoms, had subtherapeutic methadone levels. In each case, a marked escalation in methadone dose was required to counteract the development of withdrawal symptoms and allow continuation of antiretroviral therapy. Three patients continued nevirapine with methadone administered at an increased dose; however, four chose to discontinue nevirapine. CONCLUSION: To maximize HIV therapeutic benefit among opiate users, information is needed about pharmacokinetic interactions between antiretrovirals and therapies for substance abuse.

A prospective comparison of neuropsychologic function in HIV-seropositive and seronegative methadone-maintained patients.

A prospective longitudinal study of neuropsychological and psychosocial functioning in a methadone-maintained population was initiated to test the hypothesis that cognitive impairments may be present early in the course of HIV infection, before the onset of other physical symptoms. A total of 220 methadone-clinic patients without evidence of HIV-related illnesses were given baseline psychological screening tests, as well as serological testing for HIV antibodies. At baseline, 83 (38%) had antibodies to HIV and 137 (62%) did not. On initial testing, controlling for race/ethnicity, age, sex and drug use, the seropositives were more cognitively impaired than the seronegatives. The differences were statistically significant for three subtests on univariate analysis: finger tapping (dominant), digit span (forward) and similarities. Ninety-one patients whose current serological status was known were given follow-up neuropsychological and psychosocial assessments after a mean interval of 7.4 months from baseline testing. At follow-up, seropositives continued to be more cognitively impaired than seronegatives, but there was no deterioration in the performance of the initial seropositives over the time interval.

The spectrum of HIV-1-related disease among outpatients in New York City.

OBJECTIVES: To define the spectrum of HIV-1-related disease in New York City (NYC) and to determine how the clinical spectrum of illness differs in various populations. DESIGN AND METHODS: The medical records of the 2983 HIV-infected individuals who had received care through 1989 at four hospital outpatient clinics and two private physicians' offices were reviewed retrospectively. RESULTS: Sixty-one per cent of the study patients and 48% of patients seen in 1989 had AIDS. HIV-infected women were significantly less likely to have AIDS and CD4 lymphocyte counts less than 200 x 10(6)/l than men. For every 100 AIDS patients seen in 1989, there were 88 non-AIDS patients with CD4 counts less than 500 x 10(6)/l, of whom 41 had CD4 counts less than 200 x 10(6)/l; thus, in addition to an estimated 16,425 individuals living with AIDS in NYC, we estimate that there are at least 14,454 HIV-infected individuals without AIDS with CD4 counts less than 500 x 10(6)/l, of whom 6734 have CD4 counts less than 200 x 10(6)/l. Men who have sex with men were significantly more likely to have Kaposi's sarcoma, cytomegalovirus disease and retinitis, cryptosporidiosis and lymphoma, and significantly less likely to have Pneumocystis carinii pneumonia, esophageal candidiasis, extrapulmonary tuberculosis (TB) and bacterial pneumonia than intravenous drug users. Whites were significantly less likely to have pulmonary TB than Hispanics, non-Haitian and Haitian blacks, toxoplasmosis than Hispanics and Haitian blacks, and salmonella septicemia than non-Haitian blacks. The frequencies of most diagnoses did not differ by sex; gynecologic diseases were recorded infrequently in the medical records of women in this study. CONCLUSIONS: These data indicate that there are more than 30,000 HIV-infected adults living in NYC with significant immunosuppression, that an increasing proportion of AIDS cases in NYC will occur among women, and that the spectrum of HIV-related disease varies markedly in different populations.

Increased risk of bacterial pneumonia in HIV-infected intravenous drug users without AIDS.

Although patients with AIDS have been noted to be at risk for bacterial pneumonia as well as opportunistic infections, little is known about the risk of bacterial pneumonia in HIV-infected populations without AIDS. To determine the incidence of bacterial pneumonia in a well defined population of intravenous drug users (IVDUs), and to examine any association with HIV infection, we prospectively studied 433 IVDUs without AIDS, enrolled in a longitudinal study of HIV infection in an out-patient methadone maintenance program. At enrollment, 144 (33.3%) subjects were HIV-seropositive, 289 (66.7%) were seronegative. Over a 12-month period, 14 out of 144 (9.7%) seropositive subjects were hospitalized for community-acquired bacterial pneumonia, compared with six out of 289 (2.1%) seronegative subjects. The cumulative yearly incidence of bacterial pneumonia was 97 out of 1000 for seropositives and 21 out of 1000 for seronegatives (risk ratio = 4.7, P less than 0.001). Eleven out of 14 (78.6%) cases among the seropositive patients were due to either Streptococcus pneumoniae [5] or Hemophilus influenzae [6]. Two out of 14 (14.3%) cases among the seropositives were fatal. Stratifying by level of intravenous drug use indicated that even among subjects not reporting active intravenous drug use at study entry, eight out of 82 (9.8%) seropositives compared with three out of 211 (1.4%) seronegatives were hospitalized for bacterial pneumonia over the study period (risk ratio = 6.9, P less than 0.01). This study shows a markedly increased incidence of bacterial pneumonia associated with HIV infection in IVDUs without AIDS.(ABSTRACT TRUNCATED AT 250 WORDS)

Laboratory markers and the risk of developing HIV-1 disease among injecting drug users.

OBJECTIVE: To characterize the progression to HIV-1 disease among injecting drug users (IDU) according to laboratory markers. DESIGN: Prospective study of cohort of HIV-1-seroprevalent IDU, with case-comparison component. METHODS: Different laboratory markers were examined as predictors of progression to HIV-1-associated diseases including AIDS in a cohort of 318 HIV-1-infected IDU. The cohort was enrolled from a methadone treatment program in the Bronx, New York, USA. The independent utility of non-CD4 cell markers was evaluated after adjustment for the association of low CD4 lymphocyte count with AIDS risk. Clinical events in the natural history of HIV-1 were related to changes in levels of two variables related to duration of infection, CD4 lymphocyte count and serum beta 2-microglobulin (beta 2M) concentration. RESULTS: On univariate analysis, AIDS incidence measured from baseline increased with declining CD4 lymphocyte number and percentage, increasing serum beta 2M level, low platelet count, low leukocyte count and p24 antigenemia. Among HIV-1-related outcomes prior to any AIDS diagnosis, the relative risk of pyogenic bacterial infections conferred by these markers was similar to the relative risk of AIDS. For all HIV-1 outcomes, the elevated risk encountered at CD4 lymphocyte number < or = 200 x 10(6)/l was entirely due to the high risk at < or = 150 x 10(6)/l. On multivariate analysis, control for CD4 lymphocyte count eliminated the association of any other marker with increased AIDS hazard. HIV-1-related outcomes tended to occur in this order: multiple constitutional symptoms, oral candidiasis, pyogenic bacterial infections and AIDS. CONCLUSIONS: In HIV-1-infected IDU, several laboratory markers may predict AIDS when analyzed individually. These are not, however, independently related to increased AIDS risk after adjustment for low CD4 lymphocyte count. A CD4 count < or = 150 x 10(6)/l is more strongly related to immediate risk of adverse outcome than a count of 200 x 10(6)/l. A progressive series of clinical events is associated with markers of duration of HIV-1 infection, prior to and including AIDS diagnosis.

Survival differences in patients with AIDS.

To define the clinical, demographic, and behavioral variables that may influence survival in patients with AIDS, we studied 526 patients with AIDS diagnosed through September 1987 who were cared for at a single medical center. A diversity of racial and ethnic backgrounds, ages, both men and women, and all risk behaviors except hemophilia were well represented. The initial AIDS defining diagnosis was the most powerful predictor of survival. The median survival was 12.8 months for patients presenting with Kaposi's sarcoma (p less than 0.001), 10.9 months for patients presenting with Pneumocystis carinii pneumonia (p less than 0.001), and 4.8 months for patients presenting with other infections or neoplasms (p less than 0.02). For the entire series, male sex and younger age were associated with more favorable survival (p less than 0.025). For those presenting with Pneumocystis carinii pneumonia, in addition to younger age (p less than 0.025), black race (p less than 0.025) and the combination of male sex and intravenous drug use (p less than 0.005) were associated with a more favorable survival. Within a setting of comparable clinical care, survival from the point of diagnosis of AIDS is associated most strongly with the initial AIDS diagnosis, but differences in age, gender, race, and risk behavior also exert an influence on survival.

Cervical and vaginal squamous cell abnormalities in women infected with human immunodeficiency virus.

We sought to determine whether women infected with human immunodeficiency virus (HIV) had cervicovaginal cellular changes suggesting lower genital tract neoplasia or human papillomavirus (HPV) infection at a rate different from that in women without HIV infection. In a blinded fashion, cytological preparations of cervicovaginal smears from women infected with the HIV were analyzed and compared to preparations from women at high risk for but not infected with HIV. Eleven of 35 (31%) HIV-infected subjects had evidence of squamous abnormalities compared with 1 of 23 (4%) non-HIV-infected women (p = 0.019). Nine of 35 (26%) HIV-infected women had cytohistological evidence of human papillomavirus (HPV) infection compared to 1 of 23 (4%) non-HIV-infected women (p = 0.072). We conclude that HIV-infected women have a high prevalence of cervical and vaginal cytological abnormalities and evidence of genital HPV infection. Further study is necessary to determine whether there is an increased risk for cervicovaginal neoplastic disorders in women infected with HIV.

Pharmacokinetic interactions of zidovudine and methadone in intravenous drug-using patients with HIV infection.

Pharmacokinetic parameters for methadone and zidovudine (ZDV), alone and in combination, were determined in 14 HIV-infected individuals including nine former intravenous drug users (IVDU) who were receiving methadone maintenance therapy. The serum levels of methadone were measured prior to and after initiation of ZDV treatment, with each patient serving as his or her own control. Concurrent administration of ZDV did not alter either the peak methadone concentration or the area under the methadone concentration-time curve (AUC). Serum and urine ZDV and ZDV-glucuronide concentrations were measured by both high pressure liquid chromatography (HPLC) and radioimmunoassay (RIA), and pharmacokinetic parameters determined at least twice in each of nine methadone-maintained former IVDU patients initiating ZDV therapy. These parameters were compared to those for ZDV in a group of five control patients who were neither receiving methadone nor had a history of i.v. drug use. The serum ZDV levels were significantly higher in the methadone patients, with a 43% increase (p less than 0.05) over the mean AUC of 7.68 microM h observed in the control patients. Furthermore the methadone patients could be divided into two groups based on their ZDV AUC: four patients whose ZDV AUC averaged twofold higher than the control group, and five patients whose ZDV AUC were equal to control. No significant differences were found between the control and methadone groups for ZDV bioavailability or Tmax, serum half-life, glucuronidation, or urinary excretion. Methadone also did not affect ZDV glucuronidation in an in vitro assay using human hepatic microsomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical cytologic abnormalities and papillomavirus in women infected with human immunodeficiency virus.

We investigated the relationship of human papillomavirus (HPV) infection of the female genital tract, cervical cytology, and human immunodeficiency virus (HIV) infection in 67 women. Forty-eight women had a history of intravenous drug use, 18 were heterosexual partners of HIV-infected intravenous drug users, and one was a transfusion recipient. Patients received a Pap smear, cervicovaginal lavage for HPV determination by Southern blot, HIV serum antibody by enzyme immunoassay with Western blot confirmation, and thorough screening for other sexually transmitted diseases. Seventeen of the 35 (49%) women seropositive for HIV had HPV infection, compared with 8 of 32 (25%) seronegative women (p less than 0.05). Fourteen of 35 (40%) HIV-positive women had squamous intraepithelial lesions (SIL) on cervical cytology, compared with three of 32 (9%) HIV-negative women (p less than 0.01). Of 22 women with symptomatic HIV infection, 11 (50%) had SIL on cytology; 10 of these 11 were HPV-positive. Among 13 asymptomatic HIV-positive women, only three (23%) had such cytological lesions. Our findings strongly suggest that HIV-induced immunosuppression exacerbates HPV-mediated cervical cytologic abnormalities.

Community-acquired opportunistic infections and defective cellular immunity in heterosexual drug abusers and homosexual men.

Fourteen previously healthy young patients with unusual community-acquired opportunistic infections were seen over a period of three years. They differ from patients previously described in that 11 were heterosexual drug abusers (including two women) and only three were homosexual men. There were eight Puerto Ricans, five blacks, and one white. Infections included Pneumocystis carinii pneumonia (seven), disseminated Mycobacterium intracellulare infection, histoplasmosis, cryptococcosis, and cytomegalovirus infection (one each), oral thrush (13), and Candida esophagitis (two). All patients had impaired cellular immunity manifested by cutaneous anergy and lymphopenia, and all 11 tested had a markedly decreased ratio of T helper/inducer cells to T suppressor/cytotoxic cells. Twelve had evidence of associated viral infection (Epstein-Barr virus in nine, cytomegalovirus in five, Herpes simplex type 2 in two). Clinical presentation was with a severe opportunistic infection or with a prodrome consisting of oral thrush and nonspecific findings including malaise, fever, lymphadenopathy, or cough. The syndrome of immunodeficiency and opportunistic infection occurs in nonwhite heterosexual drug abusers, not exclusively in white homosexual men, and patients may present for medical care before the onset of a severe opportunistic infection.

Complications of intravenous therapy with steel needles and Teflon catheters. A comparative study.

Complications of intravenous therapy with steel needles and small-bore Teflon catheters were compared in a randomized study of 954 cannula insertions. Cannulas were inserted and cared for by an intravenous team following a standard protocol. There were no cases of cannula-related septicemia and only one case of local infection, a cellulitis in the group in which Teflon catheters were used. There was a low incidence of positive semiquantitative cannula cultures in both treatment groups (steel needles 1.5 percent, Teflon catheters 1.4 percent). The risk of phlebitis was significantly greater with Teflon catheters (18.8 percent with Teflon catheters, 8.8 percent with steel needles, adjusted odds ratio 1.87). Steel needles were significantly associated with infiltration (17.9 percent with Teflon catheters, 40.1 percent with steel needles, adjusted odds ratio 0.39). The over-all rate of complications was significantly greater for the group in which steel needles were used (53.8 versus 64.0 percent, adjusted odds ratio 0.72), principally due to the increased risk of infiltration with steel needles. Analysis of the per day risk of infiltration and phlebitis revealed that these relationships were present for each day the cannulas remained in place. We conclude (1) that steel needles and small-bore Teflon catheters can both be used with low risk of infection and (2) that Teflon catheters more frequently cause phlebitis, whereas steel needles infiltrate more readily.

The recovery of Mycobacterium avium complex and Mycobacterium tuberculosis from blood specimens of AIDS patients using the nonradiometric BACTEC NR 660 medium.

The ability of the nonradiometric BACTEC NR 660 aerobic 6A blood culture medium to support mycobacterial growth was investigated. During a 19-month period blood cultures from 140 AIDS patients were sent to the microbiology laboratory. After the cultures were incubated for seven days, aliquots of medium from the vials were centrifuged, sediments examined microscopically for mycobacteria, and cultured to mycobacterial media. Seventy-one AIDS patients (51%) had at least one blood culture positive for mycobacteria. There was a significant difference in the percent of female AIDS patients positive for mycobacteria compared to male patients (72% vs. 44%, P less than 0.01). Forty-four percent of all subsequently positive cultures were detected by an acid fast stain of the specimen sediment. Subcultures from the BACTEC 6A suspensions were positive on mycobacterial media at one-seven weeks (mean three weeks) after planting. Sixty-nine of the isolates were Mycobacterium avium complex, while two were Mycobacterium tuberculosis. Some bacteremias with M. tuberculosis may have been undetected because growth experiments with a reference strain showed that, in contrast to M. avium complex, M. tuberculosis did not increase in concentration in 6A medium.

Interactions between methadone and medications used to treat HIV infection: a review.

BACKGROUND: It is critical for providers caring for HIV-positive methadone recipients to have accurate information on pharmacologic interactions between methadone and antiretroviral therapy. If providers do not have these data, symptoms of narcotic withdrawal or excess due to medication interactions may be mismanaged, and antiretroviral regimens may be suboptimal in efficacy or associated with increased side effects and toxicities. This review was undertaken to clarify what is known about interactions between pharmacotherapies of opiate dependence and HIV-related medications, to suggest clinically useful approaches to these issues, and to outline areas which need further study. METHOD: A search for relevant published papers and abstracts presented at scientific meetings was conducted using electronic databases. These documents were obtained and reviewed, and additional publications referenced in them were also reviewed. RESULTS: Pharmacokinetic interactions between methadone and zidovudine, didanosine, stavudine, abacavir, nevirapine, efavirenz and nelfinavir have been documented. The mechanisms, clinical implications and management of these interactions are reviewed. CONCLUSIONS: Interactions between methadone and some HIV-related medications are known to occur, yet their characteristics cannot reliably be predicted based on current understanding of metabolic enzyme induction and inhibition, or through in vitro studies. Only carefully designed and conducted pharmacologic studies involving human subjects can help us define the nature of the interactions between methadone (and other pharmacotherapies for opiate dependence) and specific HIV-related medications. Clinicians must be aware of known interactions and be alert to the possibility that interactions which are still undocumented may be present among their patients.

Perioperative use of cefoxitin in primary cesarean section.

We performed a randomized, double-blind trial on a relatively low-risk population comparing the use of three doses of cefoxitin vs. placebo in the prevention of infection following primary cesarean section. Major site-related morbidity (endometritis, wound infection and septicemia) was significantly reduced in the cefoxitin group (8.9% vs. 27.8%; p = 0.017). Febrile morbidity alone tended to occur in the cefoxitin group (15.6% vs. 3.7%; p = 0.091), and all five urinary tract infections occurred in the cefoxitin group as well. Total morbidity was therefore not significantly different (cefoxitin, 35.6%; placebo, 31.5% [not significant]). Duration of hospitalization (mean, 6.0 days) and need for further postoperative antibiotic therapy were similar in the two groups. Our study demonstrated a modest benefit from the perioperative use of antibiotics in relatively low-risk patients undergoing primary cesarean section. Issues that need further study include definition of the optimal prophylactic regimen and of high-risk populations for whom prophylaxis would be most helpful.

Abdominal wall actinomycosis associated with an IUD. A case report.

Abdominal wall actinomycosis without pelvic organ involvement in users of intrauterine contraceptive devices (IUDs) has not been reported on previously. We encountered one such patient, whose uterine cervix was colonized superficially with Actinomyces. We suggest that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Papanicolaou smears or in endocervical curettings. Such patients should be treated with appropriate antibiotic therapy, especially prior to any surgical intervention.

PIP: This paper presents the 1st reported case of actinomycosis of the subcutaneous tissues and abdominal wall without pelvic organ involvement in an IUD user. The patient, a 39-year old woman, para 4-0-1-4, presented with lower abdominal pain. Pap smear findings were reported as cervical intraepithelial neoplasia, grade I-II, and endocervical curettage showed colonies of Actinomyces species. A subsequent cone biopsy revealed carcinoma in situ but no evidence of Actinomyces. The final diagnosis was cervical intraepithelial neoplasia, leiomyomata, and actinomycotic abscesses of the abdominal wall. It is suggested that systemic actinomycosis be included in the differential diagnosis of pain in IUD users when Actinomyces is found on Pap smears or in endocervical curettings. Treatment of actinomycosis generally involves intravenous aqueous penicillin, 10-20 million units/day for 4-5 days, followed by 2-15 million units/day of oral penicillin for 3 weeks-1 year. Longterm antibiotic therapy is particularly important prior to any surgical intervention. If left untreated, actinomycosis can lead to infection, brain abscess, or death.