Anaerobes in pelvic inflammatory disease: implications for the Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases

In preparing the 1998 sexually transmitted disease treatment guidelines of the Centers for Disease Control and Prevention, we reviewed evidence regarding the need to eradicate anaerobes when treating pelvic inflammatory disease (PID). Anaerobes are present in the upper genital tract during an episode of acute PID, with the prevalence dependent on the population under study. Vaginal anaerobes can facilitate acquisition of PID and cause tissue damage to the fallopian tube, either directly or indirectly through the host inflammatory response. Use of several broad-spectrum regimens appears to result in excellent clinical cure rates, despite the fact that some combinations fall short of providing comprehensive coverage of anaerobes. There are limited data on the long-term effects of failing to eradicate anaerobes from the upper genital tract. Concern that tissue damage may continue when anaerobes are suboptimally treated has prompted many experts to caution that therapeutic regimens should include comprehensive anaerobic coverage for optimal treatment of women with PID.

[Pelvic tumoral actinomycosis: a difficult diagnosis. Two case reports]

Two cases of intra-uterine device-associated occlusive pelvic pseudo-tumoural actinomycosis are presented. A pre-operative diagnosis of ovarian carcinoma was considered in both cases and lead to a wide and difficult surgery. Actinomycosis was confirmed by the postoperative histopathologic examination, and the patients were successfully treated with penicillin. The difficulties and limits of the clinical and histopathological diagnosis are exposed. The interest of the pre and intra-operative diagnosis which can avoid an extensive surgery with high morbidity is highlighted.

Pelvic inflammatory disease in the postmenopausal woman

OBJECTIVE

Review available literature on pelvic inflammatory disease in postmenopausal women.

DESIGN

MEDLINE literature review from 1966 to 1999.

RESULTS

Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses.

CONCLUSION

Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.

Pelvic inflammatory disease in the postmenopausal woman

OBJECTIVE

Review available literature on pelvic inflammatory disease in postmenopausal women.

DESIGN

MEDLINE literature review from 1966 to 1999.

RESULTS

Pelvic inflammatory disease is uncommon in postmenopausal women. It is polymicrobial, often is concurrent with tuboovarian abscess formation, and is often associated with other diagnoses.

CONCLUSION

Postmenopausal women with pelvic inflammatory disease are best treated with inpatient parenteral antimicrobials and appropriate imaging studies. Failure to respond to antibiotics should yield a low threshold for surgery, and consideration of alternative diagnoses should be entertained.

The effect of laser radiation on the metabolic processes of cellular membranes in pelvic inflammatory disease

The metabolic products of peroxide oxidation of cellular membrane lipids and the activity of the antioxidant enzyme superoxidismutase in blood plasma was determined in 68 patients with acute pelvic inflammatory disease and exacerbation of chronic pelvic inflammatory disease. The analyses were done before treatment, after routine antibiotic therapy, and after low energy laser radiation treatment. During acute inflammation and exacerbation of chronic inflammation, peroxide oxidation of cellular membrane lipids intensifies and antioxidant enzyme activity decreases. Helium-neon laser rays in addition to routine antibiotics appear to stabilize peroxide oxidation and normalize antioxidation enzyme activity more than antibiotics alone.

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.

Bilateral ruptured tubo-ovarian abscesses following bilateral tubal ligation several years earlier

The occurrence of pelvic inflammatory disease and tubo-ovarian abscesses previously has been regarded as essentially nonexistent in the patient who has undergone tubal sterilization, although there have been isolated reports in the literature. This case describes a patient who underwent tubal ligation approximately 6 years prior to presenting with bilateral ruptured tubo-ovarian abscesses. The patient underwent emergency surgery and had an uneventful recovery. Theoretically, although bilateral tubal ligation should preclude the development of pelvic inflammatory disease, it is a diagnosis that should be considered in the patient presenting with lower pelvic and abdominal pain.

Design of the PID Evaluation and Clinical Health (PEACH) Study

This paper describes the PID Evaluation and Clinical Health Study (PEACH), a multicenter, randomized clinical trial designed to compare treatment with outpatient and inpatient antimicrobial regimens among women with pelvic inflammatory disease (PID). PEACH is the first trial to evaluate the effectiveness and cost-effectiveness of currently recommended antibiotic combinations in preventing infertility, ectopic pregnancy, chronic pelvic pain, recurrent PID, and other health outcomes. It is also the largest prospective study of PID ever conducted in North America. We describe the PEACH study's specific aims, study organization, patient selection criteria, conditions for exclusion, data collected upon entry, randomization and treatment, adherence measures, follow-up activities, quality-of-life measures, outcomes, and statistical analyses. In the first 11 months of enrollment (March 1996-January 1997), 312 women were randomized. Of eligible women, 59% consented to enroll. Participating women are primarily black (72%) and young (mean age 24 years). After a median of 5.5 months of follow-up, we were in contact with 95% of study participants. The PEACH study will provide a rationale for selecting between inpatient and outpatient antibiotic treatment, the two most common treatment strategies, for PID.

The availability and cost of antibiotics for treating PID in the Central Region of Ghana and implications for compliance with national treatment guidelines

The availability and cost of antibiotics for treating pelvic inflammatory disease (PID) were assessed in 17 drug-dispensing outlets in 5 districts of the Central Region, Ghana. The outlets included the dispensaries of 2 regional and 4 district hospitals, 4 privately-owned pharmacies and 7 chemical seller shops. The most common antibiotics available, including co-trimoxazole, metronidazole, benzylpenicillin, amoxycillin, chloramphenicol and gentamicin, were also the lowest-priced drugs. Conversely, the most expensive antibiotics including ceftriaxone, ciprofloxacin, cefuroxime and spectinomycin, were also the least commonly available. Recommended anti-gonococcal antibiotics (ciprofloxacin, ceftriaxone) may not be prescribed if they are not available in the districts.

The management of pelvic inflammatory disease in the Central Region of Ghana is not standardized

We evaluated the management of pelvic inflammatory disease (PID) in 2 regional level hospitals and 4 district hospitals of the Central Region of Ghana. We retrospectively reviewed 208 case notes of inpatients clinically diagnosed with PID and interviewed 25 clinicians at these hospitals. Overall, 20 antibiotics were prescribed in 62 different regimens. Between 9 and 26 antibiotic regimens were prescribed in each hospital. Metronidazole, gentamicin, amoxycillin, ampicillin, benzylpenicillin and tetracycline were frequently prescribed while the recommended anti-gonococcal antibiotics, ciprofloxacin and ceftriaxone, were rarely prescribed. The commonest regimens were prescribed for a shorter duration than recommended. Condom promotion, partner notification and management were scarcely or never undertaken. Fifty-six per cent of clinicians had never seen the national treatment guidelines; 32% had received in-service training in STD case management. The findings provide the basis for improving the management of PID in the Central Region of Ghana.

Pelvic inflammatory disease: the importance of aggressive treatment in adolescents

Pelvic inflammatory disease (PID), an infection of the female genital tract, presents a number of difficult challenges in diagnosis and management. Adolescents in particular require aggressive care of PID to prevent the long-term sequelae of chronic pelvic pain and infertility. This article reviews the etiology, microbiology, diagnosis, and management of PID, with an emphasis on treating adolescents with PID.

[The use of the antibiotic cefoxitin (Mefoxin) in gynecological practice]

The aim of this presentation is to study the advantages and disadvantages of perioperative prophylaxis with the antibiotic Mefoxin against the classical postoperative antibiotic prophylaxis with penicillin and gentamicine, as well as to analyse the place of this antibiotic in modern treatment of different forms of pelvic inflammatory disease. The authors conclude that the qualities of Mefoxin (high resistant wide spectrum antibiotic, covering aerobes and anaerobes), make it an ideal antibiotic for perioperative prophylaxis in gynaecologic and oncologic surgery; the clinical effectiveness of Mefoxin in the treatment of inflammatory diseases of the female pelvis precludes the need for a combined parenteral antibiotic therapy.

[Bacterial vaginosis]

Bacterial vaginosis being the most frequent vaginal infection is the leading cause of genital fluor. The author reviews the latest developments regarding the etiology, diagnostics and therapy of disease. Per os metronidazol and intravaginal clindamycin play the main role in treatment. The most often occurring complications of bacterial vaginosis are premature rupture of membrane and premature labour, postpartum endometritis, pelvic inflammatory disease and gynecological postoperative infections.

Treatment of polymicrobial intra-abdominal, pelvic, and diabetic foot infections

Intra-abdominal, pelvic, and diabetic foot infections are generally polymicrobial. Antimicrobial resistance occurs commonly, complicating treatment. Among numerous therapeutic options, a beta-lactam with a beta-lactamase inhibitor, and newer fluoroquinolones, may be particularly useful in managing these infections.

Doppler flow characteristics in patients with pelvic inflammatory disease: responders versus nonresponders to therapy

PURPOSE

The objective of this retrospective study was to evaluate the role of Doppler flow studies in predicting the response to antibiotic treatment in patients with pelvic inflammatory disease (PID).

METHODS

The resistance indices in pelvic masses of 24 patients with clinical diagnoses of PID were analyzed.

RESULTS

Twelve patients responded favorably to antibiotic treatment (the conservative treatment group), while the other patients showed no clinical improvement and underwent surgery (surgical treatment group). The mean resistance index in the conservative treatment group was significantly higher (0.60 +/- 0.15) than that in the surgical treatment group (0.52 +/- 0.08; p < 0.05).

CONCLUSIONS

In keeping with hyperemia of inflammation, fallopian arterial resistance seems to decrease with the severity of PID.

In vitro bactericidal activities and morphologic changes in Escherichia coli and Bacteroides fragilis by cephalosporins

Polymicrobial infections with aerobes and anaerobes are common in pelvic inflammatory diseases. New parenteral cephalosporins have been widely used against those infections. We investigated in vitro morphologic changes and bactericidal activities on Escherichia coli and Bacteroides fragilis by cephalosporins; cefluprenam (CFLP), ceftazidime (CAZ) or cefotaxime (CTX). CFLP induced morphologic changes (filamentation) and bactericidal activities on E. coli and B. fragilis. Morphologic changes were observed by electron microscope. The filamentation induced by CFLP was time and concentration dependent. The bactericidal activity of CFLP against E. coli was almost equal to those of CAZ and CTX. The bactericidal activity of CTX against B. fragilis was superior to those of CFLP and CAZ. These results suggest that there are characteristic aspects in each cephalosporin.

[New approaches to the diagnosis and treatment of inflammatory diseases of the adnexa uteri]

The paper summarizes follow-ups of 2500 patients with inflammatory diseases of the uterine appendages, provides evidence for the benefits of laparoscopic diagnosis and treatment of all types of this condition, which makes it possible to verify the diagnosis and perform less traumatic organ-sparing operations. To use combined antiinflammatory antibiotic therapy in view of the etiology of inflammation, as well as immunomodulators is the requisite condition for treating acute types of a disease. The new approaches to the diagnosis and treatment of inflammatory diseases of the uterine appendages substantially improved therapeutical outcomes and maintained female reproductive function.

C-reactive protein and the treatment of pelvic inflammatory disease

OBJECTIVE

The significance of C-reactive protein (CRP) in assessing the treatment of pelvic inflammatory disease (PID) was established and compared with body temperature (BT), erythrocyte sedimentation rate (ESR) and serum leukocyte concentration (L).

METHOD

In 51 patients with PID, 20 (39%) of them with tubo-ovarial abscess (TOA), measurement of BT and laboratory investigations were carried out on admission and during treatment on days 3-4, 6-8 and 18-21. The changes in these values were compared with the changes in clinical condition.

RESULT

Prior to treatment, the majority--49 patients or 96.1%--had increased CRP values. In successful treatment, the CRP values decreased significantly in PID patients without TOA on day 3-4, in patients with TOA on day 6-8 and reached normal values in both groups on day 18-21. Changes in clinical condition were most concurrent with changes in CRP.

CONCLUSION

In assessing PID treatment, the determination of CRP has precedence over L, ESR and BT as the percentage of patients with increased CRP is higher and because the changes in value follow the changes in clinical condition more reliably.

[Change of cytokines and clinical efficacy of panipenem/betamipron in obstetric and gynecological infections. Yamagata Study Group of Panipenem/Betamipron in Obstetric and Gynecological Infections]

Efficacy and safety of panipenem/betamipron (PAPM/BP) in treatment of obstetric and gynecological infections, and change of interleukin-6 (IL-6) and interleukin-8 (IL-8) levels in blood, as markers of infection, were investigated. The results were as follows; 1) Clinical efficacy of PAPM/BP by drip infusion of 1-2 g/day for 3-14 days against 52 patients with intrauterine infection (n = 29), pelveoperitonitis (n = 19), and other infections were 14 "Excellent" in 14 cases, "Good" in 35 cases, and efficacy rate was 94.2% (49/52). Both efficacy rate analy by causative organisms and eradication rate were 35/37 (94.6%). No subjective or objective side effects and no abnormal labolatory findings were observed. 2) Changes of IL-6 (> 4 pg/ml) levels in serum, as an infection marker, were observed in 8 cases out of 14 cases (57.1%), and correlation between CRP and IL-6 in the treatment process was noticed. However, changes of serum IL-8 (> 12.5 pg/ml) were observed in only 2 cases of those 14 cases (14.3%), indicative that IL-8 has no significance as a marker of infection.

Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata

PURPOSE

Our purpose was to study the unusual and rare late manifestation of severe pelvic abscess, following oocyte pickup (OPU), for in vitro fertilization and embryo transfer (IVF-ET).

PATIENTS

The patients were three infertile women with stage IV endometriosis and ovarian endometriomata, as the sole reason for their infertility. Medical and surgical modalities to treat endometriosis and infertility proved to be unsuccessful.

INTERVENTIONS

All patients were prepared for IVF-ET employing a long GnRH-a and hMG protocol. Transvaginal OPU was performed under ultrasound guidance. Intravenous (i.v.) prophylactic antibiotic was routinely administered.

RESULTS

All women underwent ET, and one conceived. Forty, 24, and 22 days after OPU, respectively, these patients presented with acute symptoms of severe pelvic inflammatory disease (PID) and were found to have pelvic abscess. Broad-spectrum i.v. antibiotics were employed in all cases, however, two patients did not respond and bilateral adnexectomy was eventually performed.

CONCLUSIONS

Severe endometriosis with ovarian endometriomata seems to be a significant risk factor for pelvic abscess development, following transvaginal OPU for IVF-ET. Prophylactic IV cefazolin does not seem to prevent this complication. Late manifestation of pelvic abscess supports the notion that the presence of old blood in an endometrioma provides a culture medium for bacteria to grow slowly after transvaginal inoculation.

A profile of inpatient STD-related pelvic inflammatory disease in the Top End of the Northern Territory of Australia

OBJECTIVE

To obtain a profile of inpatient STD-related pelvic inflammatory disease (PID) in the Top End of the Northern Territory.

DESIGN

Review of case records.

SETTING

The Royal Darwin Hospital, the tertiary referral centre for the Top End, during the three years from June 1991 to May 1994.

PATIENTS

All admissions with a diagnosis of STD-related PID.

MAIN OUTCOME MEASURES

The presentation and incidence of STD-related PID in Aboriginal and non-Aboriginal women.

RESULTS

PID was the reason for 14% of admissions of Aboriginal women and 2% of non-Aboriginal women. Of 175 episodes of PID in 169 patients admitted over the three years of the study, 41 (23%) had gonorrhoea, 64 (37%) had chlamydia and 7 (4%) had both organisms isolated on genital swab. Aboriginal women were more than twice as likely to have gonorrhoea (38% versus 18%; risk ratio, 2.12; 95% confidence interval, 1.27-3.53) as non-Aboriginal women. Median time from first symptoms to presentation was six days. All gonococcal isolates were penicillin susceptible.

CONCLUSIONS

STD-related pelvic inflammatory disease is an important problem among women in the Top End of the Northern Territory. As PID is a preventable illness, further measures aimed at prevention and earlier, more effective treatment of STDs that cause PID are urgently required.

[Lymph dilution as a method of treatment in endotoxicosis]

Lymph dilution was used in 26 females with inflammation of the uterine appendages and 22 patients with appendicular infiltrate. 500 ml of sodium chloride solution with gentamycin (1.4 mg/kg) were dripped in the subcutaneous fat of the femur anterior surface. Pneumocompression was performed on the unit APKU-5. The response was identical to the direct endolymphatic antibiotic therapy.

Women's health. Sexually transmitted diseases

When providing health care for women, one of the more common problems facing the primary care physician is sexually transmitted diseases (STDs). It is important to be able to develop an accurate diagnosis and appropriate treatment plan for STDs to reduce the potential long-term sequelae of these infections. It is also vital for the primary care physician to provide counseling for patients with STDs to improve compliance with the treatment regimens and prevent any further risk-taking behavior.

Oral clindamycin and ciprofloxacin versus intramuscular ceftriaxone and oral doxycycline in the treatment of mild-to-moderate pelvic inflammatory disease in outpatients

This multicenter, prospective, double-blind study compared the safety and efficacy of clindamycin and ciprofloxacin versus ceftriaxone and doxycycline in the treatment of outpatients with mild to moderate pelvic inflammatory disease (PID) diagnosed by laparoscopy. Samples taken from the endocervix, endometrium, and abdominal cavity before treatment and from the endocervix after treatment were cultured for aerobes, anaerobes, Neisseria gonorrhoeae, and Chlamydia trachomatis. Of the 138 patients enrolled, 131 were evaluable for efficacy. The most prevalent bacteria were streptococci, staphylococci, and Escherichia coli (among aerobes) and Bacteroides species and peptostreptococci (among anaerobes). N. gonorrhoeae was present in 2% (3) of the 131 evaluable patients, and C. trachomatis was in 11% (15). The clinical cure rate was 97% (65 of 67) in the clindamycin and ciprofloxacin group and 95% (61 of 64) in the ceftriaxone and doxycycline group. Side effects were similar in both groups. In conclusion, the two regimens for the outpatient treatment of mild to moderate PID were similarly effective and safe.

A multicenter study comparing intravenous meropenem with clindamycin plus gentamicin for the treatment of acute gynecologic and obstetric pelvic infections in hospitalized women

We conducted a multicenter trial to compare the efficacy and safety of meropenem with the efficacy and safety of clindamycin plus gentamicin in the treatment of 515 hospitalized patients with acute gynecologic and obstetric pelvic infections. At the end of treatment, the rates of satisfactory clinical and bacteriologic response were high (88%) in both treatment groups: the rates of response were 90% for the meropenem group and 86% for the clindamycin/gentamicin group. No serious adverse events occurred. The most frequently reported drug-related adverse clinical events in the meropenem group were nausea and injection-site reactions (> 1% of patients), and the most common drug-related laboratory abnormality was thrombocythemia. Similar patterns of adverse events occurred in the clindamycin/gentamicin group; however, the incidence of diarrhea and eosinophilia was higher in this group. In summary, this trial demonstrated that meropenem is an effective and safe alternative to the combination of clindamycin plus gentamicin for the treatment of women with acute gynecologic and obstetric pelvic infections.

The adolescent with pelvic inflammatory disease: assessment and management

More than 1 million women in the United States are reported to have pelvic inflammatory disease (PID). Of these women, 70% are under 25 years of age. Many cases go unreported and often are unrecognized, especially in 11- to 15-year-old adolescents. The presentation of PID can be a diagnostic challenge for the clinician. Many clinicians assert that a diagnosis of PID in an adolescent is an indication for hospitalization, simply because of the high rate of noncompliance with a two-drug regimen in this age group. However, many health care plans no longer support hospitalization for uncomplicated PID. This article presents an overview of the risk factors, range of presenting symptoms, diagnostic methods, and criteria. Treatment and follow-up guidelines are discussed, along with issues related to patient compliance with various regimens. A sample contract for use with adolescent clients in an attempt to improve compliance is also provided. The article includes case studies that typify common presentations.

Antibiotic use in the emergency department. IV: Single-dose therapy and parenteral-loading dose therapy

There are a number of infectious diseases that can be treated efficaciously with a single dose of an antimicrobial agent. Other infections that can be treated with oral antibiotics on an outpatient basis may resolve more quickly if a parenteral loading dose is given in the emergency department (ED) prior to discharge. This article reviews the supporting literature and indications for single-dose and parenteral first-dose-loading antimicrobial therapy in the ED. This approach may be appropriate for such diverse infections as streptococcal pharyngotonsillitis, otitis media, urinary tract infections, chlamydial genital infections, vaginitis due to yeast, bacteria, or trichomoniasis, pneumonia, gonorrhea and pelvic inflammatory disease, and pediatric fever without a source.

[Antibiotic therapy in the treatment of inflammatory diseases in the minor pelvis]

Pelvic inflammatory diseases are usually caused by sexually transmitted microorganisms, as are Neisseria gonorrhoeae and Chlamydia trachomatis, either alone or associated with endogenous flora of the lower genital tract, as with other gram-positive and gram-negative anaerobic and aerobic bacteria [1, 2].

SUBJECT

The aim of the study was to estimate the effect of three broad-spectrum combinations of antimicrobial therapy in the treatment of pelvic inflammatory diseases in hospitalized patients.

MATERIAL AND METHODS

We analysed the therapeutic success of some antimicrobial therapies in 154 patients with pelvic inflammatory disease, who were treated in the Narodni Front Hospital of Gynaecology and Obstetrics in Belgrade, during 1992 and 1993. Three drug therapies were applied. The combination of Ceftriaxon plus Doxycycline was given to 51 women. Fifty five women were treated by a combination of Gentamycin plus Clidamycin, and 48 women were treated by a combination of Gentamycin and Metronidazole.

RESULTS

The therapeutic success after the application of the three different antibiotic therapies was recorded in 139 of 154 women (90.26%). Of 136 patients with uncomplicated pelvic inflammatory diseases, the therapeutic success was noted in 129 (94.85%) individuals, while of 18 women with tubo-ovarian abscess therapeutic success was recorded in 10 (55.56%) patients. Of 51 women treated by the combination of Ceftriaxon plus Doxycycline, the therapeutic success was observed in 46 (90.19%) patients. Fifty five women treated by the combination of Gentamycin plus Clindamycin, the therapeutic success was noted in 50 (90.19%) subjects. Of 48 women, treated by the combination of Gentamycin plus Metronidazole, the therapeutic success was found in 43 (89.58%) women. No statistically significant difference was found among the applied antibiotic therapies (p > 0.05). Of 18 women with tubo-ovarian abscess 8 were operated on. Of these 8 women in 6 patients hysterectomy with bilateral salpingo-oophorectomy was performed and in two women unilateral salpingo-oophorectomy was carried out.

DISCUSSION

Pelvic inflammatory diseases are often of polymicrobial aetiology. In 43 patients we found two types of bacteria in the cervical culture. The therapeutic success was achieved by these three antibiotic therapies. It was 90.26%, the therapeutic success in the treatment of pelvic inflammatory diseases by Ceftriaxon plus Doxycycline was noted in 90.19% of patients. The therapeutic success of antibiotic therapy with Gentamycin plus Clindamycin was obtained in 90.91% of patients. The success of antibiotic therapy with Gentamycin plus Metronidazole was recorded in 89.59% of patients. Our results are similar to those of other authors [3, 4, 6, 7]. No statistically significant difference was found among the applied antibiotic therapies.

CONCLUSION

An early diagnosis and an aggressive treatment may prevent serious sequelae of this increasingly common sexually transmitted disease. The antibiotics should be of antimicrobial broad spectrum. Good effects can be best reached by a combined antibiotic therapy. Duration of parenteral administration of antibiotics should be several days and for at least 48 hours after the patient's defervescence.

Pelvic inflammatory disease: a contemporary approach

Pelvic inflammatory disease (PID) results from an ascending polymicrobial infection of unclear pathogenesis. One in 10 women in the United States has PID during her reproductive years. Medical costs of managing the disease and its sequelae are over $5 billion per year. One out of four women with PID has serious sequelae, including infertility, ectopic pregnancy or chronic pelvic pain. Patients with PID present with a spectrum of clinical symptoms and signs, none of which conclusively makes the diagnosis. The diagnosis of PID relies on a high index of suspicion, coupled with empiric therapeutic intervention and careful follow-up. Revised guidelines from the Centers for Disease Control and Prevention include recommendations for the use of broad-spectrum antibiotics, which are initiated before culture results are obtained. Indications for hospitalization are more liberal now than under the previous CDC recommendations. Prompt recognition, patient compliance with recommended therapy and treatment of the sexual partner decrease the risk of sequelae. Family physicians can make significant contributions to the health care of women through skillful management of PID.

Recent advances in antibiotic regimens for the treatment of obstetric-gynecologic infections

This paper reviews new information on antimicrobial agents for the treatment of obstetric-gynecologic infections. The bacteriology of these infections is complex, reflecting the bacteria that usually colonize the vagina and cervix. In general, these infections are polymicrobial in nature: the most frequently isolated microorganisms are gram-negative facultative aerobes, anaerobes, Chlamydia trachomatis, and Neisseria gonorrhoeae. Antibiotic regimens that do provide coverage of these pathogens showed unacceptably high failure rates. A review of the studies recently published confirmed the recommendations of the US Centers for Disease Control and Prevention for severe (inpatients) and mild-to-moderate (outpatients) pelvic inflammatory disease infections. In the case of severe infections, two regimens are recommended: a second-generation cephalosporin like cefoxitin or cefotetan, plus doxycycline or clindamycin/gentamicin. In the case of mild-to-moderate infection, a second- or third-generation cephalosporin plus doxycycline, or oral clindamycin plus an oral quinolone are recommended. Such studies produce high bacteriologic and clinical success rates. New studies indicate that gentamicin may be replaced with a monobactam such as aztreonam; this regimen leads to slightly better efficacy and less toxicity. The possibility of using clindamycin and a quinolone antibiotic is also discussed.

[Role of the immune parameter neopterin in adnexitis]

Neopterin is a sensitive marker of macrophage activity, and elevated urine excretion has been observed in viral and bacterial infections. Including 48 patients, we investigated whether neopterin could be a valid parameter for classification of PID. Urinary Neopterin was determined pretherapeutically and throughout the follow-up by means of high pressure liquid chromatography. In about one third of the patients elevated levels of neopterin were observed and these were characterized by higher PID-scores, accelerated erythrocyte sedimentation rate and higher levels of C-reactive protein. The results indicate that in patients with PID macrophages are regularly activated. Neopterin may give additional information for classification of PID although because of lack of sensitivity and specificity it may not be helpful for differential diagnosis or follow-up of these patients.

[Acute pelvic inflammatory disease: comparison of therapeutic protocols]

Acute pelvic inflammatory disease is a serious medical and economic consequence of sexually transmitted diseases among young women. The aim of the study is to compare the efficacy and safety of gentamycin plus clindamycin with that of ceftazidime plus doxycycline in the treatment of hospitalized patients with acute pelvic inflammatory disease. A total of 78 patients with acute PID, hospitalized in II Obstretic and Gynecologic Clinic of II University of Naples (Italy), entered and randomized into two treatment groups: gentamycin plus clindamycin (N = 40) and ceftazidime plus doxycycline (N = 36). Patients were excluded if they were pregnant or were not over the age of 16 years of had a history of allergy to one of the drugs used in the Study of had hepatic disease or kidney trouble or had IUD. Acute PID was diagnosed by the following criteria: 1) lower abdominal pain; 2) cervical motion tenderness; 3) adnexal tenderness (all three should be present); plus at least one of the following additional criteria: a) temperature over 38 degrees C; b) leukocytosis (greater than 10.500 mm3); c) purulent material from the peritoneal cavity bt culdocentesis; d) inflammatory mass present on binomial pelvic examination and/or sonography; e) erythrocyte sedimentation rate > 15 mm/hr. Patients were enrolled into the study after obtaining informed consent, pretreatment and posttreatment cultures were obtained from the endocervix from Neisseria gonorrhoeae and Chlamydia trachomatis and aerobic-anaerobic bacteria. The study has shown that the acute PID has a polymicrobal origins. Both antibiotic regimens were very effective in the treatment of the PID: a complete recovery was obtained in over 90% of patients.

The Fitz-Hugh-Curtis syndrome, an unusual presentation

The Fitz-Hugh-Curtis syndrome consists of adnexitis combined with perihepatitis. Prompt therapy with adequate antibiotics is required to prevent damaging complications. We describe a young woman with an unusual presentation, leading to initial confusion about the proper diagnosis.

Pelvic inflammatory disease: clinical overview

Acute pelvic inflammatory disease (PID) adversely affects the health of 1 million American women annually. The best understood etiologic organisms are Chlamydia trachomatis and Neisseria gonorrhea; however, information regarding the contributions of facultative and causative anaerobes continues to emerge. Chronic PID presents a diagnostic and management challenge to health care providers. Because of morbidity and sequelae the importance of early detection of, and intervention for, upper tract pelvic infections cannot be overemphasized. Nursing interventions in PID prevention, early assessment, accurate diagnosis, and thorough treatment can have a positive impact on women's health.

A clinical pathway for pelvic inflammatory disease for use on an inpatient service

OBJECTIVE

(1) To create a guideline to improve care of adolescent patients diagnosed with pelvic inflammatory disease (PID); (2) to promote cost-effective, consistent care while minimizing delays and ensuring timely and appropriate use of laboratory tests and other interventions; and (3) to describe the process of the development and the implementation of a clinical pathway for PID.

METHODS

The study involved the creation and piloting of a multidisciplinary, collaborative clinical pathway for uncomplicated PID on an inpatient service, and the development of a standardized form for analysis of demographics and variances from the pathway. The setting was an inpatient adolescent service at a children's hospital in an urban setting. All patients admitted with a clinical diagnosis of PID from April 1, 1993, to November 30, 1993, were followed up by means of the clinical pathway. All patients discharged with a diagnosis of uncomplicated PID in fiscal year 1992 (FY92: October 1, 1991, to September 30, 1992) were used as a comparison population. The main outcome measures included length of stay, charges per patient, timing of antibiotic administration, use of laboratory tests at admission and at 48 to 72 hours, and documentation of pathway variances.

RESULTS

A clinical pathway was created by consensus during a period of several months. During implementation, 28 of 34 (82%) patients admitted by use of the pathway had a final diagnosis of PID; 23 of the 28 (82%) had uncomplicated PID. Variances from the pathway included missed rapid plasma reagins (RPRs) and laboratory tests that were not indicated. For uncomplicated PID, length of stay was reduced (p=.08) from a median of 4 days in FY92 (mean, 5.0 1 3.1 days; range, 2-15 days) to a median of 3 days in the study group (mean, 3.5 + 1.0 days; range, 2-4 days), with differences not reaching the level of significance. There were significantly more patients staying 5 days or longer in FY92 than in the study group (p<.03). Average charges per patient also decreased by 10% (median, $5,275 in FY92 to $4,919), although these results were not statistically significant.

CONCLUSION

A clinical pathway for uncomplicated PID can be developed and implemented through a multidisciplinary, collaborative process, with ongoing use as a means of quality improvement and continuing education. Variances from the pathway highlight the need for ongoing education for health care providers. Downward trends in charges per patient and length of stay, although not significant, are encouraging; but they require longitudinal follow up with larger numbers of patients and analysis of outcomes.

Pelvic inflammatory disease: an ongoing epidemic

In the absence of a practical screening test, diagnosis is based on physical and laboratory findings, a strategy compromised by low sensitivity and specificity--and by asymptomatic cases. Antibiotic combinations must be directed against a wide range of pathogens, including Neisseria gonorrhoeae and Chlamydia trachomatis.

[Chlamydia infections in gynecology and obstetrics]

Urogenital infections with Chlamydia trachomatis belong to the most prevalent sexual transmitted diseases worldwide. In women, Chlamydia trachomatis can cause an infection of the cervix, the urethra, the endometrium and the Fallopian tubes. As potential sequelae, tubal infertility and ectopic pregnancies are associated with urogenital infections caused by this pathogen. An infection of the cervix in pregnancy can lead to neonatal and maternal complications. Therefore, by April 1st, 1995 a cervical swab for Chlamydia trachomatis has been included in the German antenatal care guide lines. The significance of these infections in health care is in contrast to its often hardly symptomatic or asymptomatic course. New diagnostic methods facilitate the detection of the pathogen and allow a specific antibiotic therapy. The aim of this review is a presentation of the clinical significance, diagnosis and therapy of urogenital infections with Chlamydia trachomatis in obstetrics and gynaecology to contribute to the prevention of potentially severe sequelae.