An unusual cause of pelvic inflammatory disease due to Neisseria meningitidis

A case of pelvic inflammatory disease due to Neisseria meningitidis is described. The importance of the definitive diagnosis of Neisseria to a species level is underscored for public health issues, appropriate contact tracing, as well as potential psychosocial implications. A review of the literature of genitally related N. meningitidis cases is made.

[Using GnRH-agonists (Zoladex) in the treatment of genital endometriosis]

METHODS AND MATERIALS

The study is prospective and involves 112 patients suffering from pelvic endometriosis aging from 19-38 years. (28.6 average age). The disease was diagnosed via laparoscopy and the stage was determined using the revised AFS classification. Zoladex (Goserelin depot--3.6 mg) is being applied every 28 days for 6 months in the hypodermic tissue of the front abdomen wall. All patients are being examined monthly after every Zoladex application (for subjective complaints--dysmenorrheal, dyspareunea, pelvic pain; serum estradyol-E2; amenorrhea; side effects) and every 24 months (recuperation of the menstrual cycle, pregnancy).

RESULTS

In 88% of the patients amenohrea is obsereved in the first eight weeks of therapy. The menstrual cycle takes an avarege of 68 (31-139) after the last Zoladex application to reappear. At the end of the first month after the first application the serum level of estradyol E2 is lowered to a menopause level (from 750-800 to 120-130 Pmol/L) and it remains as low till the end of the treatment. Eight weeks after the completion of the therapy it goes back to its normal values. During the course of the first month of amenorrhea condition a 38% fall in the level of complaints (dysmenorrheal, dyspareunea, pelvic pain) is observed. After the 6th month 88% of the patients have no complaints. Side effects observed during the course of treatment include warm waves, sweating, vaginal dehydration (60-80%) which do not in any way disturb the patients to the point of quitting the therapy and do disappear with its end. The focus group contains 54 infertile patients with endometrioses willing to get pregnant. In 12 months after the completion of the treatment 16 of the patients become pregnant, followed by 12 more in the next one year.

CONCLUSION

Zoladex causes amenorrhea, which lasts till the end of the treatement. It causes a rapid drop of the serum consentration to a menopause level. Causes a strong and durable treatment of the symptoms of endometriosis. The side effects disappear with the end of the therapy. The treatment is easy to go through and there no cases of a quitting patient. The treatment has a curable effect over the endometriosys and in cases of infertility provides a possibility for pregnancy.

[Severe pelvic inflammatory disease. Response to ertapenem]

Pelvic inflammatory disease (PID) is an important health problem. Delay in diagnosis and effective treatment contributes to inflammatory sequelae with risk of future fertility problems and chronic pelvic pain. Treatment regimens must provide empiric, broad-spectrum coverage of likely pathogens but also take into account patient's risk profile. In this article we report the case of a young woman affected by a rare genital malformation who required the creation of a neovagina made of abdominal skin. Years later, the patient presented with symptoms that support the diagnosis of PID. There was no clinical analytical response to classical parenteral antimicrobial regimen, even after surgical intervention for tubal abscess. Peptostreptococci isolated in abdominal cavity culture showed an infrequent clindamycin resistance, so we started monotherapy treatment with ertapenem, with excellent results. In conclusion, more clinical trials are needed to discover the pathogens usually involved in PID in our setting and their antibiotic resistance to re-evaluate standard antimicrobial regimens and perhaps recommend new agents, such as ertapenem.

Effectiveness of Treatment Strategies of Some Women With Pelvic Inflammatory Disease

OBJECTIVE

Among all women with pelvic inflammatory disease (PID), prevention of adverse reproductive consequences appears to be similarly achieved by outpatient treatment and inpatient treatment. We assessed whether outpatient is as effective as inpatient treatment in relevant age, race, and clinical subgroups of women with PID.

METHODS

Women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease (n = 831) were randomized into a multicenter trial of inpatient treatment, initially employing intravenous cefoxitin and doxycycline compared with outpatient treatment consisting of a single intramuscular injection of cefoxitin and oral doxycycline. Comparisons between treatment groups during a mean of 84 months of follow-up were made for pregnancies, live births, time to pregnancy, infertility, PID recurrence, chronic pelvic pain, and ectopic pregnancy.

RESULTS

Outpatient treatment assignment did not adversely impact the proportion of women having one or more pregnancies, live births, or ectopic pregnancies during follow-up; time to pregnancy; infertility; PID recurrence; or chronic pelvic pain among women of various races; with or without previous PID; with or without baseline Neisseria gonorrhoeae and/or Chlamydia trachomatis infection; and with or without high temperature/white blood cell count/pelvic tenderness score. This was true even in teenagers and women without a previous live birth. Ectopic pregnancies were more common in the outpatient than the inpatient treatment group, but because these were so rare, the difference did not reach statistical significance (5 versus 1, odds ratio 4.91, 95% confidence interval 0.57-42.25).

CONCLUSION

Among all women and subgroups of women with mild-to-moderate PID, there were no differences in reproductive outcomes after randomization to inpatient or outpatient treatment.

LEVEL OF EVIDENCE

I.

Improvement in the clinical cure rate of outpatient management of pelvic inflammatory disease following a change in therapy

OBJECTIVE

In the United Kingdom many genitourinary medicine clinics use oral doxycycline and metronidazole to treat pelvic inflammatory disease (PID). A retrospective case note review of PID treatment at our department in 2000 showed that the clinical cure rate (CCR) was only 55% with oral doxycycline and metronidazole for 2 weeks. We therefore added ceftriaxone 250 mg intramuscularly to the doxycycline and metronidazole for treating PID. We have repeated the review and compared the results with those from 2000.

METHODS

All patients diagnosed as having PID between 1 July 2002 and 31 December 2002 were identified. These episodes were diagnosed on clinical presentations of pelvic pain, vaginal discharge or bleeding, and cervical motion tenderness on physical examination. The CCR was defined as patients who fully resolved their symptoms and signs during 2 week and 4 week follow up. The results were compared with those from 2000.

RESULTS

Women receiving ceftriaxone, doxycycline, and metronidazole had a CCR of 72%. In 2000 the CCR for women receiving only doxycycline and metronidazole was 55%. There were only 8% non-responders in 2002 compared with 18% in 2000. Comparing CCR and non-response rate, in 2002 there was a significant improvement in cure rate, OR 3.01 (95% CI 1.28 to 7.47) p = 0.009. Using an intent to treat analysis and including the defaulters as treatment failures there was still a significant improvement in cure rate, OR 2.03 (95% CI 1.18 to 3.50) p = 0.009.

CONCLUSIONS

The treatment of PID with ceftriaxone, doxycycline, and metronidazole gave a significantly higher CCR than doxycycline and metronidazole. Our experience would suggest that doxycycline and metronidazole alone is not a suitable regimen for treatment of PID in the United Kingdom.

Pelvic Inflammatory Disease in Adolescents

Pelvic inflammatory disease (PID) is a polymicrobial infection typically occurring in sexually active females. It occurs when microorganisms ascend from the lower genital tract into the upper genital tract. The clinical presentation varies in severity, with most patients presenting with mild disease. Complications include tubo-ovarian abscess, ectopic pregnancy, infertility, and chronic pain. The newly revised criteria issued by the Centers for Disease Control and Prevention now include either cervical motion tenderness or adnexal tenderness with unchanged additional criteria.

Significant Reduction in Inflammatory Response in the Macaque Model of Chlamydial Pelvic Inflammatory Disease with Azithromycin Treatment

We inoculated 45 female macaques in the cervix with Chlamydia trachomatis once weekly for 5 weeks and randomly assigned them to treatment with doxycycline (n=12), azithromycin (n=12), or placebo (n=21). At hysterectomy, cervical cultures remained positive in 12 of 21 placebo-treated monkeys, versus 0 of 12 doxycycline- or azithromycin-treated monkeys (P<.01); cervical ligase chain reaction remained positive in 15 placebo-, 1 doxycycline-, and 0 azithromycin-treated monkeys. Tubal swabs remained positive in 3 placebo-, 1 doxycycline-, and 0 azithromycin-treated monkeys. Immunopathologic damage was moderate to widespread in upper and lower reproductive-tract tissues from placebo- and doxycycline-treated monkeys but were significantly reduced in azithromycin-treated monkeys. Transforming growth factor- beta was also significantly less prevalent in azithromycin-treated monkeys. Azithromycin treatment dramatically reduced the inflammatory response and was highly effective in eradicating C. trachomatis from the lower and upper reproductive tract (12/12), compared with doxycycline (7/12) and placebo (3/21).

Is Mycoplasma genitalium a Cause of Pelvic Inflammatory Disease?

The evidence for M genitalium as a sexually acquired infection in women is strong, and the organism has been associated with cervicitis and urethritis. In vitro evidence supports the concept that M genitalium causes inflammation in the fallopian tube epithelium, and animal studies have demonstrated the potential for infection to spread from the lower to the upper genital tract. Serologic data in humans who have PID are somewhat conflicting, but studies in infertile women suggest a link between M genitalium and tubal damage. The organism has also been isolated in the endometrium and fallopian tubes of women who have PID. The evidence is therefore accumulating that M genitalium is a cause of PID, and the assessment of reliable tests to further investigate the importance of this organism and its relevance in designing future treatment strategies is urgently needed.

[Changes in vaginal microbiocenosis in patients with chronic pelvic inflammatory diseases following antibiotic therapy]

The species composition of the vaginal microorganisms in healthy women and in patients with chronic pelvic inflammatory diseases before and after treatment in a gynecological hospital was studied. The study revealed that antibiotic therapy did not lead to complete clinical convalescence. During bacteriological investigation of patients changes in vaginal microbiocenosis, manifested by a decreased number of microbial species, an increased proportion of Escherichia coli, the occurrence of Staphylococcus aureus, a decreased number of Lactobacillus ssp., were observed. Antibiotic therapy aggravated the dysbiotic microbial picture of the vagina.

Adnexitis und «Pelvic Inflammatory Disease»

Pelvic inflammatory disease and upper genital tract infection describe inflammatory changes in the upper female genital tract of any combination: endometritis, salpingitis, tubo-ovarian abscess, peritonitis in the small pelvis. The International Infectious Disease Society for Obstetrics and Gynecology recommends a revision of the CDC guidelines taking into account the type of germ or the triggering agent and the seriousness of the disease. Infections with Chlamydia trachomatis and Neisseria gonorrhoeae are increasing worldwide. They are one of the main causes of tubal sterility, chronic abdominal pain and ectopic pregnancies. More than 30% of the infections are subclinical and asymptomatic. Therefore it is most recommendable to generally screen young, sexually active women with any of the risks mentioned above. Antibiotic therapy should be started as early as possible, in case of doubt even probatively, and should cover a broad spectrum of germs. C. trachomatis and N. gonorrhoeae should be treated according to resistance testing. In uncomplicated cases, hospitalization is unnecessary, ambulant therapy is sufficient.

Pelvic inflammatory disease in adolescents: high incidence and recurrence rates in an urban teen clinic

STUDY OBJECTIVE

To determine pelvic inflammatory disease (PID) incidence and recurrence rates in an urban teen clinic.

DESIGN/SETTING

A retrospective chart review of female patients seen as outpatients over an 18-month period at an urban teen clinic. 192 patients were diagnosed with PID, and the charts of these patients were reviewed in depth.

MAIN OUTCOME MEASURES

PID incidence and recurrence rates.

RESULTS

A PID incidence of 9.7% was identified. Of the adolescent females diagnosed with PID, 47% had recurrent PID. Of the females with recurrent PID, 27% had three or more episodes. Only 36% of adolescent females diagnosed with PID ever reported that their partners had been treated.

CONCLUSIONS

This study suggests a higher incidence of PID as well as PID recurrence in the present clinic-based adolescent population than previously reported. More accurate monitoring of incidence and recurrence rates in well-defined populations of adolescents should be conducted with the hope of identifying effective avenues of intervention.

Adherence to oral therapies in pelvic inflammatory disease

PURPOSE

To assess adherence to oral therapies in pelvic inflammatory disease (PID).

METHODS

Medication adherence to oral doxycycline therapy (100 mg) was measured using electronic event monitoring (EEM) among adult women with PID. Subjects (n = 91), who were predominantly black and with a high school or lower educational attainment, were randomly selected from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Study, a trial in which subjects were randomized to either (1). initial inpatient then outpatient or (2). fully outpatient treatment with doxycycline and cefoxitin. Summary statistics calculated within treatment groups and in the cohort as a whole included the percentage of administrations taken, percentage of days with correct dosage, percentage of days with no drug taken, time elapsed until the first drug holiday, and percentage of optimal dosing intervals.

RESULTS

Study subjects took an average of 70% of prescribed doses, took the prescribed two daily doses for less than half of their outpatient days, took an unscheduled drug holiday for almost 25% of their outpatient days, and took only 16.9% of their doses within the optimal timing interval. In general, working, not bleeding with sex, and not drinking hard liquor were positively associated with measures of adherence. Adherence estimates were similar among women in the inpatient and outpatient groups after hospital discharge.

CONCLUSIONS

The disturbing rates of time interval adherence, even after hospitalization, suggest the need to determine the effectiveness of antibiotic regimens involving shorter courses and longer dosing intervals.

Pelvic inflammatory disease in adolescents

Pelvic inflammatory disease (PID) is an infection of the upper female genital tract. It encompasses an array of inflammatory disorders, including endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, and perihepatitis. In most adolescents with acute severe infections it is difficult to differentiate some of these entities; thus the term PID is used commonly. Perihepatitis (Fitz-Hugh-Curtis syndrome) and tubo-ovarian abscess are acute complications, whereas chronic complications include infertility, ectopic pregnancy, and chronic pain.

Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain

Fitz-Hugh-Curtis syndrome--inflammation of the liver capsule associated with genital tract infection--occurs in up to one fourth of patients with pelvic inflammatory disease (PID). Classically presenting as sharp, pleuritic right upper quadrant pain, usually but not always accompanied by signs of salpingitis, it can mimic many other common disorders such as cholecystitis and pyelonephritis.

Amoxycillin/clavulanic acid (augmentin) compared with triple drug therapy for pelvic inflammatory disease

Sixty Jordanian women with pelvic inflammatory disease (PID) were studied. Of these, 31 were given oral amoxycillin/clavulanic acid (augmentin) for a mean duration of 8.4 days and 29 were given a standard triple drug regimen of oral ampicillin, intramuscular gentamicin and metronidazole tablets/pessaries for a mean duration of 7.2 days. Bacterial culture (cervical and high vaginal swabs) was positive in every case, most often E. coli but sometimes more than one pathogen was isolated. No gonococci were isolated and tests for chlamydia in 16 patients (8 in each group) were negative, suggesting a dissociation between the etiology of PID and sexually transmitted disease in this Jordanian study. After 3 days of treatment, more patients in group I (augmentin) showed diminution of symptoms of pain and discharge (P less than or equal to 0.05) compared to group II. At the end of treatment, complete cure or satisfactory improvement was recorded in 93.1% and 92.9% of cases in the two groups, corresponding to in vitro bacterial efficacy of 90.4% and 96.5%, respectively. No serious side effects were noted in either regimen. The results of this comparative study suggest that oral amoxycillin/clavulanic acid (augmentin) may be a convenient alternative to the triple drug regimen usually administered for the treatment of pelvic inflammatory disease.

Syndromic management of vaginal discharge and pelvic inflammatory disease among women in a rural community of Haryana, India: agreement of symptoms enquiry with clinical diagnosis

World Health Organisation (1984) advocated syndromic approach for management of reproductive tract infections/sexually transmitted diseases. Some investigators have cautioned against using this approach to diagnose and treat vaginal discharge and pelvic inflammatory disease. The prevalence of RTIs in rural areas of Haryana is high and availability of per-speculum examination facility is scarce. The scope for laboratory diagnosis of RTI in rural areas is remote in near future. A community-based study was conducted to assess the agreement of symptoms enquiry with the syndromic diagnosis of RTIs/STDs (based upon per speculum examination). A total of 812 women were interviewed by ANMs and were examined by a lady doctor. History based ANM's diagnosis was found to be having high sensitivity (80.5%) and high positive predictive value (81.3%). However it had low specificity (48.6%) and low negative predictive value (47.5%) compared to clinical diagnosis. Level of agreement was found to be fair (Kappa = 0.28, 95% CI = 0.20-0.36). The chances of over treatment for vaginal discharge and pelvic inflammatory disease were only 16% and 15% respectively. However, history based syndromic protocols need revision. Proposed protocol is discussed in this paper.

Clinical observation in 102 cases of chronic pelvic inflammation treated with qi jie granules

OBJECTIVE

To observe the therapeutic effects of Qi Jie Granule [see: symbol text] on chronic pelvic inflammation.

METHOD

The therapeutic effect, T-lymphocytic subgroups and indexes of blood rheology were observed when 102 cases of chronic pelvic inflammation in the treatment group were treated with Qi Jie Granule, and another 70 cases were treated with Qian Jin Pian as the controls.

RESULTS

The total effective rate was 96.08% in the treatment group, but 84.29% in the control group with a significant difference between the two groups (P < 0.01). Qi Jie Granule was also found effective in improving blood viscosity and regulating T-lymphocytic subgroups, and the difference before and after the treatment was also very significant (P < 0.05 or P < 0.01).

CONCLUSION

The nature of chronic pelvic inflammation is qi deficiency and blood stasis in accordance with the theory of traditional Chinese medicine (TCM). As a drug that is indicated for chronic pelvic inflammation, its mechanism may be related to the improved blood circulation, accelerated inflammatory absorption and regulated immune function.

Treatment of sexually transmitted diseases in women

Guidelines for the treatment of patients with sexually transmitted infection are developed by the Centers for Disease Control and Prevention after consultation with a group of professionals knowledgeable in the field. This article briefly introduces various infections, reviews new diagnostic information, and presents the latest guidelines for therapy. All recommended and alternative regimens are drawn from the most recent treatment guidelines. Although this article focuses primarily on therapy, it also emphasizes the importance of counseling and prevention. Clinicians have the opportunity and obligation to provide education and counseling to patients. Prevention messages should be tailored to the individual patient with consideration given to her specific risk behaviors.

STD trends and patterns of treatment for STD by physicians in private practice in Peru

OBJECTIVES

To describe trends in STD visits to physicians in private practice in Peru over a 15 year period and in the patterns of treatments used for STD.

METHODS

IMS Health conducts for pharmaceutical marketing purposes surveys of a random cluster sample of 1.63% of practising physicians in Peru, stratified by region and specialty. Physicians record details of diagnoses and treatments for all patients seen during a 7 day period every 6 months. Data collected on selected STD syndromes were retrospectively reviewed over a 15 year period.

RESULTS

The number of first visits for pelvic inflammatory disease (PID) and trichomoniasis, and total visits for genital herpes increased from 1983-5 to 1996-7; while first visits for gonorrhoea and total visits for syphilis have changed little in recent years. Treatment for gonorrhoea usually involved the use of spectinomycin or an aminoglycoside only. Treatments offered for PID were remarkably inadequate and for trichomoniasis often involved products not known to be effective for trichomoniasis or other causes of vaginal discharge.

CONCLUSIONS

This form of active surveillance provides information potentially useful to guide policies for prevention and management of STDs and HIV infections in developing countries.

Ciprofloxacin-tinidazole combination, fluconazole- azithromicin-secnidazole-kit and doxycycline- metronidazole combination therapy in syndromic management of pelvic inflammatory disease: a prospective randomized controlled trial

BACKGROUND

Pelvic inflammatory disease is a common problem faced by the gynecologists in there out patient department.

AIM

The aim of the study was to evaluate the efficacy of three treatment combinations in the syndromic management of pelvic inflammatory disease in the out patient setting. SETTING DESIGN: In the medical college hospital patients presenting in gynecology out patient department were enrolled.

MATERIAL AND METHODS

One hundred and sixty five women with diagnosis of pelvic inflammatory disease were randomized into three equal groups getting ciprofloxacin (500 mg) and tinidazole (600 mg) combination twice daily for 7 days (Group 1), a kit containing fluconazole (150 mg), azithromycin (1 gm) and secnidazole (2 mg) as one time dose (Group 2) and Doxycycline 100mg twice daily and metronidazole 200 mg thrice daily for seven days (Group 3). Severity score was determined on first visit and after 1 week and 4 weeks when patients were called for follow up.

STATISTICAL ANALYSIS

Chisqare test, Krusker wallis test and Mann Whitney test.

RESULTS

There was significant reduction in severity score after 1 week of treatment, which was further reduced after 4 weeks in all the three groups. Cure rate was highest in-group 1 (96%) followed by group 2 (93.5) and group 3 (91.3%) but the difference was not statistically significant. Resolution of inflammatory mass was highest in group 1. The incidence of side effects was highest and compliance was lowest in the doxycycline -metronidazole group, but the difference was not statistically significant.

CONCLUSION

All the three treatment combinations were found to be equally effective in the syndromic management of pelvic inflammatory disease.

Planning of empirical antibiotic therapy for women with pelvic inflammatory diseases: a geographical area-specific study

OBJECTIVE

Elaboration of an empiric antibiotic regimen for women with pelvic inflammatory disease (PID) for a geographical area in eastern Hungary.

STUDY DESIGN

Pathogens were identified by culturing or polymerase chain reaction (PCR) from 2215 patients with suspected PID between 1 January 1999 and 31 December 2001. Empiric guidelines for PID treatment were based on susceptibility testing of the recovered bacteria, patient acceptance and cost-effectiveness of drugs and recommendations of earlier studies.

RESULTS

Chlamydia trachomatis was detected in 11%, Neisseria gonorrhoeae in 2%, Streptococcus spp. in 17%, Enterococcus spp. 9%, genital mycoplasmas in 25%, all obligate anaerobic pathogens in 30% of the patients. All antibiotics chosen for our regimen were effective in vitro against one or more recovered pathogens at least in 80%; this regimen produced 98% clinical cure rate in mild cases of PID.

CONCLUSION

Early detection and prompt empirical antimicrobial therapy adapted to the local microflora and its resistance pattern can lead to good clinical results.

Pelvic inflammatory disease: new diagnostic criteria and treatment

PID is a common infection in reproductive-age women that presents an enormous public health and economic burden. It is responsible for much short- and long-term morbidity that may necessitate interventions subsequent to the original infection. Mild PID seems to be much more common than severe or "classic" PID, and the importance of early recognition and treatment cannot be understated. Current treatment regimens seem to be effective in terms of immediate clinical efficacy. As we learn more about the frequency and importance of subclinical PID, the true burden of upper genital tract infection upon reproductive age women continues to be elucidated.

Psychiatric side effects of ofloxacin used in the treatment of pelvic inflammatory disease

The Clinical Effectiveness Group of the Medical Society for the Study of Venereal Diseases and the Association of Genitourinary Medicine published guidelines on the management of pelvic inflammatory disease in 1999. Subsequently, the use of ofloxacin has increased in our department. However, ofloxacin can cause serious psychiatric side effects, particularly in those with a past psychiatric history. This is of relevance to genitourinary medicine (GUM) physicians as there is a high prevalence of psychiatric illness amongst patients attending GUM clinics. We present two cases of ofloxacin causing severe psychiatric symptomatology, in one case causing an acute psychotic reaction. It is recommended a psychiatric history is taken prior to prescribing ofloxacin and that consideration is given to alternative therapy for those with previous psychiatric illness.

[Severe infectious complications after an excessively long use of intrauterine device]

Intrauterine device (IUD) is a widely used method of contraception in the world. The aim of our study was to examine infectious cases due to a prolonged use of IUD. We present four patients who had carried IUD for about seventeen years. On admission, all cases were presenting symptoms of acute adnexitis. On further examination, we diagnosed tubo-ovarian abscess in two patients. In our article, we carefully describe all cases and focus attention on side effects of abnormally extended period of using IUD. We conclude that the only proper way of informing patients how to use IUD and good gynecological care while using IUD may protect against severe infectious complications of the genital tract.

A randomized controlled trial of coil removal prior to treatment of pelvic inflammatory disease

OBJECTIVE

To evaluate the effects of removing coils on the treatment of mild and moderate pelvic inflammatory disease (PID).

METHODS

Of 126 women who had mild to moderate PID during coil usage, 60 were treated following coil removal and 66 without. Clinical symptoms, findings of gynecologic examination, erythrocyte sedimentation rates (mm/h), leukocyte counts (mm(-3)) were recorded before and after treatment and recovery rates of symptoms and findings were compared with Chi-square and Fisher's absolute Chi-square tests. Student's t-test was used for the comparison of mean sedimentation rates and leukocyte counts.

RESULTS

Recovery rates of pelvic pain, purulent vaginal discharge, dysuria/frequency and dyspareunia and clinical improvements in abdominal and cervical tenderness were significantly higher (P<0.05) in the coil removed group.

CONCLUSIONS

Removing the coil before medical therapy, increases the rates of clinical improvement in mild to moderate PID.

Pelvic inflammatory disease and sepsis

Pelvic inflammatory disease affects approximately 1 million women per year in the United States alone and has a variety of causative organisms. Because the diagnosis of PID is based on clinical judgment, health care providers need to be guided by the CDC recommendations for diagnosing and treating PID. Because presenting symptoms are often vague, the health care provider should assess female patients for risky behaviors that may lead to PID and should use screening data when making clinical judgments and differential diagnoses. Whenever possible, female patients with PID should be treated as outpatients. If diagnosis and treatment are not performed in a timely manner, PID may cause sepsis, septic shock, and even death. Even if they survive, as many as 15% to 20% of these women experience long-term sequelae of PID, such as ectopic pregnancy, tubo-ovarian abscess, infertility, dyspareunia, and chronic pelvic pain. The best treatments for PID are interventions that lead to prevention and early detection. The critical care nurse has an important role in recognizing the variables that may lead to PID-related sepsis and in encouraging health-seeking and health-maintenance behaviors among women with these diagnoses.

[Pelvic inflammatory disease associated with Neisseria meningitis bacteremia]

The Pelvic Inflammatory disease (PID) caused by Neisseria meningitidis (Nm), as an extraneurological manifestation considered as a case study with few precedents. It is so far known that the occasional transposition of ecological niches occurs. There are several bibliographical reports that show an increase in the colonization of the genitourinary tract due to Nm. These may or may not cause disease in individuals during colonization. In adults, the symptoms and any complications which may arise are similar to those caused by Neisseria gonorrhoeae (Ng). It is highly necessary to correctly identify the agents of Neisseria gender which are obtained from the genital tract. This permits an accurate diagnosis to be made and results in a better understanding of the epidemiology. Morbimortality arising from Nm infection is worth studying to produce a better knowledge of the pathogenia of the infection caused by this microorganism.

Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease

The objective of the study was to compare the efficacy of azithromycin, alone or with metronidazole, versus two standard multidrug regimens for the treatment of acute pelvic inflammatory disease (PID). Patients with PID were treated with once-daily intravenous (i.v.) azithromycin 500 mg for 1 day or 2 days followed by once-daily azithromycin 250 mg orally for a total of 7 days, alone or with three-times-daily metronidazole 400 mg or 500 mg i.v. then orally for a total of 12-14 days. The comparators were either metronidazole + doxycycline + cefoxitin + probenecid or doxycycline + amoxycillin/clavulanate given at standard recommended doses for up to 21 days. In total, 309 patients were treated for PID. The diagnosis was confirmed laparoscopically in 74.8% of patients. Rates of clinical success for azithromycin, alone (97.1%) or with metronidazole (98.1%), were comparable to those for the comparator regimens (94.6%). Eradication rates for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis and anaerobes were also comparable for each of the treatment groups. Both azithromycin regimens were well tolerated. In conclusion, azithromycin, alone or with metronidazole, provides a shorter, simpler treatment option for the successful management of acute PID.

Endometritis does not predict reproductive morbidity after pelvic inflammatory disease

OBJECTIVE

We investigated the association between endometritis and reproductive morbidity.

STUDY DESIGN

Participants were 614 women in the PID Evaluation and Clinical Health (PEACH) Study with pelvic pain, pelvic organ tenderness, and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. We compared women with endometritis (>or=5 neutrophils or >or=2 plasma cells), Neisseria gonorrhoeae or Chlamydia trachomatis upper genital tract infection (UGTI) or both to women without endometritis/UGTI for outcomes of pregnancy, infertility, recurrent pelvic inflammatory disease (PID), and chronic pelvic pain (CPP), adjusting for age, race, education, PID history, and baseline infertility.

RESULTS

Endometritis/UGTI was not associated with reduced pregnancy (odds ratio [OR] 0.8, 95% CI 0.6-1.2) or elevated infertility (OR 1.0, 95% CI 0.6-1.6), recurrent PID (OR 0.6, 95% CI 0.4-0.9), or CPP (OR 0.6, 95% CI 0.4-0.9). PEACH participants with and without endometritis/UGTI had higher age- and race-specific pregnancy rates than 1997 national rates.

CONCLUSION

Among women with clinically suspected mild-to-moderate PID treated with standard antibiotics, endometritis/UGTI was not associated with reproductive morbidity.

[Integral mathematical parameters of a gemogram as criteria for evaluation of severity of chronic adnexitis and of treatment efficacy in conservative therapy]

A number of hematological indices of the peripheral blood in patients with chronic adnexitis were mathematically calculated to evaluate a disease severity and an effect of recovery by using the traditional therapy method. It was established that the integral-and-mathematical indices of hemogram reflect clinical disease acuteness while receiving patients to hospital. A comprehensive evaluation of hematological indices makes it possible to determine the severity of inflammatory process in women, to detect the efficacy of a conducted therapy and to choose a strategy for further metabolic correction to ensure a maximum treatment effect.

Sexually transmitted diseases in Manitoba: evaluation of physician treatment practices, STD drug utilization, and compliance with screening and treatment guidelines

BACKGROUND AND GOAL

There is little information in Manitoba on the utilization of drugs for sexually transmitted disease (STD) treatment and the extent to which physicians comply with STD screening and treatment guidelines. This study was undertaken to provide such information to inform policy and program development.

METHODS

Physicians providing STD care were asked to complete a simple record for each new STD index client or contact seen. This information was subsequently linked with data from provincial diagnostic and treatment databases.

RESULTS

Between October 1997 and September 1998, there were 2535 reports of STD treatments. Only about 25% of drugs provided by the provincial health department to physicians for STD treatment could be accounted for on the basis of the treatment reports received. Seventy-four percent of all treatments provided were presumptive ones for urethral or cervical infection or pelvic inflammatory disease (PID), and 14.4% of these were associated with subsequent positive tests for Chlamydia trachomatis or Neisseria gonorrhoeae. About three quarters of presumptive treatments were in compliance with provincial guidelines, as were most etiology-based treatments for chlamydial infection and 72% of etiology-based treatments for gonorrhea. Noncompliance with guidelines was commonly due to presumptive treatment that covered only C trachomatis, nonrecommended treatment for N gonorrhoeae, and incorrect treatment of PID. Only about 25% of women and 4% of men aged 15 to 24 years who visited a physician in 1997 were tested for C trachomatis.

CONCLUSION

Increased educational efforts are required to improve physician compliance with STD screening and treatment guidelines, as well as ensure the appropriate use of STD drugs provided. Opportunities are being missed for screening for C trachomatis among young people, the majority of whom are seen regularly by a physician.

[Pelvic and abdominal actinomycosis. Case report and review of the literature]

Pelvic and abdominal actinomycosis is a chronic suppurating granulomatosis caused by a Gram positive gem, Actinomyces Israelii. Manifestations of this rare disease may mimic cancer, inflammatory bowel disease, or diverticulitis. These syndromes lead to surgical exeresis. The diagnosis is obtained from the pathology report. We report the case of a 56 years old woman with large bowel obstruction secondary to extensive pelvic and abdominal actinomycosis. A review of the literature shows that the abdominal-pelvic form has been increasing over the past 10 years secondary to the increased and prolonged use of the intrauterine device. Treatment of this condition consists of a combination of antibiotics and surgery to achieve complete recovery.

[Peri-hepatitis abscess secondary to pelvic peritonitis]

OBJECTIVE

To report the case of a 42-year-old patient referred for exploration of a tumor of the right flank and evidence of inflammation.

MATERIAL

and methods. Ultrasonography and computed tomography showed a liver mass associated with a heterogeneous adnexal mass. Serum CA-125 was elevated and ovarian cancer with liver metastasis was suspected. An alternative diagnosis was salpingitis complicated by Fitz-Hugh-Curtis syndrome in this patient wearing an intra-uterine contraceptive device.

RESULTS

Exploratory laparoscopy was performed and confirmed the diagnosis of salpingitis complicated by an ovarian abscess and Fitz-Hugh-Curtis syndrome with rare abscess formation. Outcome was favorable after adapted antibiotic treatment.

CONCLUSION

Fitz-Hugh-Curtis syndrome can take on an atypical aspect and should be entertained as a possible diagnosis in young women presenting pain of the right flank and fever.

Fecundity and morbidity following acute pelvic inflammatory disease treated with doxycycline and metronidazole

We studied fecundity and late sequelae of 39 women who had laparoscopic and microbiological sampling-proven acute pelvic inflammatory disease (PID) treated with the same antimicrobial regimen. The grade and etiology of index PID were classified using laparoscopy, endometrial biopsy and microbiological cultures from the cervix, endometrium and tubes: 20 had mild and 19 severe PID. The mean (SD) follow-up period after the index PID was 125 (44) [range 8-204] months. The primary end-point was pregnancy. All other or recurrent infections or other diseases related to the infection, including infertility, were evaluated. Twenty (51%) women had laparotomy or second laparoscopy during follow-up and findings were evaluated. Chlamydia trachomatis was isolated in 38% of all cases. Eleven (28%) of 39 women avoided conception or it was no longer possible. Twenty-eight women had tried to conceive after the index PID and 25 (89%) of them had at least one pregnancy. Twenty-five women had 56 pregnancies, 33 (59%) of which ended in delivery, 9 (16%) miscarried, 13 (23%) were induced abortion and only one (1.8%) tubal pregnancy occurred. Etiologic factors or severity of PID made no difference to the conception rate. Patients with mild or moderate salpingitis had a high conception rate. Endometriosis was found in 6 (30%) out of 20 women with second laparoscopy or laparotomy. Hysterectomy had been performed in 4 cases. Precise diagnosis of acute PID is the cornerstone for the treatment of the condition. Combination regimens, including drugs against the most common factors underlying acute PID against both aerobic and anaerobic microbes, prevent late sequelae in cases with mild or moderate salpingitis but not in cases with tubal or pelvic abscess.

Incidental tubo-ovarian abscess at abdominal delivery: a case report

Tubo-ovarian abscess in the third trimester of pregnancy is extremely rare. In this report, an unusual case with asymptomatic tubo-ovarian abscess, diagnosed incidentally during Cesarean section performed for an obstetric indication, is presented. Unlike other reported cases, no signs or symptoms attributable to pelvic abscess throughout the pregnancy were observed in our patient. To our knowledge, this is the first report of such a case in the literature.

An audit of outpatient management of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a common condition presenting to Genitourinary Medicine clinics in the UK. It is unclear what is the best therapeutic option in the outpatient setting. A clinical audit of current standard of care in women presenting with PID was conducted. A total of 150 women were diagnosed clinically during a six-month period. Chlamydia and gonorrhoea were identified in 30% and 4% of patients respectively. The clinical and microbiological cure rates of oral doxycycline and metronidazole were assessed. In 57% of patients their symptoms resolved, but 18% had persistent signs and symptoms; 25% did not attend for follow up visit. Partner notification was discussed in 87% of patients. With a treatment failure rate of 18% we felt it appropriate to change the antibiotic regimen of PID in our department.