Cholesterol sulfate metabolism in human fetal adrenal mitochondria.

The metabolism of cholesterol sulfate (5-cholesten-3 beta-ol sodium sulfate) and cholesterol to pregnenolone sulfate and pregnenolone, respectively, in human fetal adrenal mitochondria has been investigated. Cholesterol sulfate (50 microM) was converted efficiently to pregnenolone sulfate (5-pregnen-3 beta-ol-20-one sodium sulfate; 1.6 nmol min-2 mg-1 protein). Pregnenolone sulfate biosynthesis from endogenous mitochondrial precursors could not be detected. The rate of pregnenolone biosynthesis in the presence of cholesterol (50 microM) was 0.2 nmol min-1 mg-1 protein. In contrast, mitochondria obtained from the adrenal tissue of a boy and two adult men did not produce detectable amounts of pregnenolone sulfate after the addition of cholesterol sulfate (50 microM). Pregnenolone was produced efficiently by adrenal mitochondria from endogenous mitochondrial precursors and was not stimulated by the addition of cholesterol (100 microM). The results suggest that human fetal adrenal mitochondria contain a specific cholesterol sulfate desmolase and that cholesterol sulfate may be the predominant sterol substrate for the large amounts of steroid sulfates produced by this tissue. Whereas the metabolism of cholesterol to form pregnenolone was increased by the addition of 1 mM calcium ions, the metabolism of cholesterol sulfate to produce pregnenolone sulfate was not stimulated by calcium ions. This latter finding may indicate that the metabolism of cholesterol sulfate in the human fetal adrenal gland is controlled separately from the metabolism of cholesterol.

Sterol sulfate metabolism in the adrenals of the human fetus, anencephalic newborn, and adult.

The sulfurylation of pregnenolone (delta 5P), dehydroepiandrosterone (D) and cholesterol in subcellular fractions of the separated zones of normal human fetal adrenals as well as the mitochondrial sterol desmolase activities are investigated. The values obtained are compared to those found in adrenal tissues of anencephalics and adults. The 3 beta-hydroxysteroid sulfotransferase activity is localized principally in the cytosolic fraction of the tissues assayed. The highest rate of sulfurylation of delta 5P and D is found in the cytosol of the fetal zone (5 nmol min-1 mg protein-1). The corresponding activities in fetal neocortex, anencephalic, and adult adrenocortical tissues are one tenth of that in the fetal zone. Cholesterol sulfurylation is not detectable under similar assay conditions. The specific activities of cholesterol and cholesteryl sulfate desmolases are 3- 4-fold greater in the fetal zone than in the neocortex. Cholesterol desmolase activity, but not cholesteryl sulfate desmolase activity, is found in adrenal tissues of the anencephalic newborn and adult adrenal cortex. It is concluded that the high levels of delta 5P sulfate and D sulfate found in human fetal plasma arise not only as a consequence of the high capacity of the human fetal adrenal fetal zone to sulfurylate the unconjugated compounds, but also as a result of the conversion of cholesteryl sulfate to delta 5P sulfate and thence to D sulfate.

Steroidogenesis in dispersed cells of human fetal adrenal.

Steroidogenesis in dispersed fetal zone cells of midtrimester human fetal adrenal was stimulated acutely by ACTH. Polypeptide hormones such as hCG, alpha MSH, ovine PRL, and LH did not produce a similar stimulation of steroidogenesis. The principal steroid products of ACTH-stimulated fetal adrenal cells were dehydroisoandrosterone sulfate, pregnenolone, pregnenolone sulfate, and 17 alpha-hydroxypregnenolone. Only minimal production of the delta 4-3-ketosteroids, cortisol, corticosterone, and progesterone, was observed. Cyanoketone (2 alpha-cyano-4,4,17 alpha-trimethyl-17 beta-hydroxyandrost-5-en-3-one; an inhibitor of 3 beta-hydroxysteroid dehydrogenase activity) treatment of the cells caused only a minor increase in 3 beta-hydroxysteroid formation, confirming that 3 beta-hydroxysteroid formation is the principal steroidogenic fate of cholesterol in these cells. SU-10603 [7-chloro-3,4-dihydro-2-(3-pyridyl)naphthalen-1-(2H)one; a steroid 17 alpha-hydroxylase inhibitor] treatment of the cells caused a marked accumulation of pregnenolone sulfate, indicating that the C-19 steroids are produced from C-21 steroids in this tissue and possibly that dehydroisoandrosterone sulfate is synthesized directly from pregnenolone sulfate. ACTH-stimulated pregnenolone synthesis was inhibited by AY-9944 [trans-1,4-bis-(2-chlorobenzylaminomethyl) cyclohexane dihydrochloride; an inhibitor of cholesterol biosynthesis]. Thus, cholesterol synthesized de novo was the likely steroidogenic precursor in the acute hormonally stimulated fetal adrenal cells.

Sulbactam/ampicillin versus cefoxitin for uncomplicated and complicated acute pelvic inflammatory disease.

In this study, 17 women were treated for uncomplicated acute pelvic inflammatory disease requiring hospitalisation for therapy, and 5 women were treated for the same infection complicated by pelvic abscesses. Treatment regimens were sulbactam 1g plus ampicillin 2g (14 women) or cefoxitin 2g (8 women) given by intravenous infusion every 6 hours. On the third day of therapy, a rash developed in 1 woman who was being successfully treated for uncomplicated disease with sulbactam/ampicillin. The other 21 women were cured. No other adverse clinical reactions and no significant abnormal laboratory results were observed with either regimen. Bacteriological efficacy, 98% for sulbactam/ampicillin and 94% for cefoxitin, closely paralleled clinical efficacy. Sulbactam, a suicide-type beta-lactamase inhibitor, appears to have restored and expanded the antibacterial activity of ampicillin.

Cefazolin for hysterectomy prophylaxis.

Efficacy data for single-dose cefazolin prophylaxis at hysterectomy are meager, and there are none evaluating the impact of route of administration on efficacy. For these reasons, 772 women undergoing elective abdominal or vaginal hysterectomy for benign diseases were given 1 g cefazolin either intramuscularly or intravenously in a randomized clinical trial. Preoperative diagnoses and clinical, surgical, and outcome variables were similar by route of administration for each surgical approach. Risk factors for infection after abdominal hysterectomy included younger age, lower postoperative hemoglobin concentration, and pelvic hematoma; women who developed infection after vaginal hysterectomy were heavier than those who remained uninfected and were more likely to have a pelvic hematoma. The overall incidence of major operative site infection requiring parenteral antimicrobial therapy in evaluable women was 7.2%: 7.6% for 539 women undergoing abdominal hysterectomy and 6.3% for 207 women undergoing vaginal hysterectomy. Postoperative infection was unrelated to route of cefazolin administration.

Alterations in lower reproductive tract flora after single-dose piperacillin and triple-dose cefoxitin at vaginal and abdominal hysterectomy.

There are no current data regarding the effect of a newer, broad-spectrum penicillin on lower reproductive flora at hysterectomy. To identify any existing differential effect on species and their susceptibilities, we obtained pre- and postoperative lower reproductive tract culture material from 209 women who were given single-dose piperacillin, then placebo or triple-dose cefoxitin, intravenously for prophylaxis at vaginal and abdominal hysterectomy in a prospective, randomized, blinded clinical trial. Significantly more preoperative endocervical bacteria were susceptible to piperacillin. Piperacillin caused less alteration in the numbers of lower reproductive tract flora when preoperative species were compared with postoperative species. More resistance to cefoxitin was identified postoperatively in bacteria recovered from the vaginal cuff of women who remained uninfected.

Single-dose cefoxitin prophylaxis for premenopausal women undergoing vaginal hysterectomy.

A prospective randomized blinded study was conducted comparing a single 2-g preoperative dose of cefoxitin with three 2-g doses of cefoxitin over 12 hours given to premenopausal women scheduled for vaginal hysterectomy in Parkland Memorial Hospital. The incidence of major pelvic infection in 58 women given one dose was 1.7%, and it was 3.7% for 54 women given three doses. The mean hospital stay (4.5 days) was similar for both regimens; for those who developed major infection it was eight days. More aerobic bacteria with altered species dominance and fewer anaerobic bacteria were recovered from the vaginal cuff at discharge from the hospital when compared with those recovered from the endocervix preoperatively. There was a trend toward increasing minimal inhibitory concentrations to cefoxitin in bacteria isolated after surgery, which was more frequent in women given three doses. There was not a statistically significant intergroup difference in the recovery of bacteria resistant to cefoxitin in vitro after surgery. A single preoperative dose of cefoxitin was as effective in preventing major infection as were three perioperative doses, while providing other real and theoretic benefits.

Cefotaxime sodium therapy for endomyometritis following cesarean section: dose-finding and comparative studies.

One hundred eighteen women who developed endomyometritis after cesarean section in Parkland Memorial Hospital were treated with parenteral cefotaxime sodium. The requirement for additional antimicrobial therapy was significantly higher at an initial daily dose of 3 g/day (16.4%) than when the dose was 6 g/day (4.8%) (P less than .05). The latter clinical efficacy and the observed in vitro susceptibility of 88% of isolates indicate that cefotaxime is well suited for single-agent parenteral therapy for this polymicrobial pelvic infection. Subsequently, 120 women with the same diagnosis were randomly treated with cefotaxime or clindamycin and gentamicin. Patient populations, surgical variables, in vitro microbiologic data, and side effects were similar for both groups. Clinical success observed was also similar: it was 97.5% for women given cefotaxime and 95% for women given clindamycin and gentamicin.

Cefoperazone and cefoxitin prophylaxis for abdominal hysterectomy.

One hundred one women undergoing elective abdominal hysterectomy were given perioperative cefoperazone or cefoxitin in a prospective randomized blinded study. Both regimens were well tolerated and no significant toxic or allergic manifestations were observed. Interrelationships between antimicrobial concentration in serum and pelvic tissues, intraoperative cardinal ligament cultures, febrile morbidity, and major postoperative infection were determined. At uterine removal, mean cefoperazone concentrations in serum (56.1 micrograms/mL) and pelvic tissues (18.6 micrograms/g) were significantly higher than mean concentrations of cefoxitin, ie, 16.1 micrograms/mL and 8.1 micrograms/g, respectively (P less than .001). The incidence of major postoperative infection was 6% or less with both regimens. Perioperative prophylaxis significantly reduced the incidence of this infection. When it did develop, however, it continued to cause significant morbidity, prolonging hospital stay a mean of more than four days (P less than .001) and increasing the hospital bill a mean of almost $1500 (P less than .001).

Upper and lower reproductive tract bacteria in 126 women with acute pelvic inflammatory disease. Microbial susceptibility and clinical response to four therapeutic regimens.

To more clearly understand the microbiology of acute salpingitis in our patients and to evaluate the clinical efficacy and safety of recommended and new therapeutic regimens, 126 women who met clinical diagnostic criteria for acute community-acquired pelvic inflammatory disease underwent endocervical and endometrial cultures prior to random intravenous therapy with cefoxitin plus doxycycline, ceftizoxime plus doxycycline or ceftizoxime alone (two regimens). Nine women (7%) had Chlamydia, and 70 (56%) had gonococci in endometrial specimens (P less than .001). Only two women (3.4%) given monotherapy required altered medical therapy, and none required surgery. Parenteral combination therapy was associated more frequently with adverse clinical and laboratory events.

Single-dose antimicrobial prophylaxis at abdominal hysterectomy. Cefamandole vs. cefotaxime.

Two hundred twenty-three women were given a single, 1-g, intravenous dose of cefamandole or cefotaxime at elective abdominal hysterectomy in a multicenter, prospective, randomized, blind clinical trial of efficacy and safety. The demographic, surgical, efficacy and safety variables were statistically similar. Prior to discharge from the hospital, 12 women (5.3%) developed major postoperative pelvic infections that required parenteral antimicrobial therapy; no wound infections occurred. There was no correlation between a depressed antimicrobial development of significant postoperative infection. An expanded spectrum of antibacterial activity and a longer serum half-life did not improve clinical efficacy, and single-dose intravenous cephalosporin prophylaxis before abdominal hysterectomy was associated with a low incidence of pelvic infection.

Single-agent therapy for acute pelvic inflammatory disease: sulbactam/ampicillin versus cefoxitin.

A total of 54 women with acute salpingitis were treated intravenously with ampicillin/sulbactam or cefoxitin in a prospective, randomized, ongoing study. Of the organisms isolated, Gram-negative species (excluding Neisseria gonorrhoeae) were considerably more likely to produce beta-lactamase than were Gram-positive species. Clinical efficacy was 94% for 2 g ampicillin plus 1 g sulbactam and 89% for 2 g cefoxitin, all given intravenously every 6 h. The addition of sulbactam, an irreversible beta-lactamase inhibitor, to ampicillin restored both the microbiological and clinical activities of ampicillin. Both regimens were equally safe and demonstrated good efficacy in the treatment of the acute, symptomatic phase of infection.

Doxycycline and cefamandole prophylaxis for premenopausal women undergoing vaginal hysterectomy.

Fifty-one premenopausal women were given perioperative intravenous antimicrobial prophylaxis at vaginal hysterectomy in a prospective, blinded comparative study. Febrile morbidity developed in 14 women (27.4 per cent), but only nine (17.6 per cent) required antimicrobial treatment. The incidence of postoperative pelvic infection was 19.2 per cent for 26 women given 200 milligrams of doxycycline preoperatively and 16 per cent for 25 women given 5 grams of cefamandole in four doses over a period of 18 hours. Infections were polymicrobial, usually occurred during the initial hospitalization and significantly prolonged hospital stay (p less than 0.01). No variables were identified that allowed prediction of infection. A single dosage of doxycycline was as effective at preventing posthysterectomy pelvic infection as were multiple dosages of cefamandole.

Preoperative cefoxitin prophylaxis for elective abdominal hysterectomy.

Fifty women were randomly given one, two, or three 2 gm parenteral doses of cefoxitin with placebo blinding perioperatively at abdominal hysterectomy. A single preoperative intramuscular dose was more efficient, less frequently associated with the development of bacterial resistance, and less expensive than two or three doses.

Piperacillin and a combination of clindamycin and gentamicin for the treatment of hospital and community acquired acute pelvic infections including pelvic abscess.

Therapy for acute polymicrobial pelvic infections is empiric and must include predictable anaerobic coverage. Single agent therapy, if effective, is advantageous for the patient, nurses, pharmacy and hospital. Piperacillin sodium was compared with a combination of clindamycin and gentamicin as therapy for 63 female patients who were hospitalized with acute pelvic infections including pelvic abscess complicating community acquired salpingitis. Over-all clinical efficacy with piperacillin was 96.8 per cent and 90.3 per cent for clindamycin and gentamicin. Fewer bacteria demonstrated in vitro resistance to piperacillin (p = 0.008) and the cost of treatment for these infections was significantly less with piperacillin (p less than 0.05). Serious adverse reactions were not observed with either regimen. Piperacillin provides effective, cost-efficient therapy for women with acute polymicrobial pelvic infections.

Single-agent therapy for women with acute polymicrobial pelvic infections.

Pathogens that cause acute polymicrobial female pelvic infections usually do not differ from those that compose the normal flora of the lower reproductive tract. Accurate identification of these bacteria is difficult because cultures obtained via the lower tract can easily be contaminated. Although use of a double-lumen catheter-protected brush culture cannot completely eliminate the risk of contamination, it is the least invasive method for obtaining culture material from the upper reproductive tract. Compounding the problem of accurately identifying pathogens that cause acute upper tract infections is the fact that bacteria appear to be present in the upper tracts of asymptomatic women with normal examinations. Because of these problems and because of the polymicrobial nature of these infections, empiric therapy frequently includes more than one antimicrobial agent. Newer, semisynthetic penicillins and cephalosporins have expanded spectrums of in vitro activity against most of the bacteria frequently recovered from pelvic infection sites. Comparative clinical trials have shown these agents to be as effective when used alone as is combination therapy. With few exceptions, empiric monotherapy with one of these newer antimicrobials will be curative for women with acute upper tract infection, will have less potential toxicity, will require less space, materials, and manpower to administer, and will be less expensive.

Prevention of major infection after elective abdominal hysterectomy: individual determination required.

A retrospective chart analysis of women undergoing elective abdominal hysterectomy in Parkland Memorial Hospital indicated significant postoperative antibiotic administration. For that reason, we conducted a prospective, double-blind, placebo-controlled study to determine the incidence of infection and febrile morbidity in this patient population and to evaluate the efficacy of perioperative cefoxitin in modifying the incidence of these conditions. Three 2 gm intramuscular doses of cefoxitin over 12 hours significantly reduced the incidence of major infection to 12% from 32% observed in the placebo group. The mean hospital stay for women given cefoxitin (5.6 days) was also significantly reduced when compared to that for women given placebo (6.4 days). The incidence of febrile morbidity not requiring therapy was significant and was not altered by perioperative cefoxitin. Febrile morbidity was observed in 42% of women given cefoxitin and in 34% of women given placebo. Administration of perioperative antimicrobial agents is necessary for women undergoing elective abdominal hysterectomy in our hospital, but we believe that individual determination is required.

Cefotaxime treatment for women with community-acquired pelvic abscesses.

Forty-one women with pelvic abscesses complicating salpingitis were treated with parenteral cefotaxime, a newer cephalosporin. Abscesses ranged in size from 4 by 4 to 13 by 15 cm, and in 10 women (24%) they were greater than or equal to 10 cm. Neisseria gonorrhoeae was recovered from the endocervix in 17 women (41%). A mean of 26.7 gm of cefotaxime was given over a mean of 6.5 days, and operation was not required during initial therapy. Only two women (5%) required the addition of another antimicrobial. Chronic pelvic pain and recurrent infection were infrequent during the 31- to 43-month follow-up period. Five women (12%) were readmitted for elective surgical therapy because of persistent or recurrent adnexal mass 1 to 33 months following study entry. Six (15%) women became pregnant and were delivered of their infants a mean of 25 months following cefotaxime therapy.

Ceftriaxone and cefazolin prophylaxis for hysterectomy.

Two hundred and twenty-five women scheduled for elective hysterectomy were entered into a prospective, comparative, randomized, double-blind clinical trial of antibiotic prophylaxis; 117 had vaginal hysterectomy and 108 had abdominal hysterectomy. They were given a 1 gram preoperative dose of ceftriaxone, an investigational cephalosporin or three 1 gram parenteral doses of cefazolin over a 16 hour period. Antibiotic concentrations were measured in serum and vagina, myometrium, fallopian tube or ovary and mean ceftriaxone concentrations were consistently higher than those of cefazolin. Both regimens were safe, well tolerated and equally effective at preventing major postoperative infection. Diabetes increased the risk for infection regardless of regimen and surgical approach (p = 0.009) and specific risk factors were identified for women undergoing vaginal hysterectomy. The incidence of infection was 1.7 per cent after vaginal hysterectomy, significantly lower than the 7.4 per cent observed after abdominal hysterectomy (p = 0.039). Several of the clinical and surgical variables were identified that could explain this difference.