Metronidazole for Prevention of Pelvic Cellulitis and Abscess after Laparoscopic Hysterectomy: A Triple-blinded, Randomized, Placebo-controlled Clinical Trial.

STUDY OBJECTIVE: To determine whether a postoperative 5-day treatment schedule with vaginal metronidazole added to conventional antibiotic prophylaxis with 2 g cefazolin modifies the risk of pelvic cellulitis (PC) and pelvic abscess (PA) after total laparoscopic hysterectomy (TLH). DESIGN: A randomized, controlled, triple-blind, multicenter clinical trial. SETTING: Two centers dedicated to minimally invasive gynecologic surgery in Colombia. PATIENTS: A total of 574 patients were taken to TLH because of benign diseases. INTERVENTION: Patients taken to TLH were divided into 2 groups (treatment group, cefazolin 2 g intravenous single dose before surgery + metronidazole vaginal ovules for 5 days postoperatively, control group: cefazolin 2 g intravenous single dose + placebo vaginal ovules for 5 days postoperatively). MEASUREMENTS AND MAIN RESULTS: The absolute frequency (AF) of PC and PA and their relationship with the presence of bacterial vaginosis (BV) were measured. There was no difference in AF of PC (AF, 2/285 [0.7%] vs 5/284 [1.7%] in the treatment and placebo groups, respectively; risk ratio, 1.75; 95% confidence interval, 0.54-5.65; p = .261), nor for PA (AF, 0/285 [0%] vs 2/289 [0.7%]; p = .159, in the treatment and placebo groups, respectively). The incidence of BV was higher in the metronidazole group than the placebo group (42.5% vs 33.4%, p = .026). CONCLUSION: The use of vaginal metronidazole ovules during the first 5 days in postoperative TLH added to conventional cefazolin prophylaxis does not prevent the development of PC or PA, regardless of the patient's diagnosis of BV.

Devastating Gynecological Infections in Women with STAT3 Deficiency.

We provide the first description of a series of 9 severe gynecological infections (mastitis and pelvic cellulitis) occurring in the French national cohort of women with STAT3 deficiency. Each episode had unique features in terms of clinical presentation, microbial documentation, location, treatment duration, and related persistent esthetic damage.

Pelvic surgical site infections in gynecologic surgery.

The development of surgical site infection (SSI) remains the most common complication of gynecologic surgical procedures and results in significant patient morbidity. Gynecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative sites and can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses. Multiple host and surgical risk factors have been identified as risks that increase infectious sequelae after pelvic surgery. This paper will review these risk factors as many are modifiable and care should be taken to address such factors in order to decrease the chance of infection. We will also review the definitions, microbiology, pathogenesis, diagnosis, and management of pelvic SSIs after gynecologic surgery.

Parametrial anisakidosis.

Anisakidosis is a parasitic infection caused by anisakid nematodes in the genera Anisakis and Pseudoterranova. Infection is not uncommon in the United States due to increased raw seafood consumption. We report the first known case of parametrial anisakidosis in a 42-year-old woman and review existing literature.

[How is agonizing leg pain associated with an intrauterine device?]. / In welchem Zusammenhang stehen quälende Beinschmerzen und eine intrauterine Spirale?

We report on a typical clinical course of pelvic actinomycosis: initial uncharacteristic discomfort develops into a systemic illness associated with a pelvic mass, which progresses so fast that along with the systemic infection further symptoms can be reduced to its growth rate--tiredness, abdominal pain, micturition deficiency, and leg pain. Distinction between malignancy and pelvic actinomycosis could be made only intraoperative. After hysterectomy and with antibiotics the patient recovered quickly.

Patient cost in the treatment of postsurgical female pelvic infection.

Soft tissue female pelvic infections, that is, postpartum endomyometritis, pelvic cellulitis, and salpingitis, are frequently polymicrobial, involving aerobic and anaerobic bacteria. The most common antibiotic regimen employed for the treatment of these patients is clindamycin and an aminoglycoside. Single-agent therapy, utilizing the newer beta-lactams, is more economical, potentially less toxic, and as effective.

Aztreonam plus clindamycin as therapy for pelvic infections in women.

Aztreonam, a new monobactam antibiotic with specific gram-negative aerobic activity, was used in combination with clindamycin in the treatment of 40 women with pelvic infection, including post-partum endometritis, pelvic inflammatory disease, and post-hysterectomy pelvic cellulitis. Clinical cure was achieved in 87 percent of patients. Failure was related to the limited gram-positive aerobic spectrum of clindamycin. All aerobic gram-negative enteric organisms were sensitive in vitro to less than 0.125 microgram/ml of aztreonam.

Antibiotic prophylaxis for abdominal hysterectomy.

Ninety-one patients were enrolled in a prospective randomized double-blind study evaluating the efficacy of systemic antibiotic prophylaxis in reducing the incidence of operative site infection after abdominal hysterectomy. Forty-five patients received a 2-dose course of cefoxitin; 46 patients received a placebo. Although patients in the antibiotic group had a lower fever index, there were no statistically significant differences between groups with respect to incidence of pelvic cellulitis, urinary tract infection, wound infection, need for therapeutic antibiotics, or duration of hospitalization. It is concluded that, in this patient population, the theoretic risks of widespread use of systemic antibiotics for prophylaxis outweigh the observed benefits.

Bacteremia in obstetrics: clinical course.

The authors reviewed all documented cases of bacteremia in obstetric patients between 1975 and 1979, with emphasis on the clinical course. The incidence of bacteremia was 7.5:1000 obstetric admissions and 9.7% of those patients sampled. One hundred seventy-six bacteremic obstetric patients had the following diagnoses: endoparametritis (123), pyelonephritis (29), chorioamnionitis (14), and other (10). No deaths, clinical evidence of septic shock, or cases of postinfection endocarditis were found. The most common bloodstream isolates were Escherichia coli (57), group B streptococcus (28), and Bacteroides sp (26). The patients with endoparametritis had a fever index of 86.2 +/- 47.1F-hours, an average hospital stay of 6.5 +/- 3.1 days, a 7.3% rate of complications, and a 19.5% rate of failure of primary antibiotics. The patients with chorioamnionitis had a fever index of 32.7 +/- 48.9F-hours and an average hospital stay of 4.8 +/- 2.3 days. These clinical measures are comparable with those in the general population with the same diagnoses at the authors' hospital. In this obstetric population, prompt, vigorous treatment rendered the clinical course of bacteremic patients with genital infections remarkably similar to that of nonbacteremic patients with the same kinds of infection.

Acute appendicitis during pregnancy. Diagnosis and management.

Twelve patients underwent appendectomy during pregnancy or in the puerperium. The clinical presentation of acute appendicitis is altered during gestation, and diagnosis becomes increasingly difficult when close to term. Abdominal pain, nausea, and vomiting are important symptoms. Peritoneal signs occur in the right lower quadrant early in pregnancy, but the upper quadrant or entire right side are more common locations, as the appendix is displaced upward by the enlarging uterus. Delay in treatment is common because of uncertainty in making the diagnosis and hesitancy to proceed with surgery. In the group of six patients with perforation, there was one maternal death and a loss of three fetuses. There were no complications in the absence of perforation. Prompt diagnosis is the cornerstone of a good outcome, and early surgical intervention is indicated if acute appendicitis is suspected. Pregnancy is not a reason to delay surgery. We review the literature on this topic and present and analyze principles of management.

Haemophilus influenzae in genitourinary tract infections.

Haemophilus influenzae was isolated in pure or predominant culture from genital specimens from nine females and two males. Four of the females had vaginitis, two had IUD-related endometritis, one had an incomplete septic abortion, and one had probable urethral syndrome. Two males had urethritis.

PIP: This report was prompted by the isolation of Haemophilus influenza from cultures of specimens from genital sites in 11 patients. All cervical, vaginal, and urethral specimens submitted to the Section of Clinical Microbiology Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota, for bacterial culture are routinely inoculated onto blood agar, eosinmethylene blue (EMB) agar, chocolate blood agar, Columbia colistin-nalidixic acid (CNA) blood agar, and unless previously directly inoculated by the attending physician, modified Thayer-Martin medium. As a rule, identification and reporting of isolates is limited to Neisseria gonorrhoeae, N. meningitidis, Gardnerella vaginalis, beta-hemolytic streptococci, Listeria monocytogenes, and Staphylococcus aureus. Cultures for anaerobic bacteria are restricted to endocervical or endometrial aspirates which are submitted to the laboratory in anaerobic transport vials. Cultures for fungi, Chlamydia trachomatis, and Ureaplasma urealyticum are performed by specific request, as is miscroscopic examination for Trichomonas vaginalis. Haemophilus influenzae was identified with the porphyrin test according to the Kilian's taxonomic system. Genital tract specimens from 11 patients yielded H. influenzae in pure or predominant culture. 9 patients were females, of whom 4 had vaginitis, usually with a yellowish, foul smelling discharge. 2 had IUD-related endometritis and parametritis, 1 had an incomplete septic abortion, and 1 had probable urethral syndrome. 2 males had urethritis. Cultures were negative for N. gonorrhoeae in every case and for C. trachomatis in the 6 patients whose specimens were cultured for this agent. Only 2 women -- 1 with vaginitis and 1 with probable urethral syndrome -- had G. vaginalis in cultures of vaginal secretions, while U. urealyticum was isolated from vaginal or cervical secretions of 3 of 4 women cultured for the organism.

Experimental infection of the upper genital tract of female grivet monkeys with Mycoplasma fermentans.

Mycoplasma fermentans inoculated directly into the uterine tubes of female grivet monkeys produced a self-limiting acute salpingitis and parametritis. The inflammation was accompanied by a significant rise in titre of specific indirect haemagglutinating antibodies. Inoculation of M. fermentans into the uterine cavity through the cervical canal without dilatation of the cervix produced practically no signs of inflammation and no antibody response. However, when the intrauterine inoculation of mycoplasmas was followed by currettage of the endometrium, in animals whose uterine tubes had been closed by ligatures, pronounced upper genital-tract inflammation developed, together with a significant antibody response.

A comparison of two different dosages of pivampicillin and doxycycline in patients with gynaecological infections.

The efficacy of 500 mg pivampicillin twice daily, 350 mg pivampicillin 3-times daily and 100 mg doxycycline daily was compared in 106 patients with salpingitis, parametritis or endometritis. Both the pivampicillin regimens were equally effective. The average duration of therapy needed to produce a satisfactory clinical response was shorter with pivampicillin (14 days) than with doxycycline (21 days). Pivampicillin improved the patients' gynaecological status in 90% of the subjects treated compared to only 70% of patients given doxycycline. Fewer relapses were recorded in women given pivampicillin (4%) than in subjects treated with doxycycline (15%). Gonococci were isolated from 10% of vaginal swabs. The involvement of Chlamydia and Mycoplasma was not studied. However, the high cure rate indicated that, if present, they did not pose a therapeutic problem. Side-effects, mainly dyspepsia, were observed in 2 patients in each group. The twice-daily administration of pivampicillin is recommended, since it is more practical and increases patient compliance.

Short-term prophylactic antibiotic for elective abdominal hysterectomy: how short?

A prospective double-blind study was conducted in order to evaluate the effect of antibiotic prophylaxis on patients undergoing elective abdominal hysterectomy. In the first stage of the study, 116 patients received, on call to the operating room and subsequently 8 and 16 h post-operatively, cefazolin sodium or placebo. In the second stage of the study, 90 patients received the same antibiotics, but treatment was extended to 6 doses, 8 h apart. Of the 53 women who received placebo, 27 (50.9%) became morbid, while only 15 of the 63 (23.8%) who received 24 h prophylaxis were classified as morbid (p less than 0.005). By extending the prophylactic treatment to 48 h further reduction of the morbidity was achieved. Of the 90 patients only 11 (12.2%) became morbid (P less than 0.005). When morbidity rates were compared between different ethnic groups, over-weight and normal weight patients, pre- and post-menopausal women, it was not possible to define a group which is at a higher risk for post-operative morbidity. It was thus concluded that prophylactic antibiotics should be administered routinely to all patients undergoing abdominal hysterectomy, preferably for 48 h.

Complications of rectal suction biopsy.

Complications following use of the rectal suction biopsy technique in the diagnosis of Hirschsprung's disease, are rare. In a series of 1,340 consecutive biopsies, complications included three clinical perforations of the bowel, one resulting in death, and three rectal hemorrhages requiring transfusion. A plea is made for the use of greater care in this technique.

[Parametritis caused by an IUD]. / Parametritis door een IUD.

PIP: A 29 year old woman who had used a Lippes Loop D for 4 years was examined for acute pelvic pain. The IUD was removed and tests determined the presence of endomyometritis and parametritis on the left side of the pelvis. The patient, who had a history of thromboembolic disease, developed thrombosis of the left leg in spite of anticoagulant prophylaxis. The patient later underwent an operation to effect sterilization by using rings, and on the left side of the pelvis varicosis of the left ligamentum infundibulopelvic and the parametritis were observed. After the operation, the patient developed, in spite of prophylaxis, a pulmonary embolism, which was successfully treated.^ieng

[Use of ceftriaxone against parametritis after radical surgery for cancer of the uterine cervix].

1. The bacteria isolated from pelvic dead space drainage well reflect the characteristics of prophylactic drugs. As drugs advance from penicillin (PC) to tetracycline (TC) to the first, second and third generation cephems, detection rates for Gram-negative bacilli, mainly Escherichia coli, decrease remarkably, while those for Gram-positive cocci, mainly Enterococcus faecalis, increase. 2. The bacteria isolated from the drainage and those which later caused parametritis and purulent lymphocyst were closely related. It is therefore very important to identify bacteria present in the drainage. 3. Judging from changes occurred in blood levels of ceftriaxone (CTRX) and its effective transfer to the pelvic dead space when CTRX 2 g was administered once daily, this administration regimen is considered to control even parametritis and purulent lymphocyst satisfactorily. 4. CTRX 2 g was administered once daily for 5 consecutive days to each of 4 patients with parametritis, and it was observed that the general efficacy was good in 3 of the 4 cases.

[Basic and clinical studies on cefminox in the field of obstetrics and gynecology].

Basic and clinical studies were carried out on cefminox (CMNX, MT-141), a new cephem antibiotic. Results obtained were as follows. Following each 1 g of intravenous drip infusion and intravenous injection, transfer of CMNX to the internal genital organs was good. Transfer of CMNX into exudate of the pelvic dead space was also good and showed high concentration. CMNX was given to 2 cases. Clinical efficacy was good in 1 case, and could not be evaluated in 1 case. No side effects were observed in both cases. The above results show that CMNX is an effective agent.

[Investigation on administration method of carbapenems].

Seventy-two women diagnosed as parametritis were enrolled in this study and examined on the effective administration method of carbapenems, imipenem/cilastatin (IPM/CS), panipenem/betamipron (PAPM/BP) and meropenem (MEPM). The total dosage of each carbapenem was 1.5 g/day, and administration frequency was twice a day (0.75 g x 2) or three times a day (0.5 g x 3). We reviewed the highest body temperature, white blood cell count and CRP value, before treatment and the fourth day after the start of treatment. Three times a day method was statistically superior to twice a day method in the highest body temperature, and CRP value. When we use carbapenem antimicrobial agents, the basis of PK/PD of time above MIC would lead to the increasing clinical effects.