Metronidazole for bacterial vaginosis. A comparison of vaginal gel vs. oral therapy.

OBJECTIVE: To compare the efficacy and safety of 0.75% metronidazole vaginal gel with oral metronidazole for the treatment of bacterial vaginosis (BV). STUDY DESIGN: Nonpregnant women with BV were enrolled in a multicenter, randomized, investigator-blind treatment trial. Patients were randomly assigned to either 0.75% metronidazole vaginal gel (5 g twice daily for five days) or oral metronidazole (500 mg twice daily for seven days). Follow-up visits occurred approximately two and five weeks after initiation of therapy. RESULTS: BV was clinically eliminated at the first follow-up visit in 83.7% (36/43, 95% CI 72.3-95.1%) of the intravaginal group and 85.1% (40/47, 95% CI 74.6-95.6%) of the oral group. At the final visit, BV was eliminated in 70.7% (29/41, 95% CI 56.3-85.1%) of the intravaginal group and 71.1% (32/45, 95% CI 57.4-84.8%) of the oral group. Significantly more patients in the oral treatment group (51.8%) reported gastrointestinal complaints as compared to the intravaginal treatment group (32.7%, P = .04). CONCLUSION: The efficacy of 0.75% metronidazole vaginal gel twice daily for five days in treating BV was similar to that of standard oral metronidazole treatment and was associated with fewer gastrointestinal complaints.

Results of noncomparative studies of cefotetan in the treatment of obstetric and gynecologic infections.

In a multicenter trial involving 11 centers, 160 women were enrolled to evaluate the safety and effectiveness of 1 or 2 gm of cefotetan administered every 12 hours in the treatment of obstetric and gynecologic infections. The 133 evaluable patients generally were under 25 years of age, were nonwhite, and had hospital-acquired endometritis or pelvic inflammatory disease caused by both aerobic and anaerobic bacteria. Escherichia coli, Neisseria gonorrhoeae, group D streptococci, Bacteroides sp., and Peptococcus sp. were among the most frequently isolated pathogens. The patients were treated for a mean of 5.6 +/- 1.6 days and received a total dose of 19.27 gm. The signs and symptoms of infection were cleared or improved in 93% of the 133 patients evaluable for clinical response. Of the 116 evaluated bacteriologically, 95% had a satisfactory or presumed satisfactory response; only six patients (5%) were considered to be bacteriologic failures. Differences in the results of several clinical laboratory tests performed before and after treatment were statistically, but not clinically, significant (p less than 0.05). Safety was evaluated in the 158 patients who received cefotetan, and only four (3%) had adverse reactions considered related to the drug. Cefotetan was clearly effective and produced no untoward reactions in these women with obstetric and gynecologic infections caused by both aerobic and anaerobic organisms when administered at 1 or 2 gm every 12 hours.

Adolescent contraception.

Many adolescents are at risk for unplanned pregnancy. Health professionals who care for adolescents should be familiar with the various contraceptive methods and their suitability for teenagers. Each method, with its pros and cons, is described in this article. Ultimately, the health care provider is advised to tailor contraception to fit the needs of the individual patient.

Giardiasis in pregnancy.

Giardiasis in pregnancy can be a debilitating disease with threatens the well-being of mother and fetus, as illustrated by three cases. The usual therapeutic agents are contraindicated in pregnancy. Paromomycin, an oral, poorly absorbed aminoglycoside, is an alternate, potentially less toxic agent for treatment of symptomatic giardiasis in pregnancy. The pharmacologic actions of paromomycin in human beings and its antiprotozoan efficacy are discussed.

Adolescent contraception.

PIP: Many adolescents in the United States remain at risk for an unplanned pregnancy despite advances in contraceptive technology and increased availability of birth control methods. Physicians who care for adolescents need to be familiar with the various contraceptive measures and their appropriateness for adolescents. A health professional must also be prepared to participate in sex education and to counsel or refer individual teenage patients when sexual problems occur. Attention in this discussion of adolescent contraception is directed to the following: reasons for nonuse of contraception, postcoital contraception, oral contraception (contraindications, side effects, guidelines for use in adolescents, and the mini-pill (progestogen only), IUDs, diaphragms, vaginal chemical contraceptives, condoms, withdrawal or rhythm, intervention techniques, and selection of the proper method. The average adolescent is exposed to unprotected intercourse for a year or longer before requesting contraception. Available evidence suggests that teenagers today may be using contraceptives more than ever before, yet a significant number fail to use a method for a variety of reasons. Most reasons reflect lack of knowledge; some reflect nonavailability. The reasons include ignorance of fertile periods, a belief that their age is protective, infrequent or unanticipated intercourse, and strong guilt feelings evoked by the idea of being prepared for the possibility of sexual intercourse. Many adolescents are hesitant to ask for contraceptive advice or prescriptions from private physicians because they fear lectures on morality and refusal of their requests. There is evidence in at least 1 study that locating the family planning clinic within the school is effective in lowering pregnancy rates and ensuring high continuation rates after 36 months of followup. Intervention techniques that might be effective include providing a method immediately following an event (abortion, birth, rape) when motivation is highest and tailoring the method to the individual life style and preference. If no contraindications exist, the teenager should be given the method preferred and a method that is geared to frequency of intercourse. A backup method should also be provided if the preferred method is not tolerated or never started. To maximize continuation rates, frequent followup is essential.^ieng

Menstrual extraction in the adolescent.

Menstrual extraction or suction aspiration of the uterus with a flexible cannula within 2 weeks of a missed menstrual period is infrequently used in the adolescent. Eighty-two adolescents (39 private and 43 clinic patients) underwent 90 menstrual extractions at the Medical University of South Carolina from January 1977 through March 1979. The clinic population consisted of a higher percentage of blacks and more individuals who had previously been pregnant and carried pregnancies to term. Major complications occurred in only two patients. One pregnancy continued to term. This could have been prevented if vigorous attempts had been made to encourage all patients to return for follow-up exam. The patients' shift to the use of pills and IUDs after the procedure suggests that menstrual extraction may serve as an introduction to effective birth control methods. Results of menstrual extraction in the adolescent compare favorably with those reported in adults.

Gastrointestinal complications of modern intrauterine devices.

Two cases of gastrointestinal tract injury associated with extrauterine intrauterine devices (IUDs) are reported and compared with the 6 previously reported cases. Puerperal insertion was a factor in 6 cases, but 5 of these patients developed gastrointestinal symptoms only after a subsequent labor and delivery. Significant morbidity was present in most patients, and the diagnosis was often delayed and difficult to establish. Laparotomy was required in 7 cases. An extrauterine device should be removed promptly to minimize the risk of developing serious gastrointestinal complications.

Perioperative cephalosporin prophylaxis in cesarean section: effect on endometritis in the high-risk patient.

A total of 120 patients who were to be delivered by cesarean section and who were at high risk of postoperative infection received three doses of either cefamandole, cephalothin or placebo perioperatively. Maternal serum levels for both antibiotics were in the therapeutic range. Although both drugs reduced the incidence of febrile morbidity and endometritis, only cefamandole significantly reduced the fever index. Risk factors for postoperative infections were the presence of ruptured membranes, labor, and internal fetal monitoring. Cefamandole beneficially influenced all risk factors while cephalothin was able to reduce only the risk of ruptured membranes. When a new method for obtaining endometrial tissue was utilized, 50% of cultures were negative. There was no difference in the organisms isolated from patients with and without endometritis.

Perioperative antibiotic prophylaxis is cesarean section.

The effect of an 8-hour, 3-dose perioperative regimen of cefazolin or placebo was evaluated in 97 patients. Postoperative morbidity occurred in 13 patients (27.1%) in the cefazolin group and in 17 patients (34.7%) who received placebo. The clinical sites of infection were similar in both groups except that wound infections (2) and sepsis (2) were found only in patients receiving placebo. Aerobic organisms diminished and anaerobes increased in patients who received antibiotics. Aerobic isolates were essentially unchanged and fewer anaerobes were recovered from patients given placebo. Antibiotic levels observed at cesarean section were in the therapeutic range. The only risk factor which correlated with morbidity was the presence of ruptured membranes. This short course, single drug regimen did not significantly reduce morbidity although it was bacteriologically effective.

Bacterial flora of patients with prematurely ruptured membranes.

Twenty consecutive patients with premature rupture of the membranes were studied to determine the vaginal, endocervical, and neonatal bacteriologic flora. Patients who had membranes ruptured for more than 12 hours had more anaerobic species isolated from vaginal plus endocervical or endocervical cultures alone than did those patients with membranes ruptured for less than 12 hours. Overall, aerobic organisms were more frequently isolated than anaerobic organisms, but the majority of cultures were of a mixed flora. Streptococci, corynebacteria, and Bacteroides organisms were the most frequently isolated organisms from all sites cultured. Lactobacilli were isolated in only 45% of endocervical and vaginal cultures, and Enterobacteriaceae were infrequently encountered. This study indicates that there is a change toward a preponderance of anaerobic species in the birth canal when membranes are ruptured for more than 12 hours, and that this change is detectable before delivery.