Cefoxitin for Intra-amniotic Infections and Endometritis: A Retrospective Comparison to Traditional Antimicrobial Therapy Regimens Within a Healthcare System.

BACKGROUND: Local institutional guidelines and order sets were updated in June 2023 to recommend first-line cefoxitin monotherapy for the treatment of intra-amniotic infections (IAIs) and endometritis. This study evaluated the clinical impact of this change. METHODS: This was a retrospective, observational cohort study in an 11-campus health system comparing clinical outcomes of patients with chorioamnionitis, endometritis, or septic abortion receiving intravenous antimicrobial therapy before and after implementation of first-line cefoxitin monotherapy recommendations for the treatment of these infections. Primary outcome was a composite of serious clinical events postdelivery (ie, intensive care unit admission, death, hospital readmission related to IAI or endometritis within 30 days, additional surgery or procedures, or deep surgical site infection). Baseline characteristics between the pre- and post-cefoxitin groups were compared via Student's t tests for continuous variables and chi-square tests for categorical variables. Outcomes were evaluated via generalized linear modeling. RESULTS: A total of 472 patients were enrolled, 350 (74%) in the pre-cefoxitin group and 122 (26%) in the post-cefoxitin group. Groups were significantly different by race, healthcare payor, and hospital campus. Cefoxitin was rarely used in the pre-cefoxitin group (n = 2, <0.1%) and commonly used in the post-cefoxitin group (n = 112, 91.8%). After controlling for group differences, odds of experiencing serious clinical event postdelivery in the post-cefoxitin group were noninferior to those in the pre-cefoxitin group (adjusted odds ratio, .37; 95% CI, .17-.76; P = .010). CONCLUSIONS: Local institutional guidelines with predominant use of cefoxitin therapy were noninferior to traditional antimicrobial therapy regimens for the treatment of IAI.

Detection of Anaplasma phagocytophilum in fetal and placental tissue of bovine abortions and perinatal mortalities.

BACKGROUND: Anaplasma phagocytophilum is a tick-borne zoonotic bacterium that is the aetiologic pathogen of tick-borne fever (TBF) in ruminants. In clinical bovine cases of TBF, abortion and stillbirth may be observed. However, in this regard, the pathophysiology of TBF has not yet been completely elucidated, and no clear guidelines to diagnose A. phagocytophilum-related abortions and perinatal mortalities (APM) are available. METHODS: This exploratory study aimed to investigate the presence of A. phagocytophilum in bovine cases of APM and determine whether placental or fetal spleen tissue has the greatest sensitivity for A. phagocytophilum identification. The placenta and fetal spleen of 150 late-term bovine APM cases were analysed using real-time PCR to detect A. phagocytophilum. RESULTS: A total of 2.7% of sampled placentas were positive for A. phagocytophilum, while none of the fetal spleen samples was. LIMITATIONS: No histopathology to detect associated lesions was performed. Consequently, no evidence of causality between the detection of A. phagocytophilum and APM events could be achieved. CONCLUSION: The detection of A. phagocytophilum suggests a potential role of this pathogen in bovine APM, and placental tissue seems to be the most suitable tissue for its identification.

Giant luteinized follicular cyst of pregnancy / Cisto folicular luteinizado gigante da gestação

Functional cysts usually do not cause symptoms or require surgical intervention. We reported a 17-year-old primi-gravida, gestational age of 10 weeks and 2 days, and ultrasound showing anechoic cyst in the right parauterine re-gion without septa, with a larger diameter of 13.5cm, 632ml, and Doppler color without peripheral vascularization. The patient was oligosymptomatic during gestation. At 37 weeks and 6 days, gestation was interrupted, when the cyst had 2600 ml by ultrasonography. Fetal extraction was performed by cesarean delivery, and a large adnexal cyst visualized on the right was removed. The histopathological analysis of the surgical specimen revealed a cystic le-sion coated by luteinized cells with discrete hyperchromatic and slightly pleomorphic nuclei, with underlying fibrous stroma with sparse luteinized cells, characterizing a giant luteinized follicular cyst of pregnancy. The prevalence of ovarian masses in pregnancy is rare, usually not exceeding 5 cm in diameter, and disappearing spontaneously in the second trimester. The patient in the case report had a cyst of 632 ml, increasing in volume to 2600 ml at the time of delivery. Definitive preoperative diagnosis of ovarian masses is still difficult, and predictive criteria for malignancy include the use of tumor markers, ultrasound, and Doppler. The association of these tests should guide the clinician to define the best time for surgical intervention. The association of these tests should guide the clinician to define the best time for surgical intervention (AU)

Os cistos funcionais geralmente não causam sintomas ou requerem intervenção cirúrgica. Relatamos o caso de uma primigesta de 17 anos, idade gestacional de 10 semanas e 2 dias, e ultrassonografia mostrando cisto anecoico em região parauterina direita sem septos, com maior diâmetro de 13,5cm, volume 632ml e Doppler sem vascularização periférica. A paciente permaneceu oligossintomática durante a gestação. Com 37 semanas e 6 dias, a gestação foi interrompida, quando o cisto apresentava 2.600 ml pela ultrassonografia. A extração fetal foi realizada por cesaria-na, e um grande cisto anexial visualizado à direita foi removido. A análise histopatológica da peça cirúrgica revelou lesão cística revestida por células luteinizadas com núcleos discretamente hipercromáticos e levemente pleomór-ficos, com estroma fibroso subjacente com células luteinizadas esparsas, caracterizando cisto folicular luteinizado gigante da gravidez. A prevalência de massas ovarianas na gravidez é rara, geralmente não ultrapassam o diâmetro de 5 cm, e desaparecem espontaneamente no segundo trimestre. A paciente do relato de caso apresentou cisto de 632 ml, aumentando de volume para 2600 ml no momento do parto. O diagnóstico pré-operatório definitivo de massas ovarianas ainda é difícil, e os critérios preditivos de malignidade incluem o uso de marcadores tumorais, ultrassonografia e Doppler. A associação desses testes deve orientar o clínico para definir o melhor momento para a intervenção cirúrgica (AU)

Clinical Conundrum: Neisseria meningitidis Septic Abortion.

Septic shock after abortion is an important cause of global maternal mortality but is rarely encountered in developed countries. We describe a case of septic abortion with a novel associated pathogen: Neisseria meningitidis. A 30-year-old multiparous woman presented in septic shock after an incomplete spontaneous abortion. She received empiric antibiotics and vasopressors, underwent an urgent dilatation and curettage, and was admitted to the intensive care unit. Her blood cultures and endometrial tissue were positive for N. meningitidis. Antibiotics were adjusted based on culture, and the patient recovered. Septic shock requires prompt identification, antibiotic administration, and source control. Here, we identify an uncommon pathogen associated with septic abortion and highlight the importance of broad empiric and subsequent culture-guided antibiotic choice to ensure coverage.

A 25-year retrospective study of Chlamydia psittaci in association with equine reproductive loss in Australia.

Introduction. Chlamydia psittaci is primarily a pathogen of birds but can also cause disease in other species. Equine reproductive loss caused by C. psittaci has recently been identified in Australia where cases of human disease were also reported in individuals exposed to foetal membranes from an ill neonatal foal in New South Wales.Hypothesis/Gap Statement. The prevalence of C. psittaci in association with equine reproductive over time and in different regions of Australia is not known.Aim. This study was conducted to detect C. psittaci in equine abortion cases in Australia using archived samples spanning 25 years.Methodology. We tested for C. psittaci in 600 equine abortion cases reported in Australia between 1994 to 2019 using a Chlamydiaceae real-time quantitative PCR assay targeting the 16S rRNA gene followed by high-resolution melt curve analysis. Genotyping and phylogenetic analysis was performed on positive samples.Results. The overall prevalence of C. psittaci in material from equine abortion cases was 6.5 %. C. psittaci-positive cases were detected in most years that were represented in this study and occurred in Victoria (prevalence of 7.6 %), New South Wales (prevalence of 3.9 %) and South Australia (prevalence of 15.4 %). Genotyping and phylogenetic analysis showed that the C. psittaci detected in the equine abortion cases clustered with the parrot-associated 6BC clade (genotype A/ST24), indicating that infection of horses may be due to spillover from native Australian parrots.Conclusion. This work suggests that C. psittaci has been a significant agent of equine abortion in Australia for several decades and underscores the importance of taking appropriate protective measures to avoid infection when handling equine aborted material.

Proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a referral Hospital in Bahir Dar, Northwest Ethiopia.

Background: Puerperal sepsis is any bacterial infection of the genital tract that occurs after childbirth. It is among the leading causes of maternal morbidity and mortality especially in low-income countries including Ethiopia. The aim of this study was to determine the proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a Referral Hospital in Bahir Dar, Northwest Ethiopia. Methods: A cross sectional study was conducted from January to May 2017 among 166 post-partum/aborted women admitted to Felege Hiwot Referral Hospital for medical services and suspected for puerperal sepsis.. Socio-demographic data and associated factors were collected using structured questionnaire. Bacteria were isolated and identified from blood samples on Trypton soya broth, blood, Chocolate and MacConkey agars following standard bacteriological procedures. The VITEK 2 identification and susceptibility testing system was used to determine the antimicrobial susceptibility profiles of bacterial isolates. Data were entered and analyzed using SPSS version 20. Factors associated with puerperal sepsis were considered statistically significant at P-value < 0.05. Results: The overall proportion of bacterial isolates among post-partum/aborted women was 33.7% (56/166); of which 55.4% was caused by Gram-negative and 44.6% was by Gram-positive bacteria. The most frequently isolated bacteria were Escherichia coli (32.1%) from Gram-negatives and Staphylococcus aureus (33.9%) from Gram-positives. The proportion of other isolates was (7.2%) for Coagulase Negative Staphylococci (CoNS), (12.5%) for Klebsiella pneumoniae, (10.7%) for Acinetobacter baumanni and (3.6%) for Raoultella ornithinolytica. All isolates of Gram-positive and Gram-negative bacteria were resistant to tetracycline (100%). The gram negatives show resistance to Cefazolin (72.7%), Tetracycline (93.9%) and Ampicillin (100%). The overall prevalence of multidrug resistance (MDR) was 84%. Women having multiparous parity were more likely to develop puerperal sepsis than primiparous parity (AOR 4.045; 95% CI: 1.479-11.061; P < 0.05). Other socio-demographic and clinical factors had no significant association with puerperal sepsis. Conclusion: About one third of post-partum/aborted women suspected for puerperal sepsis were infected with one or more bacterial isolates. Significant proportion of bacterial isolates showed mono and multi-drug resistance for the commonly prescribed antibiotics. Women with multiparous parity were more likely to develop puerperal sepsis than primiparous parity.

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.

Genetic Markers Associated with Field PRRSV-Induced Abortion Rates.

In gilts and sows, the more severe clinical manifestation of porcine reproductive and respiratory syndrome virus (PRRSV) occurs in late gestation and can result in up to a 40% abortion incidence. Despite the known genetic component in resilience to PRRSV, there is scarce information regarding the abortive outcome of this disease. We tested the relationship between eight molecular markers (six from published studies and two identified in the present study in the HDAC6 gene) and the probability of abortion during a PRRSV outbreak, using data from two commercial Landrace x Large White sow farms with an incidence of abortion of 35% and 17%. From the markers tested, USP18_-1533G>A did not segregate in these populations, and CD163_c.3534C>T and HDAC6_g.2360C>T did not affect the abortion rate. In contrast, the minor allele of two markers in SSC4 (WUR1000125 in GBP1 and rs340943904 in GBP5), which lower viremia in growing pigs, and the major alleles of CD163_rs1107556229 and HDAC6_rs325981825 were associated with a lower probability of abortion during PRRSV outbreaks. The more striking result was for the MX1 gene, where the odds ratio of aborting versus not aborting was nine times lower in the sows homozygous for a 275-bp insertion than in the other genotypes. Interactions between markers were not relevant. All together, we bring here the first evidence that mutations in the host genome can predispose or protect from complete reproductive failure in sows infected with PRRSV.

Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries.

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Partial protection induced by Salmonella based Brucella vaccine candidate in pregnant guinea pigs.

Residual virulence is a major drawback in current Brucella vaccines. Live vaccines induce abortions in pregnant animals. Hence, a novel anti-Brucella vaccine was developed utilizing rough Salmonella delivering four Brucella antigens. Safety implications during pregnancy, humoral immune responses, and protective efficacy against wild type Brucella was investigated in guinea pig model. The vaccine did not induce abortions or severe complications in pregnant guinea pigs when administered 4 × 108 CFU via intraperitoneal route. Systemic IgG determination against antigen components reveals induction of immunity via the Salmonella delivery. Protection efficacy against abortions was 33.3% (2/6) when midterm sow challenged with virulent Brucella 544 strain while none was protected in control group. Lower Brucella recovery in spleen and liver and reduced histopathological burden were also noticed. Although abortion induced by Brucella challenge was not completely prevented, the vaccine candidate may perform better with optimization of vaccination such as inoculation dose optimization.

Actin from the apicomplexan Neospora caninum (NcACT) has different isoforms in 2D electrophoresis.

Apicomplexan parasites have unconventional actins that play a central role in important cellular processes such as apicoplast replication, motility of dense granules, endocytic trafficking and force generation for motility and host cell invasion. In this study, we investigated the actin of the apicomplexan Neospora caninum - a parasite associated with infectious abortion and neonatal mortality in livestock. Neospora caninum actin was detected and identified in two bands by one-dimensional (1D) western blot and in nine spots by the 2D technique. The mass spectrometry data indicated that N. caninum has at least nine different actin isoforms, possibly caused by post-translational modifications. In addition, the C4 pan-actin antibody detected specifically actin in N. caninum cellular extract. Extracellular N. caninum tachyzoites were treated with toxins that act on actin, jasplakinolide and cytochalasin D. Both substances altered the peripheric cytoplasmic localization of actin on tachyzoites. Our findings add complexity to the study of the apicomplexan actin in cellular processes, since the multiple functions of this important protein might be regulated by mechanisms involving post-translational modifications.

New approach to differentiate primary from latent Toxoplasma gondii abortion through immunoglobulin and DNA interpretation.

BACKGROUND: Toxoplasma gondii is an acute or latent zoonotic abortifacient human protozoan. Women may be aborted due to recent or latent infection during pregnancy or order to flare up of the dormant bradyzoites to acute tachyzoites (latent opportunistic relapse). AIMS: 1) to validate the interpretation of IgM and IgG immunoglobulins seromonotoring with DNA comparative results in differentiating recent from latent T. gondii abortion. METHOD: Blood with the corresponding placental or uterine wash samples were collected from 73 aborted Egyptian women from Cairo and Giza labour wards. Patients aborted in any of the phases (Ph-1, Ph-2, Ph-3 and Ph-4 were corresponding to abortion at the 1st, 2nd and 3rd trimesters plus females who gave birth with congenital anomalies), respectively. All aborted patients were assayed serologically by Enzyme Linked Immunosorbent Assay (ELISA) for IgM and IgG titers and the compatible DNA from placenta and uterine wash tissues by conventional Polymerase Chain Reaction (PCR) specific for T. gondii. RESULTS: Sero-positive aborted women were 50.7% by ELISA versus 37% by PCR. Not all T. gondii sero-positive aborted women were having T. gondii DNA or harboring compatible placental T. gondii cysts. This denotes that immunoglobulins alone are insufficient criteria for confirming toxoplasma abortion. CONCLUSION: Immunoglobulins with DNA comparative results can possibly differentiate recent from latent T. gondii abortion at higher precision. We recommend the need for routine monitoring of T. gondii i.e. (pre-, during and post-delivery).

[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.

Molecular and serological data supporting the role of Q fever in abortions of sheep and goats in northern Egypt.

Q fever is a worldwide zoonotic disease, caused by Coxiella burnetii (C. burnetii), an obligate intracellular bacterium. The epidemiological data about the Q fever situation in Egypt is limited. The present study investigated the seroprevalence of Q fever among small ruminants in some localities in the northern Egypt and reported the shedders using specific real-time PCR (Rt-PCR). A total of 190 sera and vaginal swabs (110 sheep and 80 goats) were collected from aborted cases. Indirect ELISA was used to detect specific antibodies against C. burnetii, and Rt-PCR was used to detect DNA in the shedder animals. The study revealed that infection was significantly higher in sheep (22.7%) than in goats (12.5%) (p < 0.05). The Menoufia and Gharbia governorates had 20% seropositive animals while Qalubia and Alexandria had 15% and 17.5% seropositive animals, respectively. Using a Rt - PCR assay, C. burnetii was detected in 33.6% and 16.3% of sheep and goats, respectively. The findings of the study demonstrate that Q fever may be enzootic among small ruminants and distributed in the northern Egyptian Governorates. Further studies are needed in different regions to gain better understanding of the epidemiology of Q fever all over the country and to develop an appropriate preventive strategy for human and animals.

The protective effect of berberine against lipopolysaccharide-induced abortion by modulation of inflammatory/immune responses.

OBJECTIVE: Berberine is an isoquinoline derivative alkaloid with anti-inflammatory activity. In this study, we investigated the protective effects of berberine in prevention of LPS-induced abortion. MATERIALS AND METHODS: On the gestation day (GD) 9.5, the pregnant mice were injected with low, medium, and high doses of berberine or with PBS. After 4 h, berberine or PBS-pretreated mice were injected with LPS. On GD 11.5, blood samples and uterine tissues were collected from treated mice and percentage of abortion and serum levels of NO, TNF-α, IL-10, and IL12p70 were measured by macroscopic examination and sandwich ELISA, respectively. RESULTS: Our findings show that mice injected with berberine were resistant to LPS-induced abortion. We also found that this treatment prevents the reduction of IL-10 and the enhancement of NO, TNF-α, and IL-12p70 in LPS-treated pregnant mice. CONCLUSIONS: Taken together, our results suggest that berberine as an anti-inflammatory agent has protective effects on LPS-induced abortion by modulation of inflammatory/immune responses.

A multi-screening Fast qPCR approach to the identification of abortive agents in ruminants.

Abortion in ruminants represents an important economic concern for farmers. Microbial agents, such as Brucella spp., Chlamydia spp., Coxiella burnetii, Leptospira spp., Neospora caninum, Salmonella spp. and Toxoplasma gondii, are among the main infectious causes of abortion and require rapid and reliable diagnosis. This study describes the development of a multi-screening assay using Fast Real-Time PCR (Fast qPCR) that allows, in a single test, the simultaneous identification of the above-mentioned abortive agents. This multi-screening approach is characterized by a mean diagnostic sensitivity and specificity of 100% and 97%, respectively; it has a limit of detection (LOD) ranging from 5 × 103 to 4 × 104 genomic copies/g of tissue and a very good concordance with traditional end-point PCR assays used in routine diagnostic activity. The proposed method represents a rapid approach to the simultaneous detection of the main abortive agents in ruminants that allows to make an accurate diagnosis and to set up appropriate control measures in a short period of time.