Is There a Benefit to Culturing Intra-Uterine Devices in Pelvic Inflammatory Disease?

AIMS: The study aimed to compare the clinical course and disease severity between culture positive and culture negative patients with intra-uterine devices (IUD)-associated pelvic inflammatory disease (PID). METHODS: A retrospective study of all IUD-associated PID patients admitted to tertiary medical center between 2010 and 2015. All patients received standard empiric antibiotic therapy upon admission. The study cohort was divided into 2: patients with culture positive IUDs and patients with negative cultures. Electronic medical records and culture results were analyzed from the time of admission. RESULTS: During the study period, 480 hospitalized patients were diagnosed with PID. Of these, 94 patients had IUD-associated PID, 59 with positive cultures and 35 with negative cultures. While fever was more common in the latter (p = 0.01), no significant differences were found in disease severity in patient outcomes (i.e., length of stay, rates of invasive treatment, and total abdominal hysterectomies). In a sub-analysis of patients with IUD cultures of established PID pathogens only, there were no differences in disease severity and outcome in patients with antibiotic susceptible or resistant strains. CONCLUSIONS: IUD removal for culture in PID patients is probably unnecessary. Alteration of treatment according to the culture results may have little impact on disease course and outcome.

Culture- and PCR-based detection of BV associated microbiological profile of the removed IUDs and correlation with the time period of IUD in place and the presence of the symptoms of genital tract infection.

OBJECTIVES: The long-term use of intrauterine devices (IUDs) may lead to biofilm formation on the surface. The aim of this study was to perform the culture- and PCR-based detection of bacteria/fungi from the biofilm of the removed IUDs with different time periods in place. METHODS: For a 2-year period, 100 IUD users were involved in the study. In the majority of the cases, IUDs were removed because of the patients' complaints. Beside the aerobic and anaerobic culture, species-specific PCR was carried out to detect Chlamydia trachomatis Neisseria gonorrhoeae and the "signalling" bacteria of bacterial vaginosis (BV) in the biofilm removed by vortexing. RESULTS: Sixty-eight percent of IUDs were used for more than 5 years, 32% were removed after 10 years in place. In 28% of the IUDs ≥ 3 different anaerobic species typically found in BV with or without other aerobic bacteria were found by culture method. Streptococcus agalactiae (14%) and Actinomyces spp. (18%) were also isolated frequently. The PCR detection of Gardnerella vaginalis, Atopobium vaginae, Mobiluncus spp. and Ureaplasma urealyticum were 62%, 32%, 23% and 16%, respectively. Seventy-six percent of the IUDs were PCR positive at least for one "signalling" bacterium of BV. C. trachomatis was detected by PCR only in one IUD together with other aerobic and anaerobic bacteria, while the presence of N. gonorrhoeae could not be confirmed from the biofilm of these removed devices. CONCLUSION: Sexually transmitted infections (STI)-related bacteria-except for one patient-were not detected on the IUDs removed due to different reasons including clinical symptoms of infection. Presence of any BV "signaling" anaerobic bacteria were detected in a much higher number in the biofilm of the removed IUDs by PCR-based method compared to use culture method (76 versus 28 samples). Different aerobic and anaerobic bacteria colonized an equal number of IUDs, independent of the time-period in place, which may be relevant, if the IUD is removed due to planned pregnancy or due to a fear from upper genital tract infection caused by anaerobic bacteria including Actinomyces spp.

Pelvic actinomycosis and IUD.

OBJECTIVE: To summarize knowledge about the mana-gement in women with proven actinomyces in uterine cervix and inserted intrauterine device (IUD). DESIGN: An overall review. RESULTS: Actinomycosis is an uncommon but important subacute or chronic infection caused by anaerobic or microaerophilic bacteria, mainly within the Actinomyces genus. Actinomycosis can affect various organs and tissues in the human body, often manifesting draining sinuses, abscess formation and fibrosis. The pelvic form in women is the most common in the developed countries. Long-duration treatment with antibiotics can be completely effective even in cases of heavy disease. Although pelvic actinomycosis is predominantly associated with the longstanding use of intrauterine device, the risk of future symptomatic infection is extremly low even in women with a cervical Pap smear positive for actinomyces-like organisms (ALO). Therefore the identification of actinomycetes by cytology after cervical Pap smears is not diagnostic nor predictive of any disease because the actinomycetes normally reside in the female genital tract. In the absence of symptoms, patients with ALO on a Pap test do not need antimicrobial treatment or IUD removal. Nevertheless, women choosing an IUD for contraception should know that there is very low risk of developing the infection in later years after insertion. CONCLUSION: The sources of literature conclude that removal of the intrauterine device in a patients with a positive ALO in the uterine cervix is not necessary and antibiotics treatment is not required. However, IUD must be changed at least every five years in order to limit the risk of the development of pelvic actinomycosis.

Synergistic effect of amphotericin B and tyrosol on biofilm formed by Candida krusei and Candida tropicalis from intrauterine device users.

The presence of intrauterine contraceptive devices (IUDs) provides a solid surface for attachment of microorganisms and an ideal niche for the biofilm to form and flourish. Vaginal candidiasis is often associated with the use of IUDs. Treatment of vaginal candidiasis that develops in connection with IUD use requires their immediate removal. Here, we present in vitro evidence to support the use of combination therapy to inhibit Candida biofilm. Twenty-three clinical Candida isolates (10 C. krusei and 13 C. tropicalis) recovered from endocervical swabs obtained from IUD and non-IUD users were assessed for biofilm-formation ability. The rate of isolation of Candida did not differ significantly among IUD and non-IUD users (P = 0.183), but the biofilm-formation ability of isolates differed significantly (P = 0.02). An in vitro biofilm model with the obtained isolates was subjected to treatment with amphotericin B, tyrosol, and a combination of amphotericin B and tyrosol. Inhibition of biofilm by amphotericin B or tyrosol was found to be concentration dependent, with 50% reduction (P < 0.05) at 4 mg/l and 80 µM, respectively. Hence, a combination effect of tyrosol and amphotericin B was studied. Interestingly, approximately 90% reduction in biofilm was observed with use of 80 µM tyrosol combined with 4 mg/l amphotericin B (P < 0.001). This represents a first step in establishing an appropriate antibiofilm therapy when yeasts are present.

Microbiological profile and biofilm formation on removed intrauterine contraceptive devices from a sample of Egyptian women.

AIM: The aim of this study was to investigate the presence of biofilm formation around intrauterine contraceptive devices (IUCD) and to correlate the microbiological profile of the IUCD-associated genital infections to the microbiological profile of specimens retrieved from vaginal discharge. MATERIAL AND METHODS: Samples of the vaginal discharge in the posterior fornix were collected from 50 women attending the Family Planning Clinic in Ain Shams University Hospital using two high vaginal swabs. Swabs were immediately sent for Gram staining as well as microbiological culture. The IUCD was then removed. A 0.5-cm piece of the removed IUCD was cut and sent for culture. Growing colonies were tested for their abilities to form a biofilm (colorimetric method). Another 0.5-cm piece of the removed IUCD was examined by electron microscopy (EM) for detection of biofilm formation. RESULTS: Among the included 50 women, 24 (48%) women showed biofilm formation (via colorimetric methods). EM scanning was able to detect biofilm formation in the prepared pieces of the removed IUCD of 48 (96%) women. There was no significant agreement between the isolated microorganisms on the removed IUCD and the vaginal swab (proportion of agreement was 14 [11.4%]; κ = -0.089, P = 0.892). CONCLUSION: Scanning EM is a useful tool in detection of biofilm formation on removed IUCD.

Diagnosis of pelvic inflammatory disease (PID): intra-operative findings and comparison of vaginal and intra-abdominal cultures.

INTRODUCTION: Pelvic inflammatory disease (PID) is frequent in adolescents and younger women. Diagnosis is usually based on the clinical findings, and the threshold for empiric antibiotic therapy should be low. However, at least in cases of resistance toward therapy or deterioration of symptoms, laparoscopic evaluation can be helpful. METHODS: We searched the hospital charts for in-house patients who were treated for PID or tubo-ovarian abscess between 2007 and 2010. In cases with both vaginal and intra-abdominal bacterial cultures, results of those were compared. RESULTS: 73 patients with suspected PID or tubo-ovarian abscess were included. Median patients' age was 40 years (18-88), 18 of 73 (24.7 %) patients had an IUD at the time of consultation. 58 patients underwent laparoscopy or laparotomy. In 41 patients (70.7 %) tubo-ovarian abscess could be confirmed, four patients had differential gynecologic diagnoses, and two patients appendicitis. In vaginal swabs, most frequent bacteria were Streptococcus sp. (28.5 %), Escherichia coli (22.2 %), Enterococcus faecalis (15.9 %), and Staphylococcus sp. (9.5 %). In eight patients (11 %) Chlamydia trachomatis could be found, there was no case of Neisseria gonorrhea. In 33 patients both vaginal and abdominal cultures were available. In nine cases (27.3 %), identical bacteria could be found, however, 11 cases (33.3 %) showed different results. CONCLUSION: In severe cases of PID, laparoscopic evaluation and taking an intra-abdominal bacterial culture are helpful for the confirmation of diagnosis, accurate microbiologic testing and specific therapy.

Pelvic actinomycosis-like disease due to Propionibacterium propionicum after hysteroscopic removal of an intrauterine device.

A female patient presented with episodes of fever and pain in the lower right abdomen after hysteroscopic removal of an intrauterine device 2 months earlier. Pelvic actinomycosis originating from a tubo-ovarian abscess was diagnosed with Propionibacterium propionicum, formerly known as Arachnia propionica, as causative agent.

Pseudoactinomyces in cervical mucus.

Actinomyces israelii are gram-positive filamentous bacteria forming yellow sulfur granules. They are the most well known complication of intrauterine contraceptive devices (IUCD). Healthcare staff dealing with reporting cervical smears should be aware of pseudoactinomyces entity in a cervical smears and biopsies as it may raise a false alarm to the clinician and may lead to unnecessary removal of IUCD and/or medical treatment.

Biofilm formation on intrauterine devices in patients with recurrent vulvovaginal candidiasis.

A biofilm is a complex community of surface-associated cells enclosed in a polymer matrix. They attach to solid surfaces and their formation can be affected by growth conditions and co-infection with other pathogens. The presence of biofilm may protect the microorganisms from host defenses, as well as significantly reduce their susceptibility to antifungal agents. Pathogenic microbes can form biofilms on the inert surfaces of implanted devices such as catheters, prosthetic cardiac valves and intrauterine devices (IUDs). The present study was carried out to analyze the presence of biofilm on the surface of intrauterine devices in patients with recurrent vulvovaginal candidiasis, and to determine the susceptibility profile of the isolated yeasts to amphotericin B and fluconazole. Candida albicans was recovered from the IUDs and it was found to be susceptible to the antifungal agents when tested under planktonic growing conditions. These findings indicate the presence of the biofilm on the surface of the IUD as an important risk factor for recurrent vulvovaginal candidiasis.

Scanning electron and confocal scanning laser microscopy imaging of the ultrastructure and viability of vaginal Candida albicans and non- albicans species adhered to an intrauterine contraceptive device.

Although bacterial biofilms have been studied in detail, adhesion of Candida albicans and non-albicans species to an intrauterine contraceptive device (IUD) is not clear. The objective of this study was to evaluate aspects of imaging of the ultrastructure and viability of vaginal yeasts adhered to different parts of an IUD, through scanning electron microscopy (SEM) and confocal scanning laser microscopy (CSLM). We studied yeasts isolated from different patients with vulvovaginal candidiasis: C. albicans, C. glabrata, C. guillermondii, C. parapsilosis, C. tropicalis, and Saccharomyces cerevisiae. A suspension of the each yeast was prepared and incubated with IUD parts (tail, without copper, and copper-covered). SEM and CSLM showed that all the vaginal yeasts adhered to all the parts of the IUD and demonstrated viability, including 30 days after contact for C. albicans. Possibly irregularities of IUD surface contribute to the adherence process. Although all of the IUD parts contribute to retention of yeasts in the genital tract, high concentration of yeast cells on the tail may indicate the importance of this segment in maintaining the colonization by yeast cells because the tail forms a bridge between the external environment, the vagina that is colonized by yeast cells, and the upper genital tract where there is no colonization.

Pelvic actinomycosis: a rare entity presenting as tubo-ovarian abscess.

A 24-year-old woman having two children using an intrauterine contraceptive device was admitted with lower abdominal pain and fever. On clinical and radiographic examination revealed a 7x6 cm multi-loculated cystic mass in the lower abdomen. The differential diagnosis included twisted ovarian cyst, ectopic pregnancy, tubercular tubo-ovarian (TO) mass red degeneration fibroid, diverticular diseases, emphysematous cystitis, pelvic malignancy, and mesenteric cyst. On histologic examination, an actinomycotic TO abscess was found with sulfur granules.

Fatal toxic shock syndrome from an intrauterine device.

Toxic shock syndrome is a rare toxin-mediated condition that can rapidly produce multiorgan failure and severe shock. Toxic shock syndrome has been previously recognized in various clinical situations relating to surgery, nasal packing, abscesses, burns, and most notably menstrual-related cases. This case report describes a previously healthy 33-year-old woman presenting to the emergency department with complaints of nausea, vomiting, and diarrhea; vital signs at triage were normal. Within hours, she developed shock and cardiopulmonary arrest. The patient met all 6 of the Centers for Disease Control and Prevention diagnostic criteria for toxic shock syndrome, and her intrauterine device grew out Staphylococcus aureus. To our knowledge, this is the first reported case in the medical literature of fatal toxic shock syndrome related to an intrauterine device.

Endocarditis following IUD insertion in a patient with tetralogy of Fallot.

The role of antibiotic prophylaxis for prevention of infective endocarditis is unknown. Endocarditis prophylaxis is recommended for certain high-risk individuals prior to dental procedures. To our knowledge, this is the first case reported in the literature of a patient with complex congenital heart disease developing endocarditis in the period immediately following otherwise uncomplicated intrauterine device insertion.

"Fungating" tumour? No, it's bacterial!

A fit and healthy 26-year-old woman presented to the general surgical team with epigastric pain and weight loss of 2 stones over 6 months. She has also a positive family history of ulcerative colitis. As her oesophagogastroduodenoscopy and colonoscopy were normal, a contrasted CT was requested, and it detected an inflammatory mass with fat streaking around her transverse colon. An intrauterine contraceptive device (IUCD) was noted. In light of the CT findings, she underwent a diagnostic laparoscopy. As the inflammatory mass was not separable from the transverse colon, a segmental transverse colectomy was proceeded. The histology revealed multiple actinomycosis abscesses in the mesentery. Subsequently, we learnt that her IUCD had been in situ for the last 7 years, and the source of actinomycosis abscesses is likely from her IUCD. The patient was recommended to have the coil removed and commenced on a 6 months course of amoxicillin.

Case Report: Cervicovaginal Co-Colonization with Entamoeba gingivalis and Entamoeba polecki in Association with an Intrauterine Device.

Amoebic trophozoites were identified in the cervicovaginal smear of a U.S. patient without travel history at the time of intrauterine device (IUD) removal. Subsequent morphologic analysis and DNA sequencing identified a mixed cervicovaginal colonization of the female genital tract with both Entamoeba gingivalis and Entamoeba polecki in association with Actinomyces species bacteria. This highlights to the potential for colonization of the genital tract with E. gingivalis, particularly in association with IUD placement, and represents the first report of E. polecki in this context.

Actinomycosis of the appendix and pelvis: a case report.

BACKGROUND: Actinomycosis is a chronic infection caused by Actinomyces israeli, a gram-positive saprophytic anaerob, a normal inhabitant of the upper intestinal tract. CASE: We report a case of a 35-year-old female with an intrauterine device (IUD) who appeared in the emergency department with clinical characteristics of appendicitis. Ultrasound and computed tomography were performed, revealing an ovarian tumor formation and acute appendicitis. The patient underwent exploratory laparotomy, unilateral ovarectomy due to acute abscess and finally appendectomy. Diagnosis of actinomycosis was established with the presence of sulphur granules microscopically. The patient received penicillin for an extended period. Two years have passed and no clinical recurrence was mentioned. CONCLUSION: Actinomycosis is not easily apparent because of its rarity. Inflammatory intestinal and pelvic disease can easily mislead the diagnosis, giving the impression of a neoplastic process. The drug of choice is penicillin, initiating a long-term aggressive therapy. The antimicrobial treatment lasts from 6 months to a year. Prognosis is very good. The role of IUD as a factor in the dissemination of the infection is very important. Physicians should be aware of actinomycosis in cases of abdominopelvic infiltrating masses.

Clioquinol is a promising preventive morphological switching compound in the treatment of Candida infections linked to the use of intrauterine devices.

PURPOSE: Candida biofilm infections are frequently linked to the use of biomaterials and are of clinical significance because they are commonly resistant to antifungals. Clioquinol is an antiseptic drug and is effective against multidrug-resistant Candida. We investigated the effect of clioquinol and two other 8-hydroxyquinoline derivatives on Candida biofilm. METHODOLOGY: The ability to inhibit biofilm formation, inhibit preformed biofilm and remove established biofilms was evaluated using in vitro assays on microtitre plates. The action of clioquinol on biofilm in intrauterine devices (IUDs) was also investigated, describing the first protocol to quantify the inhibitory action of compounds on biofilms formed on IUDs. RESULTS: Clioquinol was found to be the most effective 8-hydroxyquinoline derivative among those tested. It prevented more than 90 % of biofilm formation, which can be attributed to blockade of hyphal development. Clioquinol also reduced the metabolic activity of sessile Candida but the susceptibility was lower compared to planktonic cells (0.031-0.5 µg ml-1 required to inhibit 50 % planktonic cells and 4-16 µg ml-1 to inhibit 50 % preformed biofilms). On the other hand, almost complete removal of biofilms was not achieved for the majority of the isolates. Candida spp. also showed the ability to form biofilm on copper IUD; clioquinol eradicated 80-100 % of these biofilms. CONCLUSION: Our results indicate a potential application in terms of biomaterials for 8-hydroxyquinoline derivatives. Clioquinol could be used as a coating to prevent morphological switching and thus prevent biofilm formation. Furthermore, clioquinol may have future applications in the treatment of Candida infections linked to the use of IUDs.

IUDs and colonization or infection with Actinomyces.

Pelvic actinomycosis is an extremely rare disease that can occur in women with a long duration of intrauterine device (IUD) use. This type of abscess is usually unsuspected and, thus, diagnosed and treated surgically; however, long-duration treatment with penicillin can be completely effective. While the occurrence of actinomycosis is well documented by case reports, it is not possible to quantify the risk during IUD use. Approximately 7% of women using an IUD may have a finding of Actinomyces-like organisms on a Pap test. The prognostic significance of this finding is minimal because of the lack of sensitivity and specificity and a low positive predictive value. In the absence of symptoms, women with Actinomyces-like organisms on a Pap test do not need antimicrobial treatment or IUD removal.

Tuboovarian abscess caused by Candida in a woman with an intrauterine device.

Candida infection should be considered in an individual with a pelvic abscess that is unresponsive to conventional antibiotic therapy, particularly in the presence of an intrauterine device. We present a case of a tuboovarian abscess caused by Candida species in a woman with an intrauterine device for >10 years. Surgical intervention followed by antifungal therapy resulted in a favorable outcome.