Juvenile fulminant adnexal tuberculosis caused by gastrointestinal tuberculosis immediately after ovarian cystectomy

Genital fulminant tuberculosis is rarely a primary site of infection. We report a case of juvenile adnexal tuberculosis possibly related to tuberculosis immediately after cystectomy in the ileocecal region in a virginal girl. A 13-year-old virginal girl visited our clinic because of a huge ovarian tumor, which was resected by cystectomy. On postoperative day 39, fever episodes were noted, and she received antibiotics, which were not effective. An abscess developed in the region of the cecum and the right adnexa. Laparotomy revealed chronic abscess formation, especially in the right adnexa. Resection of the abscess was done. The pathological diagnosis was tuberculosis with caseation, although bacterial culture and molecular biological diagnosis for Mycobacterium tuberculosis were negative in sputum, vaginal discharge, urine, and stool of the patient and her family. She was placed on anti-tuberculosis drugs, including isoniazid, rifampicin, and ethambutol, and this regimen was effective. This patient represents a rare case of fulminant adnexal tuberculosis without pulmonary disease.

Trends in serotypes and antimicrobial susceptibility of group B streptococci isolated in Korea

Studies of group B streptococci (GBS) have been limited in Korea, despite the necessity for such studies because of the increase in serious adult infections, the emergence of new serotypes, and the increase of resistance to certain antibiotics. In this study, trends in serotypes of GBS isolated in Korea were compared to determine any changes and emergence of new types, while antimicrobial susceptibility was tested and compared with that of group A streptococci (GAS). It was found that the most frequent infections caused by GBS were of the urinary tract, but other severe infections also occurred not only in newborns but also in adults. The prevalent serotypes were still Ia, Ib, and III, while new serotypes, VI and VIII, also emerged. GBS were susceptible to beta-lactam antibiotics, but were much less so than GAS. The resistance rates to erythromycin and tetracycline were much higher than those in other countries, suggesting that these antibiotics are no longer very useful in Korea for the treatment of GBS infections.

Current status and fluconazole treatment of pelvic fungal gynecological infections

The incidence of opportunistic fungal infections has recently been increasing in many clinical fields. Fluconazole is commonly used against systemic fungal infections. The present study was undertaken to investigate the current status and the efficacy of fluconazole in pelvic fungal gynecological infections. Thirty-eight patients aged 36-72 years old diagnosed with pelvic peritonitis with positive fungal culture in pelvic ascites were enrolled in this study and given fluconazole treatment. Forty-two pathogens were isolated from the 38 assessable patients. The predominant pathogen was Candida albicans with an incidence of 61.9% (26/42). Others included non-albicans Candida species amounting to 38.1% (16/42): 19.0% (8/42) Candida glabrata, 7.1% (3/42) Candida tropicalis, 7.1% (3/42) Candida parapsilosis and 4.8% (2/42) Candida krusei. The clinical cure rate at the end of fluconazole treatment was assessed as 30/38 (78.9%), and the fungal eradication rate as 26/42 (61.9%). Each rate was 29/38 (76.3%) and 26/42 (61.9%), respectively, at 1 week after the treatment, while the eradication rate of C. albicans and non-albicans species was 20/26 (76.9%) and 6/16 (37.5%), respectively. There was no adverse effect except for slight elevations of GOT, GPT and LDH observed in 1 patient (2.6%), which returned to normal after the treatment. It seems there may be an increasing trend of non-albicans species in pelvic fungal gynecological infection, against which fluconazole appears to be rather effective.

Adequate levofloxacin treatment schedules for uterine cervicitis caused by Chlamydia trachomatis

The in vivo efficacy of levofloxacin (LVFX), one of the most standard new quinolone antimicrobial agents, in the different treatment schedules of Chlamydia trachomatis uterine cervicitis in women was evaluated. Cervical C. trachomatis was detected by polymerase chain reaction. LVFX at a dosage of 300 mg t.i.d. for 5, 7 and 14 days was orally administered to 18, 33 and 35 Japanese patients, respectively. The eradication rate and the recurrence rate in the different treatment schedules of C. trachomatis were evaluated. The eradication rate in 5-, 7- or 14-day cases was 44.4, 87.9 or 88.6%, respectively. The recurrence rate of 5-, 7- or 14-day cases was 50.0, 0 or 0%, respectively. Seven-day treatment with LVFX is adequate for and effective in C. trachomatis uterine cervicitis.

In vitro and in vivo antibacterial activities of biapenem in the fields of obstetrics and gynecology

Biapenem is a new injectable carbapenem antibiotic which has favorable pharmacokinetic properties, and is stable to hydrolysis by dehydropeptidase I. Biapenem inhibited more than 90% of clinical isolates of Streptococcus agalactiae, Escherichia coli, Peptostreptococcus magnus, Bacteroides fragilis and Prevotella bivia at the concentration of 3.13 mg/l. The MIC(90) of biapenem against Pseudomonas aeruginosa was lower than that of panipenem, equivalent to that of imipenem, and greater than that of meropenem. The in vivo efficacy of biapenem was evaluated using the experimental infection model of uterine endometritis. The accumulation of neutrophils in the uterus in the biapenem- treated group was less marked than in the nontreated group, as well as bacteriological response. These results suggest that the new antimicrobial agent biapenem might be useful for the treatment of polymicrobial infections in the fields of obstetrics and gynecology.

[Clinical efficacy of cefpirome sulfate against Bacteroides species, Prevotella species and Porphyromonas species. Society of Anaerobic Bacterial Infections in the fields of obstetrics and gynecology in Gifu]

The injectable cephalosporin cefpirome (CPR) was launched in Japan in 1993. It has widely been used in the various infectious diseases. We therefore studied the clinical and bacteriological efficacy of CPR against infections caused by Bacteroides species, Prevotella species and Porphyromonas species frequently isolated from the obstetric and gynecologic infections. Thirteen institutions were involved in this study which ran from March 1994 to January 1999. The administration dosage of CPR was 2 to 4 gram per day administered by drip infusion or intravenous infusion. The duration of treatment was from 3 to 15 days. The evaluations were performed before and after the treatment. CPR was administered to 194 patients with obstetric and gynecologic infections, and 146 of 194 cases were acceptable for the evaluation of drug efficacy. Bacteroides species were identified in 102 patients. Clinical efficacy in 146 cases was excellent in 12 patients, good in 110, fair in 9 and poor in 15 patients. The eradication rate for Bacteroides species could be in 37 cases out of 54 evaluable cases; Prevotella species in 38 out of 49; and Porphyromonas species in 5 out of 5. The overall assessment of bacteriological efficacy was "eradicated" in 91 cases out of 133 (68.4%). Adverse reactions including abnormal findings in laboratory tests were seen in 8 patients (4.76%). Based on these results, CPR promises efficacy and safety in the treatment of obstetric and gynecologic infections due to Bacteroides species.

Adequate macrolide treatment schedules for uterine cervicitis caused by Chlamydia trachomatis

To evaluate in vivo efficacy of macrolides; erythromycin (EM) and clarithromycin (CAM), in the different treatment schedules of Chlamydia trachomatis uterine cervicitis im women. Cervical C. trachomatis was detected by the polymerase chain reaction. EM was orally administered to 8, 15 and 18 Japanese patients, at a dosage of 600 mg, t.i.d. for 5, 7 and 14 days, respectively. CAM was orally administered to 10, 26 and 19 Japanese patients at a dosage of 400 mg, b.i.d. for 5, 7 and 14 days, respectively. The eradication rate and the recurrence rate in the different treatment schedules of C. trachomatis were evaluated. The eradication rates after 5, 7 or 14 days of treatment with EM were 1/8, 8/15 or 13/18, respectively. The recurrence rates after 5, 7 or 14 days of treatment with EM were 1/1, 3/8 or 2/13, respectively. On the other hand, the eradication rates after 5, 7 or 14 days of treatment with CAM were 5/10, 26/26 or 19/19, respectively. The recurrence rates after 5, 7 or 14 days of treatment with CAM were 3/5, 0/26 or 0/19, respectively. A 7-day treatment with CAM would be adequate and effective for C. trachomatis uterine cervicitis.

In vitro bactericidal activities of antimicrobial agents and morphologic changes on Prevotella bivia

Prevotella bivia is common in pelvic inflammatory diseases. Parenteral antimicrobial agents have been widely used against those infections. We investigated the bactericidal activities of three cephalosporins, i.e. cefluprenam (CFLP), ceftazidime (CAZ) and cefotaxime (CTX) and of two other antimicrobial agents, i.e. clindamycin (CLDM) and imipenem (IPM) against P. bivia. We also investigated the in vitro morphological changes induced by these agents in P. bivia. Cephalosporins exhibited bactericidal activities against P. bivia and induced time- and concentration-dependent morphological changes in P. bivia (filamentation). CLDM and IPM also had bactericidal activities, but induced different morphologic alterations: formation of spheroblasts and lysis. These results confirm the fact that each antimicrobial agent has characteristic aspects.

In vitro bactericidal activities of a new oral cephalosporin, E1100, and morphologic changes on Escherichia coli

Escherichia coli is one of the most common aerobic bacteria in pelvic inflammatory diseases. Oral cephalosporins have been widely used against those infections. We investigated in vitro morphologic changes induced on E. coli by a new oral cephalosporin, E1100, and its bactericidal activity on this organism. Morphologic changes were observed by electron microscopy. E1100 induced morphologic changes (filamentation) and exerted a bactericidal activity on E. coli. The filamentation induced by E1100 was time and concentration dependent.

[Effects of levofloxacin once-a-day therapy on uterine cervicitis]

An investigation was carried out to determine the therapeutic effect of levofloxacin (LVFX) once-a-day oral therapy at the dose of 200 mg/day for 7 days on uterine cervicitis, in comparison with LVFX twice-a-day oral therapy at the dose of 200 mg/day for 7 days. Of the 102 patients enrolled in the study, 90 were subjected to the analysis. The efficacy rate on uterine cervicitis of the once-a-day therapy and twice-a-day therapy groups according to the evaluation of the Drug Efficacy Evaluation Committee were 72.0% (36/50) and 82.5% (33/40), respectively. The efficacy rate on uterine chlamydial cervicitis of the once-a-day therapy and twice-a-day therapy groups according to the evaluation of the Drug Efficacy Evaluation Committee were 88.0% (22/25) and 85.7% (18/21), respectively. Safety was evaluated as "safe" in 88 of the 90 assessable patients (97.8%). Side effects were seen in two cases, which belong to the once-a-day therapy group; mild candidiasis and mild breast distension sense. As the antimicrobial treatment started, the levels of the inflammatory cytokines, interleukin-6 (IL-6) and interleukin-8 (IL-8) in the cervical mucus, decreased. It is suggested that IL-6 and IL-8 can be useful indicators of the antimicrobial treatment in the uterine cervicitis. These results suggested that the LVFX once-a-day therapy can be useful on uterine cervicitis.

Intravaginal bacterial flora in patients with uterine cervical cancer. High incidence of detection of Gardnerella vaginalis

Gynecological diseases may affect the growth of vaginal bacterial flora. We investigated the relationship between uterine cervical cancer and the vaginal bacterial flora. In 20 patients with uterine cervical cancer, we investigated the intravaginal bacterial flora, including Gardnerella vaginalis and Mobiluncus spp. In the patients with uterine cervical cancer, there was a mixed flora of aerobes and anaerobes and, of special note, G. vaginalis was detected in 50% of the patients with uterine cervical cancer (10/20). Bacterial vaginosis was present in 8 of these 10 patients (80%). The count of G. vaginalis detected was higher than that of the other coexisting species and was higher in both pre- and postmenopausal patients with uterine cervical cancer than in a control group of pre- and postmenopausal women with benign gynecological diseases. In contrast, none of Mobiluncus spp. was detected. G. vaginalis was detected at a high incidence in patients with uterine cervical cancer, suggesting that the lesions of uterine cervical cancer provide favorable conditions for the growth of G. vaginalis and anaerobes, which leads to bacterial vaginosis.

In vitro activities of pazufloxacin, a novel injectable quinolone, against bacteria causing infections in obstetric and gynecological patients

T-3762 is an injectable new quinolone with a broad spectrum of antibacterial activity. Pazufloxacin (T-3761) is an active form of T-3762. The minimal inhibitory concentrations (MICs) of pazufloxacin for 50% of the clinical isolates tested were 3.13 microg/ml for Streptococcus agalactiae, 6.25 microg/ml for Gardnerella vaginalis, 0.025 microg/ml for Escherichia coli, 0.78 microg/ml for Pseudomonas aeruginosa, 6.25 microg/ml for Peptostreptococcus magnus, 6.25 microg/ml for Bacteroides fragilis and 12.5 microg/ml for Prevotella bivia. The MICs of T-3762 for 90% of the clinical isolates tested were 3.13 microg/ml for S. agalactiae, 6.25 microg/ml for G. vaginalis, 0.10 microg/ml for E. coli, 12.5 microg/ml for P. aeruginosa, 25 microg/ml for P. magnus, 12.5 microg/ml for B. fragilis and 25 microg/ml for P. bivia. The results of this study suggest that, subject to confirmation by clinical trials, T-3762, in combination with an agent with reliable activity against anaerobic bacteria, is suitable as an empirical therapy of patients with obstetric and gynecological infections.

Elastase activity of anaerobes isolated from amniotic fluid with preterm premature rupture of membranes

OBJECTIVE

A total of 131 anaerobes isolated from amniotic fluid with preterm premature rupture of membranes and stored were examined for elastolytic activity by the method described by Williams et al (Lett Appl Microbiol 1988;7:173-6).

STUDY DESIGN

Each strain was spot inoculated on a Columbia blood agar plate containing 1% solubilized elastin and incubated for 5 days under anaerobic conditions. Undigested elastin was precipitated by flooding trichloroacetic acid solution onto the plate, and a clear zone was visible as the elastolytic reaction around the spot of bacterial growth.

RESULTS

Ninety-three (71.0%) of 131 organisms showed a positive elastolytic reaction. Eleven of 20 strains (55.0%) of Peptostreptococcus magnus, 9 of 18 strains (50.0%) of Peptostreptococcus micros, 12 of 12 strains (100.0%) of Fusobacterium nucleatum, 15 of 28 strains (53.6%) of Bacteroides fragilis, 8 of 15 strains (53.3%) of Bacteroides thetaiotaomicron, and 38 of 38 strains (100.0%) of Prevotella bivia were elastolytic.

CONCLUSION

Anaerobic bacterial species prevalent in the normal vaginal flora that were isolated from amniotic fluid of women with preterm rupture of membranes produced elastolytic activity, plausibly inducing the destruction of host constitutive components.

The effects of the extension of transit times on qualitative and quantitative bacterial culture after clinical sampling

The effects of the extension of transit times on qualitative and quantitative bacterial culture after clinical sampling were investigated with the clinical samples, using the bacterial flora from the cancer portion inside the uterine cervix in 25 patients with the uterine cervical cancer. In the qualitative bacterial study, the strains of both aerobic and anaerobic bacteria detected were rather preserved for 6 hours after clinical sampling and decreased in a time-dependent manner in the samples of more than 6 hours after clinical sampling. In particular, number of anaerobic bacterial species detected remarkably decreased in the samples of more than 12 hours after clinical sampling. Therefore, prompt bacterial culture after clinical sampling, possibly within 6 hours after clinical sampling, may be crucial in order to detect most probable pathogenic anaerobic bacteria, particularly when anaerobic infection is suspected. In the quantitative bacterial study, the quantity of bacteria detected were rather preserved for 3 hours after clinical sampling and decreased in a time-dependent manner in the samples of more than 3 hours after clinical sampling. Therefore, quantitative bacterial culture should be performed within 3 hours after clinical sampling.

Penetration of oral fluconazole into gynecological tissues

Penetration of fluconazole into female genital tissues was examined. Fluconazole was administered orally at a dose of 150 mg to patients undergoing total abdominal hysterectomy 1 to 151 h prior to surgery. During surgery, blood, uterus, ovary, and oviduct were sampled. Fluconazole concentrations in each tissue were determined by high-performance liquid chromatography. The peak concentrations in serum reached approximately 6.1 microg/ml 1.0 h after a drip infusion was begun. At each time after the infusion, the concentrations in portio vaginalis, cervix uteri, myometrium, endometrium, ovary, and oviduct were higher than those in the serum: the peaks in the tissues ranged from 6.4 to 9.5 microg/g around 1.0 h after the drip infusion was begun. Thus, the levels of penentration of fluconazole into gynecological tissues appeared to be similar to or slightly above those in serum samples. Fluconazole can rapidly penetrate from plasma into the female genital organs, supporting high efficacy of fluconazole against fungal infections in the field of gynecology.

[Study on the therapeutic effect of panipenem/betamipron on perinatal infection in pregnant women]

An investigation was carried out to determine the therapeutic effect of panipenem/betamipron (PAPM/BP), a injectable carbapenem antimicrobial agent, on infections in pregnant women during perinatal period. Of the 41 patients enrolled in the study, 34 were subjected to the analysis, with 1 exemption because of protocol violations (regimen), 3 because of uncertain evidence symptoms of infection, and 3 because of failure to undergo laboratory tests. PAPM/BP was administered by intravenous drip infusion at doses of 0.5 g twice or three times a day daily for periods of 3 to 14 days. The efficacy rate according to the evaluation of the Drug Efficacy Evaluation Committee and the attending physicians was 79.4% (27/34), with 49 of the 61 clinical isolates (80.3%) being eradicated. Safety was evaluated as "safe" in 39 of the 41 assessable patients (94.1%). Mild headache and nausea were experienced by 1 patient (2.4%) as adverse drug reactions, but the symptoms disappeared after the completion of treatment. Slight elevations of GOT, GPT and LDH in laboratory tests were observed in 1 patient (2.4%), but these values returned to normal after the completion of treatment. These results suggested that PAPM/BP may be a useful drug in the treatment of bacterial infections during the perinatal period. To firmly establish its safety, however, further clinical and pharmacokinetic studies are needed in larger populations.

Bacterial isolates from patients with preterm labor with and without preterm rupture of the fetal membranes

OBJECTIVE

The aim of this study is to describe the bacterial flora of women in preterm labor with or without premature rupture of membranes.

METHODS

Retrospective studies of 239 patients with preterm labor were performed.

RESULTS

One hundred and twenty-three of 239 patients with preterm labor (51.5%) had bacterial vaginosis. Seventy of the 239 patients with preterm labor (29.3%) developed premature rupture of the membranes (preterm PROM). Of the 70 patients with preterm PROM, 51 (72.9%) had bacterial vaginosis. Therefore, 51 of the 123 patients with bacterial vaginosis (41.5%) developed preterm PROM. An increased number of organisms detected from the vaginal discharge in patients with preterm labor was associated with preterm PROM by Cochran-Armitage test. An increased number of organisms detected from the vaginal discharge in patients with preterm labor complicated with bacterial vaginosis was significantly associated with preterm PROM by Cochran-Armitage test.

CONCLUSIONS

In preterm labor, the number of different species detected in the vagina provide sensitive and specific prediction of preterm PROM in patients with preterm labor.

Preterm labor and bacterial intraamniotic infection: arachidonic acid liberation by phospholipase A2 of Fusobacterium nucleatum

OBJECTIVE

The studies presented in this report were undertaken to evaluate whether Fusobacterium nucleatum, a common anaerobic isolate in intrauterine infection, stimulates arachidonic acid metabolism, a rate-limiting step for prostaglandin synthesis, in the human uterine endometrium.

STUDY DESIGN

Effects of F nucleatum on arachidonic acid liberation from human uterine endometrial cells and of F nucleatum extract on lysophosphatidylcholine production in human uterine endometrial cells were investigated.

RESULTS

When human uterine endometrial cells labeled with tritiated arachidonic acid to an isotopically steady state were exposed to an extract of F nucleatum, arachidonic acid liberation was stimulated, accompanied by lysophospholipid formation. Similar stimulatory effects on phospholipid degradation were also observed in the experiment with bacterially conditioned media.

CONCLUSIONS

These results suggest that F nucleatum stimulates endometrial phospholipid metabolism, related to activity of phospholipase A2, which might induce the onset of labor associated with intraamniotic infection.