Assessing the effectiveness of empiric antimicrobial regimens in cases of septic/infected abortions.

INTRODUCTION: Infected abortion is a life-threatening condition that requires immediate surgical and medical interventions. We aimed to assess the common pathogens associated with infected abortion and to test the microbial coverage of various empiric antimicrobial regimens based on the bacteriological susceptibility results in women with infected abortions. METHODS: A retrospective study in a single university-affiliated tertiary hospital. Electronic records were searched for clinical course, microbial characteristics, and antibiotic susceptibility of all patients diagnosed with an infected abortion. The effectiveness of five antibiotic regimens was analyzed according to bacteriological susceptibility results. RESULTS: Overall, 84 patients were included in the study. The mean age of patients was 32.3(SD ±â€¯5.8) years, and the median gestational age was 15 (IQR 8-19) weeks. Risk factors for infection were identified in 23 patients (27.3%), and included lack of medical insurance (n = 12), recent amniocentesis/chorionic villus sampling or fetal reduction due to multifetal pregnancies (n = 10). The most common pathogens isolated were Enterobacteriaceae (35%), Streptococci (31%), Staphylococci (9%) and Enterococci (9%). The combination of intravenous ampicillin, gentamicin and metronidazole showed significant superiority over all the other tested regimens according to the susceptibility test results. Piperacillin-tazobactam as an empiric single-agent drug of choice and provided a superior microbial coverage, with a coverage rate of 93.3%. CONCLUSIONS: A combination of ampicillin, gentamicin, and metronidazole had a better spectrum of coverage as a first-line empiric choice for patients with infected abortion.

Abortion care

This guideline covers care for women of any age (including girls and young women under 18) who request an abortion. It aims to improve the organisation of services and make them easier for women to access. Detailed recommendations on conducting abortions at different gestational stages are also included, to ensure that women get the safest and most effective care possible.

[Septic abortion with massive coagulopathy and subsequent acute hysterectomy].

Septic abortion is a rare, but potentially life-threatening condition. Quick diagnosis and treatment is essential for the outcome. This case report describes a healthy 34-year-old woman who was admitted with abdominal pain, fever and an ongoing spontaneous abortion at gestational age week 13 + 6 days. During evacuation severe bleeding and coagulopathy was seen. She was treated with multiple coagulation products but due to a life-threatening situation an acute hysterectomy was performed. She was discharged after nine days.

Septic abortion presenting as a right lower trapezius abscess secondary to Bacteroides fragilis bacteraemia.

A 43-year-old Japanese woman was evaluated in the outpatient department for right shoulder pain and fever, which began 5 days earlier. MRI of the right shoulder revealed a high-intensity area deep in the right trapezius muscle. Aspiration revealed purulent fluid, and Gram staining of the fluid showed Gram-negative bacilli. The patient was also found to be profoundly anaemic and to have a positive urine pregnancy test. On admission, we initiated intravenous ampicillin-sulbactam and aztreonam. She underwent dilatation and curettage for septic abortion and surgical drainage of the right shoulder abscess. Bacteroides fragilis was isolated from the blood, uterine aspiration and abscess samples. On hospital day 4, a whole-body CT scan revealed no other abscesses, and ampicillin-sulbactam was continued for 28 days. The patient was discharged on hospital day 29. Gram staining is an important tool for evaluating infectious aetiologies.

Antibiotics for treating septic abortion.

BACKGROUND: A septic abortion refers to any abortion (spontaneous or induced) complicated by upper genital tract infection including endometritis or parametritis. The mainstay of treatment of septic abortion is antibiotic therapy alone or in combination with evacuation of retained products of conception. Regimens including broad-spectrum antibiotics are routinely recommended for treatment. However, there is no consensus on the most effective antibiotics alone or in combination to treat septic abortion. This review aimed to bridge this gap in knowledge to inform policy and practice. OBJECTIVES: To review the effectiveness of various individual antibiotics or antibiotic regimens in the treatment of septic abortion. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and POPLINE using the following keywords: 'Abortion', 'septic abortion', 'Antibiotics', 'Infected abortion', 'postabortion infection'. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 19 April, 2016. SELECTION CRITERIA: We considered for inclusion randomised controlled trials (RCTs) and non-RCTs that compared antibiotic(s) to another antibiotic(s), irrespective of route of administration, dosage, and duration as well as studies comparing antibiotics alone with antibiotics in combination with other interventions such as dilation and curettage (D&C). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included trials. We resolved disagreements through consultation with a third author. One review author entered extracted data into Review Manager 5.3, and a second review author cross-checked the entry for accuracy. MAIN RESULTS: We included 3 small RCTs involving 233 women that were conducted over 3 decades ago.Clindamycin did not differ significantly from penicillin plus chloramphenicol in reducing fever in all women (mean difference (MD) -12.30, 95% confidence interval (CI) -25.12 to 0.52; women = 77; studies = 1). The evidence for this was of moderate quality. "Response to treatment was evaluated by the patient's 'fever index' expressed in degree-hour and defined as the total quantity of fever under the daily temperature curve with 99°F (37.2°C) as the baseline".There was no difference in duration of hospitalisation between clindamycin and penicillin plus chloramphenicol. The mean duration of hospital stay for women in each group was 5 days (MD 0.00, 95% CI -0.54 to 0.54; women = 77; studies = 1).One study evaluated the effect of penicillin plus chloramphenicol versus cephalothin plus kanamycin before and after D&C. Response to therapy was evaluated by "the time from start of antibiotics until fever lysis and time from D&C until patients become afebrile". Low-quality evidence suggested that the effect of penicillin plus chloramphenicol on fever did not differ from that of cephalothin plus kanamycin (MD -2.30, 95% CI -17.31 to 12.71; women = 56; studies = 1). There was no significant difference between penicillin plus chloramphenicol versus cephalothin plus kanamycin when D&C was performed during antibiotic therapy (MD -1.00, 95% CI -13.84 to 11.84; women = 56; studies = 1). The quality of evidence was low.A study with unclear risk of bias showed that the time for fever resolution (MD -5.03, 95% CI -5.77 to -4.29; women = 100; studies = 1) as well as time for resolution of leukocytosis (MD -4.88, 95% CI -5.98 to -3.78; women = 100; studies = 1) was significantly lower with tetracycline plus enzymes compared with intravenous penicillin G.Treatment failure and adverse events occurred infrequently, and the difference between groups was not statistically significant. AUTHORS' CONCLUSIONS: We found no strong evidence that intravenous clindamycin alone was better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, available evidence did not suggest that penicillin plus chloramphenicol was better than cephalothin plus kanamycin for the treatment of women with septic abortion. Tetracyline enzyme antibiotic appeared to be more effective than intravenous penicillin G in reducing the time to fever defervescence, but this evidence was provided by only one study at low risk of bias.There is a need for high-quality RCTs providing reliable evidence for treatments of septic abortion with antibiotics that are currently in use. The three included studies were carried out over 30 years ago. There is also a need to include institutions in low-resource settings, such as sub-Saharan Africa, Latin America and the Caribbean, and South Asia, with a high burden of abortion and health systems challenges.

Uterine artery pseudoaneurysm hidden behind septic abortion: pseudoaneurysm without preceding procedure.

Uterine artery pseudoaneurysm (UAP) can occur after cesarean section or traumatic delivery, usually manifesting as postpartum hemorrhage. Here we report a patient with UAP possibly caused by septic abortion. She had high fever and bleeding with positive urine pregnancy test. We diagnosed this condition as septic abortion. Ultrasound revealed an intrauterine echogenic mass and color Doppler revealed swirling blood flow within the mass. Contrast-enhanced computed tomography showed a heterogeneously enhanced intrauterine mass. Selective internal iliac artery angiography revealed contrast medium within the mass immediately after medium injection. Bilateral uterine artery embolization was performed, after which medium no longer accumulated in the uterus, and hemostasis was achieved, confirming the diagnosis as UAP. Antibiotic treatment ameliorated the infection and the uterine content was expelled and absorbed. UAP can occur even without preceding procedures and may manifest abortive, and not postpartum, hemorrhage. UAP may be hidden behind septic abortion.

Daily dose of clindamycin versus standard divided doses in obstetrical and gynecological infections: a retrospective cohort study.

To compare the rates of cure of septic abortion and pelvic inflammatory disease using a daily dose of clindamycin with gentamicin versus divided doses, we conducted a retrospective cohort study, where the electronic records of 661 patients who used clindamycin 1 × , 3 × or 4 ×/day (groups 1, 3 and 4, respectively) between September 2002 and August 2010 were analysed. Major outcomes included rates of cure and failure according to the clinical records. Secondary endpoints were percentage of adverse effects related to medication regimen and the prevalence of positive VDRL and HIV. Similar conditions were observed in all groups - septic abortion: 167/116/123; pelvic inflammatory disease: 73/95/87 (groups 1, 3 and 4, respectively). No significant difference was found among groups for age or for rate of cure. Rates of cure (cure/total [rate (95%CI)]) in groups 1, 3 and 4 were 236/240 [0.983 (0.957-0.993)], 205/211 [0.971 (0.939-0.986)], 203/210 [0.966 (0.932-0.983)], respectively. Days of use of clindamycin was significantly reduced in group 1, compared to groups 3 and 4 (2.6 ± 1.3 vs. 3.5 ± 2.5 vs. 3.3 ± 1.9-mean ± SD; p < 0.0001 - ANOVA), but this may be due to differences in how length of therapy was measured and not the effect on clinical cure.

Obstetric infections.

Sepsis accounts for approximately 10% of all maternal deaths. Pregnant women are susceptible to certain infections because of alterations in their cell-mediated immunity. Obstetric sepsis requires early broad-spectrum antibiotic therapy and may necessitate surgical intervention. Group A streptococcal infection may produce necrotizing fasciitis and toxic shock. Pyelonephritis remains a common cause of sepsis during pregnancy, and associated acute respiratory distress syndrome occurs more commonly than in the nonpregnant population. Severe pneumonitis caused by influenza virus and varicella zoster infection may occur. Malaria may be more severe in the pregnant woman, and carries significant risk to both mother and fetus.

Clostridium septicum infection in a young pregnant patient.

This report describes a young pregnant woman who presented to a rural emergency department with vaginal bleeding at 7 weeks of gestation. Initially, the patient was stable; however, within 8 h the patient deteriorated into fulminant septic shock. She required aggressive resuscitation and surgical management of a septic abortion. The patient's condition improved rapidly following surgical evacuation of the uterus with dilatation and curettage. She has had no long-term sequelae. Blood and tissue cultures returned positive for Clostridium septicum. To the best of our knowledge, this is the only reported case of survival from C septicum infection in a pregnant woman and highlights the importance of improved awareness and management of such infections by the medical community so that future cases can achieve similarly successful outcomes.

Septic abortion: a 5-year experience at Siriraj Hospital.

OBJECTIVE: To report characteristics of the patients with septic abortion between 2006 and 2010. MATERIAL AND METHOD: The present retrospective study was done by reviewing the medical records of the women who were admitted to Siriraj Hospital between 2006 and 2010 with the diagnosis of septic abortion. RESULTS: Eighty-three women were admitted to Siriraj Hospital and diagnosed with septic abortion. The mean age was 25.1 years (range 14 to 40 years) and the mean gestational age was 11.3 weeks (range 6 to 24 weeks). Fifty percent of them had a history of induced abortion and 65% came with an incomplete abortion. The principal presenting symptom was abnormal uterine bleeding. Insertion of vaginal tablets appeared to be the most commonly used method of induced abortion. Ampicillin and gentamicin plus metronidazole were the mainstay empirical antibiotics. Length of hospital stay ranged from 2 to 24 days. After the clinical improvement, oral pill was the most popular contraceptive method. CONCLUSION: Septic abortion remains a big issue in Thai society. To mitigate the problem, sex education, particularly emphases on contraception, should be encouraged.

"Removal without replacement" strategy for uncontrolled prosthetic tricuspid valve endocarditis associated with abortion sepsis.

Isolated tricuspid valve (TV) endocarditis associated with abortion is a rare entity with a poor prognosis. We report the case of a 22-year-old woman with a diagnosis of isolated prosthetic TV endocarditis secondary to recurrent abortion. The patient had progressed to multiorgan failure and disseminated intravascular coagulation during her clinical course. Because of the high operative risk and uncontrolled infection, we performed an unusual surgical approach that has not previously been reported. Resection of infected valvular tissue without replacement of the prosthesis led to a rapid convalescence period and complete cure.

[Acute toxicity by methotrexate used for abortion purpose. Case report]. / Intoxicación aguda por metotrexato utilizado con fines abortivos. Reporte de caso.

We report the case of a 16 years old female patient, with a pregnancy history of 11.4 weeks by ultrasound and intrauterine fetal death. In a private clinic were prescribed methotrexate 500 mg intramuscular single dose, and vaginal misoprostol. She had a clinical feature of five days of evolution characterized by fever of 39 degrees C, nausea, general attack and vomiting. The initial diagnosis was severe sepsis secondary to septic abortion, oral candidiasis and acute poisoning by methotrexate. After that, she was referred to the Instituto Nacional de Perinatologia, where stayed with fever for four days, and was managed with hydration, antibiotics, folinic acid and alkalizing. Her recovery was gradual. She was discharged after 12 days with significant clinical improvement. The literature review describes that the use of methotrexate for abortion purpose with therapeutic-dose presents a similar adverse effects to those found in our patient, however there are no case reports that describe the use of this drug in macrodosis for the same purpose, and their cytotoxic effects. We present this case because the patient used a macrodosis of this antimetabolite and due to the premature and empirical management with folinic acid, joined with alkalinization of urine, is the ideal treatment and as it is illustrated in our case.

Are antibiotics necessary after 48 hours of improvement in infected/septic abortions? A randomized controlled trial followed by a cohort study.

OBJECTIVE: We sought to investigate whether oral antibiotics are necessary, after 48 hours of clinical improvement, in uncomplicated septic abortion. STUDY DESIGN: In a randomized double-blind clinical trial, 56 women with uncomplicated septic abortion were treated with intravenous antibiotics, followed by uterine evacuation. On hospital discharge (day 1), patients were randomized to receive either oral doxycycline plus metronidazole or placebo, until completing 10 days of treatment. Clinical cure was defined by the absence of fever (<37.7°C), reduced vaginal bleeding, and minimal or no pelvic pain. RESULTS: Cure was observed in all 56 patients. The institutional review board stopped the treatment arm as it was adding risk with no further benefit to the patients. An observational cohort with additional 75 cases was followed up in the no treatment arm and no failure was identified (probability of an adverse event, 0%; 95% confidence interval, 0-0.03). CONCLUSION: After 48 hours of clinical improvement, antibiotics may not be necessary.

Role of the infections in recurrent spontaneous abortion.

Embryo-fetal infections have been reported to cause recurrent spontaneous abortions (RSAs) at a rate lower than 4%. The possible mechanisms include production of toxic metabolic byproducts, fetal or placental infection, chronic endometrial infection, and chorio-amnionitis. Viruses appear to be the most frequently involved pathogens, since some of them can produce chronic or recurrent maternal infection. In particular, cytomegalovirus during pregnancy can reach the placenta by viremia, following both primary and recurrent infection, or by ascending route from the cervix, mostly following reactivation. Another herpesvirus, herpes simplex virus type 2, less frequently type 1, causes recurrent infections of the genital tract, which can involve the feto-placental unit. Parvoviruses have also been implicated in the development of repeated fetal loss. Among bacterial infections, Chlamydia trachomatis, Ureaplasma urealyticum,and Mycoplasma hominis have been mostly associated with occurrence of RSA. An increased risk of abortion among women with bacterial vaginosis (BV) during early pregnancy was also shown, but questions arise about the role of chronic BV in its occurrence. Although a definitive relationship between recurrently active infections and RSA is still lacking, mostly due to difficulties in demonstrating the pathogenic role of each individual isolated pathogen, diagnosis and therapy of RSA-related infections should be attempted. The diagnosis of infectious agents as a possible cause of RSA might lead to a therapeutic approach with antiviral drugs and antibiotics or using immunoglobulins, which can display both anti-infective neutralizing and immunomodulating properties.

Aborto infectado: epidemiologia, diagnóstico e conduta na urgência: [revisão] / Infected abortion: epidemiology, diagnosis and management in emergency: [review]

Abortamento é a expulsão ou extração de um produto da concepção sem sinais de vida com menos de 500 gramas ou 22 semanas de gestação. O aborto infectado ou séptico decorre da eliminação incompleta do ovo, do embrião ou da placenta, que mantém aberto o canal cervical, favorecendo a ascensão de bactérias da microbiota vaginal e intestinal à cavidade uterina. A real magnitude do abortamento é desconhecida devido à sua ilegalidade. No Brasil, há subnotificação de casos e complicações, pois nem todas as mulheres demandam assistência pós-abortamento. Ainda assim, os dados oficiais justificam a adoção de medidas preventivas e de promoção da saúde reprodutiva. O diagnóstico de aborto séptico deve ser considerado quando uma mulher na menacme apresentar atraso menstrual, sangramento vaginal, febre, dor hipogástrica e à mobilização do colo uterino. Exige tratamento imediato. Prefere-se a associação gentamicina/clindamicina.

Abortion is the expulsion or extraction of a product of conception, with no signs of life, with less than 500 grams or 22 weeks of gestation. Infected or septic abortion stems from partial removal of the egg, embryo or placenta, which keeps open the cervical channel, encouraging the rise of intestinal and vaginal bacteria to the uterine cavity. The real magnitude of abortion is unknown due to its illegality. In Brazil, there is underreporting of cases and complications because not all women require assistance in post-abortion care services. Still, official data justify the adoption of preventive measures and of reproductive healthÆs promotion. The diagnosis of septic abortion should be considered when a woman of childbearing age has missed period, vaginal bleeding, fever, hypogastric pain and pain by the cervix mobilization. It requires immediate treatment. The association of gentamicin/clindamycin is chosen.

Abortamento séptico: ainda um problema de saúde pública / Septic abortion: still a problem of public health

O abortamento é síndrome hemorrágica da primeira metade da gestação, definida como interrupção da gravidez antes de atingida a viabilidade do concepto. Pode ser classificada em evitável e inevitável, sendo que, nesta forma, o produto conceptual perde a vitalidade. A forma inevitável pode ser completa ou incompleta, na qual a existência de restos intrauterinos pode complicar com infecção localizada ou generalizada, com flora geralmente polimicrobiana, caracterizando o abortamento séptico. O diagnóstico é baseado em dados clínicos e laboratoriais, sendo que a introdução da antibioticoterapia deve ser o mais precoce possível. Alguns casos não apresentam resposta satisfatória ao tratamento clínico, evoluindo com sepse e insuficiência renal aguda (IRA), sendo então necessária a histerectomia

Bacteriología del aborto séptico en una comunidad suburbana / Bacteriology of septic abortion in a suburbane community

Se presenta la identificación microbiológica de la flora local y sistémica de una población de 100 pacientes con aborto séptico. Este trabajo también compara la eficacia de 2 regímenes de antibióticos (clindamicina más gentamicina versus penicilina más cloramfenicol y gentamicina). El microorganismo más frecuentemente aislado de los hemocultivos fue escherichia coli, seguida de streptococcus grupo B y peptostreptococcus spp. Las especies aisladas con mayor frecuencia de las muestras intrauterinas fueron peptostreptococcus spp., escherichia coli, enterococcus faecalis, bacteroides melaninogenicus, bacteroides fragilis, clostridium perfringens y streptococcus grupo B

Aborto séptico morbi-mortalidad en el Hospital Materno Infantil Germán Urquidi / Septic abortion morbility and mortality at the Obstetric Hospital German Urquidi

Se estudiarón 257 pacientes con diagnóstico de Aborto séptico, que constituyen el 14.5 por ciento de un universo de 1770 pacientes con diagnóstico de aborto, en un lapso de 5 años, comprendidos desde Enero 1989 a Diciembre de 1993 en el Hospital Meterno Infantil Germán Urquidi. La incidencia del aborto séptico es mayor en pacientes de 21 a 30 años de edad representando el 45.7 por ciento, mas en casadas con un 62.3 por ciento, los pacientes del área urbana, suburbana un 72 por ciento; entre los tipos de abortos ocupa el primer lugar espontaneo con 65.3 por ciento y el inducido el 34.27 por ciento. Entre el personal que intervienen en el aborto inducido ocupo el primer lugar el médico 36.4 por ciento, segundo enfermería un 32.9 por ciento. El mayor porcentaje de aborto séptico según la edad gestacional es entre 6-15 semanas de gestación un 78 por ciento La anemia, infección urinaria pelviperitonitis, sepsis perforación uterina, falla renal fueron las complicaciones mas importantes; el tratamiento antibiótico fue con penicilina, gentamicina y cloranfenicol, el 83.6 por ciento; el tratamiento fue conservador con legrado uterino. La mortalidad total fue de 6 pacientes que representa el 2.3 por ciento.

Conductas en infectología / Behavior in infectology

Excelente, conciso y actualizado texto sobre diagnóstico y tratamiento de Enfermedades Infecciosas y temas relacionados (por ej.: infecciones en el paciente con cáncer, fiebre de origen desconocido, uso racional de antibióticos en el hospital, infecciones vinculadas con catéteres vasculares, causas infecciosas de esterilidad, infecciones en pacientes con sistemas de derivación o shunt ventrículo-peritoneal, etc, etc). Infecciones del aparato respiratorio. Del aparato circulatorio. Del sistema nervioso. Del aparato digestivo. Del aparato genitourinario. Oculares. Osteoarticulares. De piel y partes blandas. Infecciones severas y su control. En pacientes inmunocomprometidos. Patología infecciosa prenatal y perinatal. Enfermedades exantematicas. Infecciones ganglionares y glandulares. Toma de muestras para bacteriología. Antibioticoterapia. Inmunoprofilaxis y quimioprofilaxis en condiciones especiales