Bacteriologic findings of post-cesarean endometritis in adolescents.

Two hundred four post-cesarean adolescents were compared with 751 adults to determine whether age was a risk factor for endometritis. Adolescents had an infection rate of 23%, compared with 11% for controls (P less than .001). Length of labor, duration of ruptured membranes, and the use of an internal monitor were noted to be risk factors for endometritis in adults, but not in adolescents. Endometrial aspirates from adolescents exhibited significantly higher isolation rates of Chlamydia trachomatis (21 versus 6%, P less than .05) and Gardnerella vaginalis (32 versus 9%, P less than .005) than did those from adults. Antepartum isolation of these organisms in teenagers may help to identify those at risk for postpartum endometritis.

Incidence of the prozone phenomenon in syphilis serology.

OBJECTIVE: To determine the rate of the prozone phenomenon in our patient population. METHODS: Sera from 4328 patients--3504 females (2065 pregnant, 1439 nonpregnant) and 824 males--were tested for syphilis by the rapid plasma reagin (RPR) test, and then rechecked with serial twofold dilutions of up to 16-fold to detect the prozone phenomenon. Chi-square analysis with Yates correction was used, with P < or = .05 considered significant. RESULTS: The total positivity rate in females was 6% (213 patients); 13% (27) of the positive tests were false-positive reactions as confirmed by a negative anti-treponemal antibody test. Only one prozone reaction was detected, in serum from a male subject, but it was not missed on initial screening. CONCLUSION: The rate of prozone phenomenon is very low (95% confidence interval 0-0.4%), and routine serial dilutions are not cost effective.

Transcervical uterine cultures with a new endometrial suction curette: a comparison of three sampling methods in postpartum endometritis.

The potential for cervicovaginal contamination has precluded direct sampling of the endometrial cavity and has led to the development of multi-lumen protected catheter systems, among other techniques. The extent of this presumed contamination was examined using three different techniques in 55 postpartum women with the diagnosis of endometritis. Each woman had the endometrium sampled with an unprotected cotton-tipped swab, a double-lumen catheter with brush, and a flexible endometrial suction curette. A statistically larger number of bacterial species was recovered with the cotton swab (2.4) than with the double-lumen catheter (1.3) or the suction curette (1.7) (P less than .001). A difference was also noted between the double-lumen catheter and the suction curette (P = .006); however, this represented less than one-third of a single bacterial species. The larger number of bacterial species recovered by the unprotected methods was found to result not from cervicovaginal contamination, as suspected, but from a significant increase in the recovery of bacteria commonly regarded as potential pathogens, such as Bacteroides bivius, Streptococcus faecalis, Proteus mirabilis, and Bacteroides melaninogenicus.

Gardnerella vaginalis chorioamnionitis: a report of two cases and a review of the pathogenic role of G. vaginalis in obstetrics.

Two patients with chorioamnionitis due to Gardnerella vaginalis are described. Institution of tocolytic therapy for preterm labor is associated with maternal complications of septic hypotension and pulmonary edema in one patient. Diagnostic modalities, specifically culturing techniques, are discussed, as well as suspected pathophysiologic mechanisms.

Sulbactam/ampicillin versus metronidazole/gentamicin in the treatment of post-cesarean section endometritis.

Sixty-seven patients diagnosed with post-cesarean-section endometritis were studied in a prospective comparative randomized trial of sulbactam/ampicillin, a new beta-lactamase inhibitor drug combination, versus treatment with metronidazole/gentamicin. The success rate was 91% for each antibiotic regimen. Mycoplasma spp. or Ureaplasma spp. were isolated from all treatment failures. Endometrial cultures revealed 2.3 aerobes as well as anaerobes per patient, with Enterococcus faecalis, Bacteroides bivius, and Escherichia coli the most frequently reported bacterial isolates in 64, 40, and 28% of all patients, respectively. Positive blood cultures were noted in 11 (15%) patients with Mycoplasma sp. the most commonly found isolate (45.5%). Sulbactam/ampicillin appears to be safe and equally effective as a metronidazole/aminoglycoside drug regimen in the treatment of postpartum endometritis.

Penetration of trovafloxacin into gynecologic tissues.

BACKGROUND: This randomized open-label study assessed the penetration into gynecologic tissues of trovafloxacin, a new broad-spectrum, fourth-generation fluoroquinolone with in vitro activity against anaerobes, gram-positive, gram-negative, and atypical pathogens. METHODS: Women undergoing hysterectomy or hysterectomy and adnexectomy received 200 mg trovafloxacin orally before surgery as a single dose or as multiple doses. Samples of genital tract tissue and serum were obtained simultaneously during surgery. RESULTS: In the single-dose group, trovafloxacin concentrations in genital tract tissues were measurable for up to 30 hours. Tissue concentrations of trovafloxacin after multiple doses were comparable to those after single doses. Mean tissue: serum concentration ratios after a single dose were greatest in the ovary (1.6 microg/g) and comparable in uterus, myometrium, cervix, and fallopian tubes (0.5 to 0.7 microg/g). Adverse events after a single dose were minor. CONCLUSIONS: A daily dose of 200 mg trovafloxacin produces gynecologic tissue concentrations that persist for up to 30 hours at levels necessary to prevent or treat pelvic infections. This dosing regimen is well tolerated.

Treatment of acute gynecologic infections with trovafloxacin. Trovafloxacin Surgical Group.

BACKGROUND: Trovafloxacin, a broad-spectrum fourth-generation quinolone with gram-positive and gram-negative aerobic and anaerobic bacterial activity, is available in oral and intravenous formulations. The objective of this prospective, multicenter, double-blind, randomized study was to compare the efficacy of trovafloxacin with that of cefoxitin, an approved drug for treatment of acute gynecologic infections, together with amoxicillin/clavulanic acid as oral follow-on treatment. METHODS: Patients with a clinical diagnosis of acute pelvic infection received either intravenous alatrofloxacin with oral trovafloxacin follow-on (trovafloxacin) or a combined regimen of cefoxitin followed by amoxicillin/clavulanic acid for a maximum of 14 days. The primary endpoint was clinical response to therapy on follow-up at day 30. RESULTS: Clinical success rates were comparable between the trovafloxacin (n = 107) and comparative (n = 119) groups at study end (90% vs. 86%, respectively; 95% confidence interval, -4.5, 12.5). Among clinically evaluable patients, clinical success rates for infections involving Enterococcus species were higher with trovafloxacin than with the comparative regimen at the end of treatment (96% and 85%) and at study end (96% and 86%). CONCLUSION: Intravenous alatrofloxacin followed by oral trovafloxacin for a maximum of 14 days of total therapy was efficacious in the treatment of acute pelvic infections.

Comparative pharmacokinetics of cefotetan and cefoxitin in patients undergoing hysterectomies and colorectal operations.

Forty patients undergoing hysterectomy and 16 patients undergoing colorectal surgery were given intravenous 2 g doses of cefotetan (20 in the hysterectomy group and 8 in the colorectal group) or cefoxitin (20 in the hysterectomy and 8 in the colorectal group) before surgery. Serum samples were obtained simultaneously with tissue samples. Concentrations of each drug in serum and tissue were measured by high-pressure liquid chromatography. In both experiments, the composite drug concentration profile as a function of time in serum was consistent with that observed in nonsurgical patients; that is, a half-life of approximately 3.5 hours and 0.8 hours for cefotetan and cefoxitin, respectively. This also was true of tissue kinetics, in that tissue profiles appeared parallel to, but somewhat lower than, serum. At 20 minutes after administration, the peak myometrium concentration was 158 micrograms/g for cefotetan, and the corresponding serum concentration was 298 micrograms/ml. For cefoxitin, the corresponding values were 66 micrograms/g and 101 micrograms/ml. At 47 minutes, the cefotetan tissue and serum concentrations were 29 micrograms/g and 235 micrograms/ml respectively, and the corresponding values for cefoxitin were 15 micrograms/g and 43 micrograms/ml. Similar relationships were observed with these drugs in colorectal tissue. Although both antibiotics provide good concentrations during the early phase of surgery, cefotetan's concentrations persisted longer, which may be relevant in the prevention of infection in prolonged surgical procedures.

Office diagnosis of sexually transmitted diseases.

Treatment of sexually transmitted diseases begins with prompt and accurate diagnosis. Several new diagnostic techniques allow more rapid or easier testing, however sometimes at a cost. The vast array of diagnostic methodologies available to the office practitioners are discussed with special regard to their sensitivity, specificity, and ease of use.

Cephalosporins.

The cephalosporins have had a great effect on the prevention and treatment of many obstetric and gynecologic infections. Broader spectra and greater activity often allow for effective single-agent usage. Improved pharmacokinetics have permitted the number of doses to be decreased. Excellent activity against several gram-negative organisms sometimes permits substitution of the safer cephalosporins for the aminoglycosides, thus avoiding potential renal and otic toxicities. However, these advantages come with costs of their own, such as superinfection, induction of resistance, and the potential for clinical bleeding. Nevertheless, these adverse effects fortunately are infrequent and, with careful monitoring, they can be readily avoided or controlled. Therefore, the increasing number and diversity of these helpful agents should be accompanied by greater knowledge of all these factors. This should result in increasing benefits for our patients, without sacrificing cost, safety, and future therapeutic success.

Pyelonephritis.

Pyelonephritis is a serious infection in pregnancy and is the consequence of undetected bacteriuria. When the diagnosis of pyelonephritis is made, immediate treatment is mandatory in the hope of preventing the potentially serious maternal and fetal sequelae. After successful treatment, careful surveillance and suppression are required for the remainder of the pregnancy. Moreover, owing to the high incidence of recurrences, both postpartum and during subsequent pregnancies, culture and radiologic investigations are warranted after delivery in an effort to detect underlying renal abnormalities.

A severe puerperal group A streptococcal infection causing a toxic shock-like syndrome.

Toxic shock syndrome (TSS) is classically associated with vaginal recovery of Staphylococcus aureus during menses. In this case a patient presented with fever, rash, abdominal pain and signs of shock, 6 days postpartum. Blood cultures were negative but endometrial cultures were positive for Group A beta-hemolytic streptococcus. This case presents a toxic shock-like syndrome due to streptococcus, (toxic streptococcus syndrome) and points out the importance of culturing these patients for organisms other than Staphylococcus aureus.

Female genital tract abscess formation in the rat. Use of pathogens including enterococci.

Previous animal experiments utilizing bowel flora have demonstrated synergy between various aerobes and anaerobes in the formation of intraabdominal abscesses. In these experiments, human female genital tract isolates were inserted into the abdominal and pelvic cavities of 151 female Sprague-Dawley rats. Inoculation with any single species of organism--Streptococcus faecalis, Enterobacter cloacae or Bacteroides bivius or a combination of two facultative organisms (S faecalis plus E cloacae)--did not result in a significant increase in abscess formation. Combination of a facultative organism or organisms with the anaerobe B bivius or S faecalis plus B bivius plus E cloacae resulted in 55% (P < .01) and 74% (P < .0005) rates of abscess formation, respectively, as compared with controls. Combinations including B fragilis demonstrated similar results. Thus, female genital tract facultative organisms demonstrate synergy in the presence of anaerobic organisms in the development of abscesses.

Typhoid fever in pregnancy. A case report.

A pregnant woman was treated for typhoid fever. A consideration of geographic risks and serologic clues helped determine the diagnosis.

Ciprofloxacin versus gentamicin/clindamycin for postpartum endometritis.

An open, randomized, comparative study of intravenous ciprofloxacin versus gentamicin and clindamycin was performed on women with postpartum endometritis. Ciprofloxacin alone successfully eradicated the infections in 35 of 49 patients (71%), while the combination of gentamicin/clindamycin cured 41 of 48 (85%) (P = .15). The microbiology and antibiotic sensitivity of the endometrial isolates confirmed the poor activity of ciprofloxacin against anaerobic bacteria and less-than-optimal activity against Streptococcus faecalis. Ciprofloxacin, when used alone, may not be suitable for the treatment of postpartum endometritis.

Comparison of two endometrial sampling devices. Cotton-tipped swab and double-lumen catheter with a brush.

The potential for bacterial contamination during transvaginal recovery of endometrial samples in patients with postpartum endomyometritis spawned an investigation into various protective measures and techniques. The confirmation and determination of the extent of contamination was attempted in 120 postpartum women with the diagnosis of postpartum endometritis. Each woman underwent endometrial sampling for bacterial culturing utilizing two devices--an unprotected, cotton-tipped swab and a protective, double-lumen catheter with a brush. Although a statistically greater number of bacterial species were recovered with the swab than with the brush (2.4 vs. 1.6, respectively [P less than .001]), they were not representative of species commonly thought of as causing cervicovaginal contamination. Individual species found with greater frequency with the swab were Streptococcus faecalis (P = .023), Escherichia coli (P = .007), Proteus mirabilis (P = .025), Bacteroides bivius (P less than .001 and Bacteroides melaninogenicus (P = .02). Thus, with proper cervical preparation and an extended-reach, transvaginal, cotton-tipped swab, true fundal specimens were obtained that provided a representative and cost-efficient sample of the infected endometrial cavity.

Prevalence of beta-lactamase enzyme production in bacteria isolated from women with postpartum endometritis.

One hundred eighty-four postpartum patients with the diagnosis of endomyometritis underwent intrauterine culturing. Beta-Lactamase production was tested using nitrocephin-impregnated discs in 278 bacterial isolates from patients with postpartum endometritis. beta-Lactamase production was found to be present in 149 of 278 (54%) isolates tested: 0 of 39 Streptococcus faecalis (0%), 22 of 41 Escherichia coli (54%), 66 of 68 Bacteroides bivius (97%), 0 of 13 Proteus mirabilis (0%) and 15 of 42 Staphylococcus epidermidis (36%). Anaerobes, as a group, had the highest rate of beta-lactamase production, 94 of 102 (93%), followed by gram negatives, 34 of 84 (40%), then gram positives, 21 of 91 (23%). However, it was the beta-lactamase produced by the gram-negative bacteria that was most responsive to the addition of a beta-lactamase inhibitor. The frequent isolation of beta-lactamase-producing bacteria from patients with postpartum endometritis raises concern about the use of antibiotics not resistant to these enzymes. Therefore, antibiotics combined with a beta-lactamase inhibitor may have potential as single-agent therapy in obstetric and gynecologic infections.

Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases.

Wound infections are a common surgical complication, often requiring a prolonged hospital stay and leading to increased costs. Over a one-year period, 2,431 patients were followed after cesarean delivery with prompt evaluation and culture of all suspicious wounds. Seventy subjects (2.8%) developed confirmed wound infection, and 42 (1.7%) developed noninfected open surgical wounds. Seven (0.3%) fascial dehiscences were diagnosed, requiring surgical repair. Forty of 63 (64%) infected wounds had positive bacterial cultures, with Staphylococcus epidermidis (29%), Enterococcus faecalis (17%), Staphylococcus aureus (17%), Escherichia coli (11%) and Proteus mirabilis (10%) the most frequent isolates. Only 7 of 42 (17%) noninfected wounds had positive cultures, with only S aureus, S epidermidis and Corynebacterium species isolated. Ninety-five percent of the noninfected wounds had blood or serous collections present. Rupture of membranes lasting longer than six hours, emergency cesarean delivery and morbid obesity were associated with a statistically increased likelihood of the development of infected wounds. Emergency cesarean delivery and morbid obesity, but not prolonged rupture of membranes, were associated with an increased likelihood of the development of noninfected wounds. Therefore, it appears that at least two mechanisms are responsible for the development of postcesarean open wounds: (1) increased amniotic fluid and wound colonization due to prolonged rupture of membranes, resulting in a wound infection containing one or more bacterial species derived from the cervicovaginal flora, and (2) increased exogenous bacterial contamination and flora consistent with skin species or breaks in sterile technique, often accompanying difficult or emergency surgery.

Reduction of infectious morbidity with uterine stapling device.

Due to the recent development of absorbable surgical staples, application of gynecologic stapling methods has expanded to the field of obstetrics. Several studies have been published presenting the results of utilization of a novel hysterotomy and uterine stapling device for cesarean section (Poly CS-57, U.S. Surgical Corp, Norwalk CT). A review of all available data was analyzed to determine the rate of infectious morbidity secondary to the use of the device. Four studies fulfilled several criteria, including use of proper controls. A total of 383 patients were included in these studies with an infection rate of 6.4% (12/187) versus 16.3% (32/196) for the stapled and non-stapled (traditional sutured) group, respectively (p less than 0.001). The individual investigations attributed the decreased infection rate to reductions in blood loss and incisional hematoma formation and decreased reactivity of copolymer absorbable staples.

Reduction of infectious morbidity with uterine stapling device.

Available data from comparative trials involving 483 patients were analyzed to determine the rate of infectious morbidity following the use of absorbable staples versus traditional incision and suturing of the vaginal cuff in abdominal hysterectomy. Infections occurred in 24 of 268 (9%) patients who received absorbable sutures versus 36 of 215 (16.7%) patients who received traditional suturing (p=0.007). The individual investigators attributed the lower infection rate to reduced operating time, decreased pelvic contamination from cervicovaginal flora, and decreased operative site blood loss.