Ampicillin/sulbactam versus metronidazole-gentamicin in the treatment of soft tissue pelvic infections

Antibiotic therapy for pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) affects 4% to 12% of women of reproductive age. The main intervention for acute PID is broad-spectrum antibiotics administered intravenously, intramuscularly or orally. We assessed the optimal treatment regimen for PID.  OBJECTIVES: To assess the effectiveness and safety of antibiotic regimens to treat PID.

SEARCH METHODS

In January 2020, we searched the Cochrane Sexually Transmitted Infections Review Group's Specialized Register, which included randomized controlled trials (RCTs) from 1944 to 2020, located through hand and electronic searching; CENTRAL; MEDLINE; Embase; four other databases; and abstracts in selected publications.

SELECTION CRITERIA

We included RCTs comparing antibiotics with placebo or other antibiotics for the treatment of PID in women of reproductive age, either as inpatient or outpatient treatment. We limited our review to a comparison of drugs in current use that are recommended by the 2015 US Centers for Disease Control and Prevention guidelines for treatment of PID.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two authors independently extracted data, assessed risk of bias and conducted GRADE assessments of the quality of evidence.

MAIN RESULTS

We included 39 RCTs (6894 women) in this review, adding two new RCTs at this update. The quality of the evidence ranged from very low to high, the main limitations being serious risk of bias (due to poor reporting of study methods and lack of blinding), serious inconsistency, and serious imprecision. None of the studies reported quinolones and cephalosporins, or the outcomes laparoscopic evidence of resolution of PID based on physician opinion or fertility outcomes. Length of stay results were insufficiently reported for analysis. Regimens containing azithromycin versus regimens containing doxycycline We are uncertain whether there was a clinically relevant difference between azithromycin and doxycycline in rates of cure for mild-moderate PID (RR 1.18, 95% CI 0.89 to 1.55; 2 RCTs, 243 women; I² = 72%; very low-quality evidence). The analyses may result in little or no difference between azithromycin and doxycycline in rates of severe PID (RR 1.00, 95% CI 0.96 to 1.05; 1 RCT, 309 women; low-quality evidence), or adverse effects leading to discontinuation of treatment (RR 0.71, 95% CI 0.38 to 1.34; 3 RCTs, 552 women; I² = 0%; low-quality evidence). In a sensitivity analysis limited to a single study at low risk of bias, azithromycin probably improves the rates of cure in mild-moderate PID (RR 1.35, 95% CI 1.10 to 1.67; 133 women; moderate-quality evidence), compared to doxycycline.  Regimens containing quinolone versus regimens containing cephalosporin The analysis shows there may be little or no clinically relevant difference between quinolones and cephalosporins in rates of cure for mild-moderate PID (RR 1.05, 95% CI 0.98 to 1.14; 4 RCTs, 772 women; I² = 15%; low-quality evidence), or severe PID (RR 1.06, 95% CI 0.91 to 1.23; 2 RCTs, 313 women; I² = 7%; low-quality evidence). We are uncertain whether there was a difference between quinolones and cephalosporins in adverse effects leading to discontinuation of treatment (RR 2.24, 95% CI 0.52 to 9.72; 6 RCTs, 1085 women; I² =  0%; very low-quality evidence). Regimens with nitroimidazole versus regimens without nitroimidazole There was probably little or no difference between regimens with or without nitroimidazoles (metronidazole) in rates of cure for mild-moderate PID (RR 1.02, 95% CI 0.95 to 1.09; 6 RCTs, 2660 women; I² = 50%; moderate-quality evidence), or severe PID (RR 0.96, 95% CI 0.92 to 1.01; 11 RCTs, 1383 women; I² = 0%; moderate-quality evidence). The evidence suggests that there was little to no difference in in adverse effects leading to discontinuation of treatment (RR 1.05, 95% CI 0.69 to 1.61; 17 studies, 4021 women; I² = 0%; low-quality evidence). . In a sensitivity analysis limited to studies at low risk of bias, there was little or no difference for rates of cure in mild-moderate PID (RR 1.05, 95% CI 1.00 to 1.12; 3 RCTs, 1434 women; I² = 0%; high-quality evidence). Regimens containing clindamycin plus aminoglycoside versus quinolone We are uncertain whether quinolone have little to no effect in  rates of cure for mild-moderate PID compared to clindamycin plus aminoglycoside (RR 0.88, 95% CI 0.69 to 1.13; 1 RCT, 25 women; very low-quality evidence). The analysis may result in little or no difference between quinolone vs. clindamycin plus aminoglycoside in severe PID (RR 1.02, 95% CI 0.87 to 1.19; 2 studies, 151 women; I² =  0%; low-quality evidence). We are uncertain whether quinolone reduces adverse effects leading to discontinuation of treatment (RR 0.21, 95% CI 0.02 to 1.72; 3 RCTs, 163 women; I² =  0%; very low-quality evidence). Regimens containing clindamycin plus aminoglycoside versus regimens containing cephalosporin We are uncertain whether clindamycin plus aminoglycoside improves the rates of cure for mild-moderate PID compared to cephalosporin (RR 1.02, 95% CI 0.95 to 1.09; 2 RCTs, 150 women; I² =  0%; low-quality evidence). There was probably little or no difference in rates of cure in severe PID with clindamycin plus aminoglycoside compared to cephalosporin (RR 1.00, 95% CI 0.95 to 1.06; 10 RCTs, 959 women; I²= 21%; moderate-quality evidence). We are uncertain whether clindamycin plus aminoglycoside reduces adverse effects leading to discontinuation of treatment compared to cephalosporin (RR 0.78, 95% CI 0.18 to 3.42; 10 RCTs, 1172 women; I² =  0%; very low-quality evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether one treatment was safer or more effective than any other for the cure of mild-moderate or severe PID Based on a single study at a low risk of bias, a macrolide (azithromycin) probably improves the rates of cure of mild-moderate PID, compared to tetracycline (doxycycline).

Antibiotic therapy for pelvic inflammatory disease: an abridged version of a Cochrane systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To assess the effectiveness and safety of antibiotic regimens used to treat pelvic inflammatory disease (PID).

DESIGN

This is a systematic review and meta-analysis of randomised controlled trials (RCTs). Risk of bias was assessed using the criteria outlined in the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation.

DATA SOURCES

Eight electronic databases were searched from date of inception up to July 2016. Database searches were complemented by screening of reference lists of relevant studies, trial registers, conference proceeding abstracts and grey literature.

ELIGIBILITY CRITERIA

RCTs comparing the use of antibiotics with placebo or other antibiotics for the treatment of PID in women of reproductive age, either as inpatient or outpatient treatment.

RESULTS

We included 37 RCTs (6348 women). The quality of evidence ranged from very low to high, the main limitations being serious risk of bias (due to poor reporting of study methods and lack of blinding), serious inconsistency and serious imprecision. There was no clear evidence of a difference in the rates of cure for mild-moderate or for severe PID for the comparisons of azithromycin versus doxycycline, quinolone versus cephalosporin, nitroimidazole versus no use of nitroimidazole, clindamycin plus aminoglycoside versus quinolone, or clindamycin plus aminoglycoside versus cephalosporin. No clear evidence of a difference between regimens in antibiotic-related adverse events leading to discontinuation of therapy was observed.

CONCLUSIONS

We found no conclusive evidence that one regimen of antibiotics was safer or more effective than any other for the treatment of PID, and there was no clear evidence for the use of nitroimidazoles (metronidazole) compared with the use of other drugs with activity against anaerobes. More evidence is needed to assess treatments for women with PID, particularly comparing regimens with or without the addition of nitroimidazoles and the efficacy of azithromycin compared with doxycycline.

Antibiotic therapy for pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) is an infection that affects 4% to 12% of young women, and is one of the most common causes of morbidity in this age group. The main intervention for acute PID is the use of broad-spectrum antibiotics which cover Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria, administered intravenously, intramuscularly, or orally. In this review, we assessed the optimal treatment regimen for PID.

OBJECTIVES

To assess the effectiveness and safety of antibiotic regimens used to treat pelvic inflammatory disease.

SEARCH METHODS

We searched the Cochrane Sexually Transmitted Infections Review Group's Specialized Register, which included randomized controlled trials (RCTs) from 1944 to 2016, located through electronic searching and handsearching; the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid platform (1991 to July 2016); MEDLINE (1946 to July 2016); Embase (1947 to July 2016); LILACS, iAHx interface (1982 to July 2016); World Health Organization International Clinical Trials Registry Platform (July 2016); Web of Science (2001 to July 2016); OpenGrey (1990, 1992, 1995, 1996, and 1997); and abstracts in selected publications.

SELECTION CRITERIA

We included RCTs comparing the use of antibiotics with placebo or other antibiotics for the treatment of PID in women of reproductive age, either as inpatient or outpatient treatment. We limited our review to comparison of drugs in current use that are recommended for consideration by the 2015 US Centers for Disease Control and Prevention (CDC) guidelines for treatment of PID.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. We contacted investigators to obtain missing information. We resolved disagreements by consensus or by consulting a fourth review author if necessary. We assessed the quality of the evidence using GRADE criteria, classifying it as high, moderate, low, or very low. We calculated Mantel-Haenszel risk ratios (RR), using either random-effects or fixed-effect models and number needed to treat for an additional beneficial outcome or for an additional harmful outcome, with their 95% confidence interval (CI), to measure the effect of the treatments. We conducted sensitivity analyses limited to studies at low risk of bias, for comparisons where such studies were available.

MAIN RESULTS

We included 37 RCTs (6348 women). The quality of the evidence ranged from very low to high, the main limitations being serious risk of bias (due to poor reporting of study methods and lack of blinding), serious inconsistency, and serious imprecision. Azithromycin versus doxycyclineThere was no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID (RR 1.18, 95% CI 0.89 to 1.55, I² = 72%, 2 RCTs, 243 women, very low-quality evidence), severe PID (RR 1.00, 95% CI 0.96 to 1.05, 1 RCT, 309 women, low-quality evidence), or adverse effects leading to discontinuation of treatment (RR 0.71, 95% CI 0.38 to 1.34, 3 RCTs, 552 women, I² = 0%, low-quality evidence). In a sensitivity analysis limited to a single study at low risk of bias, azithromycin was superior to doxycycline in achieving cure in mild-moderate PID (RR 1.35, 95% CI 1.10 to 1.67, 133 women, moderate-quality evidence). Quinolone versus cephalosporinThere was no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID (RR 1.04, 95% CI 0.98 to 1.10, 3 RCTs, 459 women, I² = 5%, low-quality evidence), severe PID (RR 1.06, 95% CI 0.91 to 1.23, 2 RCTs, 313 women, I² = 7%, low-quality evidence), or adverse effects leading to discontinuation of treatment (RR 2.24, 95% CI 0.52 to 9.72, 5 RCTs, 772 women, I² = 0%, very low-quality evidence). Nitroimidazole versus no use of nitroimidazoleThere was no conclusive evidence of a difference between the nitroimidazoles (metronidazole) group and the group receiving other drugs with activity over anaerobes (e.g. amoxicillin-clavulanate) in rates of cure for mild-moderate PID (RR 1.01, 95% CI 0.93 to 1.10, 5 RCTs, 2427 women, I² = 60%, moderate-quality evidence), severe PID (RR 0.96, 95% CI 0.92 to 1.01, 11 RCTs, 1383 women, I² = 0%, moderate-quality evidence), or adverse effects leading to discontinuation of treatment (RR 1.00, 95% CI 0.63 to 1.59; participants = 3788; studies = 16; I² = 0% , low-quality evidence). In a sensitivity analysis limited to studies at low risk of bias, findings did not differ substantially from the main analysis (RR 1.06, 95% CI 0.98 to 1.15, 2 RCTs, 1201 women, I² = 32%, high-quality evidence). Clindamycin plus aminoglycoside versus quinoloneThere was no evidence of a difference between the two groups in rates of cure for mild-moderate PID (RR 0.88, 95% CI 0.69 to 1.13, 1 RCT, 25 women, very low-quality evidence), severe PID (RR 1.02, 95% CI 0.87 to 1.19, 2 studies, 151 women, I² = 0%, low-quality evidence), or adverse effects leading to discontinuation of treatment (RR 0.21, 95% CI 0.02 to 1.72, 3 RCTs, 163 women, very low-quality evidence). Clindamycin plus aminoglycoside versus cephalosporinThere was no clear evidence of a difference between the two groups in rates of cure for mild-moderate PID (RR 1.02, 95% CI 0.95 to 1.09, 2 RCTs, 150 women, I² = 0%, low-quality evidence), severe PID (RR 1.00, 95% CI 0.95 to 1.06, 10 RCTs, 959 women, I² = 21%, moderate-quality evidence), or adverse effects leading to discontinuation of treatment (RR 0.78, 95% CI 0.18 to 3.42, 10 RCTs, 1172 women, I² = 0%, very low-quality evidence).

AUTHORS' CONCLUSIONS

We found no conclusive evidence that one regimen of antibiotics was safer or more effective than any other for the cure of PID, and there was no clear evidence for the use of nitroimidazoles (metronidazole) compared to use of other drugs with activity over anaerobes. Moderate-quality evidence from a single study at low risk of bias suggested that a macrolide (azithromycin) may be more effective than a tetracycline (doxycycline) for curing mild-moderate PID. Our review considered only the drugs that are currently used and mentioned by the CDC.

Antibiotic regimens for postpartum endometritis

BACKGROUND

Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during the labor process and cause infection. This is more common following cesarean birth. The condition warrants antibiotic treatment.

OBJECTIVES

Systematically, to review treatment failure and other complications of different antibiotic regimens for postpartum endometritis.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomized trials of different antibiotic regimens after cesarean birth or vaginal birth; no quasi-randomized trials were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

The review includes a total of 42 trials, and 40 of these trials contributed data on 4240 participants.Regarding the primary outcomes, seven studies compared clindamycin plus an aminoglycoside versus penicillins and showed fewer treatment failures (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.46 to 0.90). There were more treatment failures in those treated with an aminoglycoside plus penicillin when compared to those treated with gentamycin/clindamycin (RR 2.57, 95% CI 1.48 to 4.46). There were more treatment failures (RR 1.66, 95% CI 1.01 to 2.74) and wound infections (RR 1.88, 95% CI 1.08 to 3.28) in those treated with second or third generation cephalosporins (excluding cephamycins) versus those treated with clindamycin plus gentamycin. In four studies comparing once-daily with thrice-daily dosing of gentamicin, there were fewer failures with once-daily dosing. There were more treatment failures (RR 1.94, 95% CI 1.38 to 2.72) and wound infections (RR 1.88, 95% CI 1.17 to 3.02) in those treated with a regimen with poor activity against penicillin-resistant anaerobic bacteria as compared to those treated with a regimen with good activity against penicillin-resistant anaerobic bacteria. There were no differences between groups with respect to severe complications and no trials reported any maternal deaths.Regarding the secondary outcomes, three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, found no differences in recurrent endometritis or other outcomes. Four trials that compared clindamycin plus aminoglycoside versus cephalosporins identified fewer wound infections in those treated with clindamycin plus an aminoglycoside (RR 0.53, 95% CI 0.30 to 0.93). There were no differences between groups for the outcomes of allergic reactions. The overall risk of bias was unclear in the most of the studies. The quality of the evidence using GRADE comparing clindamycin and an aminoglycoside with another regimen (compared with cephalosporins or penicillins) was low to very low for therapeutic failure, severe complications, wound infection and allergic reaction.

AUTHORS' CONCLUSIONS

The combination of clindamycin and gentamicin is appropriate for the treatment of endometritis. Regimens with good activity against penicillin-resistant anaerobic bacteria are better than those with poor activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen is associated with fewer side-effects. Following clinical improvement of uncomplicated endometritis which has been treated with intravenous therapy, the use of additional oral therapy has not been proven to be beneficial.

Rational antibiotic therapy and the position of ampicillin/sulbactam

In the current context of increasing antimicrobial resistance, it is important to use antibiotics rationally and to re-assess regularly the clinical usefulness of commonly used agents. This review focuses on the efficacy of the beta-lactam ampicillin co-administered with the beta-lactamase inhibitor sulbactam, either parenterally (ampicillin/sulbactam) or orally (sultamicillin), for the treatment of bacterial infections. Clinical findings from the past decade confirm the results of numerous older studies and together provide good evidence to support the continued use of ampicillin/sulbactam and sultamicillin in hospital- and community-acquired infections both in adults and children. This is also recognised in recent published national and international guidelines, many of which recommend ampicillin/sulbactam as first-line therapy for various respiratory and skin infections.

Ampicillin/Sulbactam

Ampicillin/sulbactam is a beta-lactam/beta-lactamase inhibitor combination with a broad spectrum of antibacterial activity against Gram-positive, Gram-negative and anaerobic bacteria. Data from comparative studies justify the use of ampicillin/sulbactam in a 2 : 1 ratio in various severe bacterial infections. In comparative clinical trials, ampicillin/sulbactam has proved to be a significant drug in the therapeutic armamentarium for lower respiratory tract infections and aspiration pneumonia, gynaecological/obstetrical infections, intra-abdominal infections, paediatric infections such as acute epiglottitis and periorbital cellulitis, diabetic foot infections, and skin and soft tissue infections. Of particular interest during this era of increasing antimicrobial resistance in various settings and populations is the effectiveness of sulbactam against a considerable proportion of infections due to Acinetobacter baumannii.

Bacteroides thetaiotaomicron in posthysterectomy infection

We report a patient with clinically significant vaginal posthysterectomy infection due to Bacteroides thetaiotaomicron. The microorganism isolated from the vaginal cuff abscess was beta-lactamase producer and the antibiotic susceptibility pattern showed its resistance to piperacillin-tazobactam and cefoxitin, while the susceptibility to amoxicillin associated with clavulanic acid, metronidazole, and the newer fluoroquinolone moxifloxacin was confirmed.

Antibiotic regimens for endometritis after delivery

BACKGROUND

Postpartum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labor and birth. Antibiotic treatment is warranted.

OBJECTIVES

The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's trials register (30 January 2004).

SELECTION CRITERIA

Randomized trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected.

DATA COLLECTION AND ANALYSIS

We abstracted data independently and made comparisons between different types of antibiotic regimen based on type of antibiotic and duration and route of administration. Summary relative risks were calculated.

MAIN RESULTS

Thirty-eight trials with 3983 participants were included. Fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with the other regimen (relative risk (RR) 1.44; 95% confidence interval (CI) 1.15 to 1.80). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.94; 95% CI 1.38 to 2.72). In three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, no differences were found in recurrent endometritis or other outcomes. In four studies comparing once daily with thrice daily dosing of gentamicin there were fewer failures with once daily dosing. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea.

REVIEWERS' CONCLUSIONS

The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin- resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

Ertapenem versus piperacillin-tazobactam for treatment of mixed anaerobic complicated intra-abdominal, complicated skin and skin structure, and acute pelvic infections

BACKGROUND

Anaerobes are an important component of many serious, deep tissue infections, especially complicated intra-abdominal (IAI), complicated skin and skin structure (SSSI), and acute pelvic (PI) infections. This study compares the efficacy of ertapenem, 1 g once a day, in the treatment of adults with anaerobic IAI, SSSI, and PI to piperacillin-tazobactam, 3.375 g every 6 hours.

METHODS

Three randomized, double-blind trials comparing ertapenem to piperacillin-tazobactam for treatment of IAI, SSSI, and PI were conducted. This subgroup analysis included 623 patients, whose baseline culture grew one or more anaerobic pathogens, from these three studies.

RESULTS

Anaerobes most commonly isolated were Bacteroides fragilis group (IAI) and peptostreptococci (SSSI and PI). The median duration of ertapenem and piperacillin-tazobactam therapy, respectively, in these subgroups was 6 and 7 days for IAI, 7 and 8 days for SSSI, and 4 and 5 days for PI. Cure rates for all evaluable patients with anaerobic infection were 89.3% (242/271) for ertapenem and 85.9% (220/256) for piperacillin-tazobactam (95% CI for the difference, adjusting for infection, -2.6% to 9.3%), indicating that the two treatments were equivalent. Cure rates by infection, for ertapenem and piperacillin-tazobactam, respectively, were as follows: IAI, 86.4% (133/154) and 82.4% (117/142); SSSI, 84.4% (27/32) and 82.4% (28/34); PI, 96.5% (82/85) and 93.8% (75/80). The frequency and severity of drug-related adverse experiences were comparable in both treatment groups.

CONCLUSION

In this subgroup analysis, ertapenem was as effective as piperacillin-tazobactam for treatment of adults with moderate to severe anaerobic IAI, SSSI, and PI, was generally well tolerated, and had a similar safety profile.

Ertapenem once a day versus piperacillin-tazobactam every 6 hours for treatment of acute pelvic infections: a prospective, multicenter, randomized, double-blind study

OBJECTIVE

To compare ertapenem therapy with piperacillin-tazobactam therapy for the management of acute pelvic infections.

METHODS

In a multicenter, double-blind study, 412 women with acute pelvic infection were assigned to one of two strata, namely obstetric/postpartum infection or gynecologic/postoperative infection, and were then randomized to ertapenem, 1 g once a day, or piperacillin-tazobactam, 3.375 g every 6 hours, both administered intravenously.

RESULTS

In total, 163 patients in the ertapenem group and 153 patients in the piperacillin-tazobactam group were clinically evaluable. The median duration of therapy was 4.0 days in both treatment groups. The most common single pathogen was Escherichia coli. At the primary efficacy endpoint 2-4 weeks post therapy, 93.9% of patients who received ertapenem and 91.5% of those who received piperacillin-tazobactam were cured (95% confidence interval for the difference, adjusting for strata, -4% to 8.8%), indicating that cure rates for both treatment groups were equivalent. Cure rates for both treatment groups were also similar when compared by stratum and severity of infection. The frequency and severity of drug-related adverse events were generally similar in both groups.

CONCLUSIONS

In this study, ertapenem was as effective as piperacillin-tazobactam for the treatment of acute pelvic infection, was generally well tolerated, and had an overall safety profile similar to that of piperacillin-tazobactam.

Antibiotic regimens for endometritis after delivery

BACKGROUND

Post-partum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labour and birth. Antibiotic treatment is warranted.

OBJECTIVES

The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's trials register and the Cochrane Controlled Trials Register. Date of last search: June 2001.

SELECTION CRITERIA

Randomised trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by the reviewers. Comparisons were made between different types of antibiotic regimen, based on type of antibiotic and duration and route of administration. Summary relative risks were calculated.

MAIN RESULTS

Forty-seven trials were included. Overall the studies were methodologically poor. In the intent-to-treat analysis, fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with another regimen (relative risk (RR) 1.32; 95% confidence interval (CI) 1.09-1.60). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.53; 95% CI 1.10-2.13). In four studies that compared continued oral antibiotic therapy after intravenous therapy, no differences were found in recurrent endometritis or other outcomes. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea.

REVIEWER'S CONCLUSIONS

The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

Virulence factors of Escherichia coli isolated from female reproductive tract infections and neonatal sepsis

OBJECTIVE

The presence of enterobacteria such as Escherichia coli in the vagina of normal women is not synonymous with infection. However, vaginal E. coli may also cause symptomatic infections. We examined bacterial virulence properties that may promote symptomatic female reproductive tract infections (RTI) and neonatal sepsis.

METHODS

E. coli isolated as the causative agent from cases of vaginitis (n = 50), tubo-ovarian abscess (n = 45) and neonatal sepsis (n = 45) was examined for selected phenotypic and genetic virulence properties. Results were compared with the frequency of the same properties among fecal E. coli not associated with disease.

RESULTS

A significantly greater proportion of infection E. coli exhibited D-mannose resistant hemagglutination compared with fecal E. coli (p < 0.01). This adherence phenotype was associated with the presence of P fimbriae (pap) genes which were also significantly more prevalent among isolates from all three infection sites (p < 0.01). The majority of pap+ isolates contained the papG3 allele (Class II) regardless of infection type. Increased frequency of Type IC genes among vaginitis and abscess isolates was also noted. No significant differences in frequency of other bacterial adherence genes, fim, sfa, uca (gaf or dra were observed. E. coli associated with vaginitis was significantly more likely to be hemolytic (Hly+) than were fecal isolates (p < 0.05). The Hly+ phenotype was also more prevalent among tubo-ovarian abscess and neonatal sepsis isolates (p < 0.08).

CONCLUSIONS

E. coli isolated from female RTI and neonatal sepses possess unique properties that may enhance their virulence. These properties are similar to those associated with other E. coli extra-intestinal infections, indicating that strategies such as vaccination or bacterial interference that may be developed against urinary tract infections (UTI) and other E. coli extra-intestinal infections may also prevent selected female RTI.

Ureidopenicillins and beta-lactam/beta-lactamase inhibitor combinations

Although research and development of new penicillins have declined, penicillins continue to be essential antibiotics for the treatment and prophylaxis of infectious diseases. The most recent additions are the ureidopenicillins and beta-lactam/beta-lactamase inhibitor combinations. This article reviews the spectrum of activity, toxicity, pharmacokinetics, and clinical uses of the ureidopenicillins, and the beta-lactam/beta-lactamase inhibitor combination agents.

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.

Ampicillin/Sulbactam vs. Cefoxitin for the treatment of pelvic inflammatory disease

Objective: The safety and efficacy of ampicillin plus sulbactam were compared with those of cefoxitin in the treatment of women with pelvic inflammatory disease (PID).

Methods: This single-site, randomized, prospective, third-party-blinded, comparative, parallel-treatment study enrolled 93 women with a diagnosis of PID. Patients were treated with either ampicillin/sulbactam (2 g/1 g, administered intravenously [IV], every 6 h) or cefoxitin (2 g, administered IV, every 6 h) for a minimum of 12 doses. Patients with cultures positive for Chlamydia trachomatis also received concurrent oral or IV doxycycline (100 mg twice daily). Patients with cultures negative for C. trachomatis received prophylactic oral doxycycline (100 mg twice daily) for 10–14 days after treatment with either ampicillin/sulbactam or cefoxitin was completed.

Results: Ninety-three patients were entered in the study: 47 in the ampicillin/sulbactam arm and 46 in the cefoxitin arm. All 93 patients were evaluable for safety; 61 (66%) were evaluable for efficacy. Demographic characteristics were similar for the groups. Of the 27 evaluable ampicillin/sulbactam-treated patients, 67% experienced clinical cure, 30% improved, and 4% failed treatment. Respective values for the 34 cefoxitin-treated patients were 68%, 24%, and 9% (P = 0.67). Pathogens were eradicated in 70% of the women given ampicillin/sulbactam vs. 56% of those who received cefoxitin (P = 0.64).

Conclusions: Overall, ampicillin/sulbactam demonstrated clinical and bacteriologic efficacy at least equivalent to that of cefoxitin in the treatment of women with acute PID. The use of ampicillin/sulbactam for this indication may avoid the complex dosing regimens associated with other treatments.

Antibiotic use in the emergency department. III. The quinolones, new beta lactams, beta lactam combination agents, and miscellaneous antibiotics

This article reviews several new, relatively broad-spectrum antibiotics that have utility in the emergency department (ED). The quinolones have excellent activity against gram-negative organisms, including gonococcus, and are characterized by very high bioavailability after oral administration. The new beta-lactams aztreonam and imipenem have broad spectra but limited usefulness to the emergency physician, and should be reserved for judicious use in severe infections, particularly those involving Pseudomonas. Clavulanate, sulbactam, and tazobactam are themselves antimicrobials that have been combined with beta-lactams such as ampicillin and ticarcillin to produce agents with significant potential utility in the ED; these are typically not first-line agents, however, and their use should be governed by both clinical and cost concerns. Finally, three older antibiotics--vancomycin, metronidazole, and clindamycin--are reviewed with respect to updated indications for their use in the ED.

Randomized, double-blind study of cefotetan and cefoxitin in post-cesarean section endometritis

OBJECTIVE

The hypothesis of the study is that cefotetan and cefoxitin will be equally efficacious and safe in the treatment of post-cesarean section endometritis.

STUDY DESIGN

In a double-blind, randomized manner 140 patients with post-cesarean section endometritis were treated with cefotetan, 2 gm intravenously every 12 hours, or cefoxitin, 2 gm intravenously every 6 hours. They were followed prospectively for clinical response and side effects. Cure rates between the two groups were compared with the chi 2 test.

RESULTS

The cure rates were 83% for cefotetan and 79% for cefoxitin (p = 0.56). No patient required a change in therapy due to adverse effects, and no abnormal bleeding occurred.

CONCLUSION

In this study cefotetan and cefoxitin appeared equally effective in treating endometritis with no difference in side effects or complications.

Patient costs for prophylaxis and treatment of obstetric and gynecologic surgical infections

The use of newer broad-spectrum antimicrobials for prophylaxis and treatment in obstetric and gynecologic surgery can reduce patient morbidity and hospital costs. For prophylaxis, a single dose of a cephalosporin with a long elimination half-life can be as effective as a more prolonged course. Single-dose prophylaxis reduces not only toxicity and cost to the patient but also the likelihood of colonization of the vagina by resistant organisms. Treatment regimens for postoperative pelvic infections should have broad-spectrum coverage against aerobic and anaerobic pathogens to ensure high cure rates and prevent subsequent abscess formation. With the introduction of newer cephalosporins and penicillin combinations that include a beta-lactamase inhibitor, it is now possible to treat these polymicrobial infections effectively with monotherapy. Compared with traditional antibiotic combinations, these drugs can reduce side effects and the costs of drug administration as well as the need for therapeutic monitoring. The use of oral antibiotics to complete a course of treatment can also help decrease the high costs of parenteral antibiotic therapy and hospitalization.

In vitro comparison of cefoperazone/sulbactam with selected antimicrobials against 300 bacteroides isolates. Inhibitory activity and time-kill kinetic studies

The susceptibilities of 258 Bacteroides fragilis group isolates and 42 other Bacteroides species isolates against cefoperazone, cefoperazone/sulbactam (2:1 ratio) and selected other antimicrobials were determined by broth microdilution method. All isolates were susceptible to cefoperazone/sulbactam, ampicillin/sulbactam, ticarcillin/clavulanate, metronidazole, and imipenem. Other antibiotics showed variables levels of resistance (5-30%). Killing curves with the cef/sulb against selected B. fragilis group isolates were performed and showed excellent bactericidal activity at two to four times the minimum inhibitory concentration (MIC) after 12 hr incubation, even against the isolates with high cefoperazone MICs (greater than or equal to 64 micrograms ml). There was no regrowth at 24 hr. Cefoperazone/sulbactam is a compound with excellent inhibitory and bactericidal activity against B. fragilis group isolates.

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

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

Sulbactam/ampicillin versus cefotetan in the treatment of obstetric and gynecologic infections

In an open, randomized clinical study, the safety and efficacy of sulbactam/ampicillin was compared to that of cefotetan in 95 hospital patients with gynecologic or obstetric infections. Sulbactam/ampicillin (1 g:2 g), was administered intravenously every 8 h to 46 patients, and cefotetan (2 g) was administered intravenously every 12 h to 49 patients. All 23 patients with obstetric infections and 18 of the 23 patients with gynecologic infections treated with sulbactam/ampicillin were evaluated as cured. All 21 patients with obstetric infections and 23 of the 28 patients with gynecologic infections treated with cefotetan were evaluated as cured. No side effects requiring discontinuation of therapy or reduction of the dose administered, were observed.

Sulbactam/ampicillin in the treatment of acute pelvic inflammatory disease

Acute pelvic inflammatory disease is associated with significant adverse reproductive sequelae. To prevent these serious sequelae, treatment regimens must cover the major etiologic agents which are Neisseria gonorrhoeae, Chlamydia trachomatis, and mixed anaerobic-aerobic bacteria. This report concerns the prospective evaluation of the efficacy of the combination of sulbactam with ampicillin in patients hospitalized with acute pelvic inflammatory disease. Clinical cure was noted in 33 (94%) of 35 patients and post-treatment cultures demonstrated eradication of N. gonorrhoeae and C. trachomatis in all cases.

A comparison of ampicillin plus sulbactam versus clindamycin and gentamicin for treatment of postpartum infection

Thirty-six hospitalized patients, 18 in each of two groups, with postpartum upper genital tract infection were enrolled in a randomized, prospective study comparing treatment with sulbactam/ampicillin, to treatment with clindamycin/gentamicin. One (5.5%) clinical failure was reported in each group. Side effects were minimal in both groups and did not warrant discontinuation of treatment. The in vitro activity of ampicillin versus sulbactam/ampicillin (1:2) was evaluated and these data were compared with data from other drugs commonly used for aerobic and anaerobic infections. Sulbactam eliminated resistance to ampicillin in all anaerobic and most aerobic isolates.

Treatment of hospitalized patients with acute pelvic inflammatory disease: comparison of cefotetan plus doxycycline and cefoxitin plus doxycycline

Acute pelvic inflammatory disease remains the major medical and economic consequence of sexually transmitted diseases among young women. The polymicrobial origins of pelvic inflammatory disease have been well documented and the major organisms recovered from the upper genital tract in patients with pelvic inflammatory disease include Chlamydia trachomatis, Neisseria gonorrhoeae, and mixed anaerobic and aerobic bacteria. This study was undertaken to compare the efficacy and safety of cefotetan plus doxycycline with that of cefoxitin plus doxycycline in the treatment of hospitalized patients with acute pelvic inflammatory disease. A total of 68 hospitalized patients with acute pelvic inflammatory disease were entered and randomized into two treatment groups: cefotetan (n = 32) and cefoxitin (n = 36). There were six tuboovarian abscesses in each group. C. trachomatis was recovered from 7 (10%) and N. gonorrhoeae from 48 (71%) of the patients. Anaerobic and aerobic bacteria were recovered from the upper genital tract in 53 (78%) of the patients. Cefotetan plus doxycycline and cefoxitin plus doxycycline demonstrated high rates of initial clinical response in the treatment of acute pelvic inflammatory disease. Clinical cure was noted in 30 (94%) of the cefotetan plus doxycycline group and 33 (92%) of the cefoxitin plus doxycycline group. Four failures were sonographically diagnosed tuboovarian abscesses that responded to clindamycin plus gentamicin therapy. The fifth failure was an uncomplicated case that did not respond to cefoxitin and doxycycline and required additional therapy. At 1 week and 3 weeks, respectively, the posttreatment cultures demonstrated eradication, in all instances, of N. gonorrhoeae and C. trachomatis. These regimens also were very effective in eradicating anaerobic and aerobic pathogens from the endometrial cavity. Both regimens were well tolerated by the patients, and few adverse drug affects were noted.