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

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

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).

[Treatment of uncomplicated pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

This review of the treatment of uncomplicated pelvic inflammatory disease (PID) focuses on the susceptibility profile of the main microbiological causes as well as on the advantages and inconvenients of relevant antibiotics. As bacterial resistance is expanding in the community, the rules of adequate antibiotic prescribing are integrated in the treatment proposals. While the pathogenic role of anaerobic bacteria in uncomplicated PID remains discussed, the choice to provide anaerobes coverage is proposed. Thus, the antibiotic treatment has to cover Chamydia trachomatis, Neisseria gonorrhoeae, anaerobes as well as Streptococcus spp, gram negative bacteria and the ermerging Mycoplasma genitalium. On the basis of published trials and good practice antibiotic usage, the ceftriaxone-doxycycline-metronidazole combination has been selected as the first line regimen. Fluoroquinolones (moxifloxacin alone, or levofloxacin or ofloxacin combined with metronidazole) are proposed as alternatives because of their ecological impact and their side effects leading to restricted usage. When fluoroquinolone are used, ceftriaxone should be added in case of possible sexually transmitted infection. When detected, M. genitalium should be treated by moxifloxacin. Moreover, this review highlights the need to better describe the microbiological epidemiology of uncomplicated PID in France or Europe.

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.

Metabonomic study of the protective effect of Fukeqianjin formula on multi-pathogen induced pelvic inflammatory disease in rats

Background

Fukeqianjin formula has been effectively used in the treatment of pelvic inflammatory disease (PID) and the related complications in clinic. Although there have been some studies about the underlying mechanism that focus on its anti-inflammatory and immunoregulatory activities. But the mechanism is still not fully understood. The aim of this study was to investigate the alteration of plasma metabolic profiles in PID rats and the regulatory effect of Fukeqianjin formula on potential biomarkers.

Methods

Pelvic inflammatory model was established by intrauterine inoculation of multiple pathogens combined with mechanical injury of endometrium. Rats were randomly divided into normal group, model group, azithromycin group, high-and low-dose of Fukeqianjin formula treatment group (FF-H, and FF-L, respectively). After 14 days of intragastric administration, the plasm levels of interleukin-1β (IL-1β) and nitric oxide (NO) were measured. To further recognize and identify potential biomarkers and metabolic pathways, an ultra-performance liquid chromatography-quadrupole-Exactive Orbitrap-mass spectrometry (UPLC-Q-Exactive Orbitrap-MS) metabonomic method combined with multivariate analyses including principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA) and orthogonal partial least squares discriminant analysis (OPLS-DA), was employed to analyze the metabolic profiling.

Results

Compared with normal group, the plasma levels of IL-1β and NO were significantly increased in the PID model group (P < 0. 05), and obviously decreased after high-dose intervention of Fukeqianjin formula (P < 0. 01). The PCA, PLS-DA and OPLS-DA analysis showed that PID rats were clearly separated from normal rats. Compared with the PID model group, the metabolite profiles of Fukeqianjin formula treatment group was gradually restored to normal. Meanwhile, 14 potential metabolite biomarkers, which were mainly related to the metabolic pathways of intervening glycerophospholipid metabolism, linoleic acid metabolism/alpha-linolenic acid metabolism, amino acid metabolism, arachidonic acid metabolism, and unsaturated fatty acids biosynthesis, have been identified. Fukeqianjin formula exerts good regulatory effect on the abnormal metabolism of PID rats.

Conclusions

Intrauterine inoculation of multiple pathogens combined with mechanical injury of endometrium could significantly disturb the plasma metabolic profiles of rats. Fukeqianjin formula has potential therapeutic effect on multi-pathogen-induced PID by ameliorating metabolism disorders and alleviating the inflammatory response.

Electronic supplementary material

The online version of this article (10.1186/s13020-018-0217-6) contains supplementary material, which is available to authorized users.

Review on the Outpatient Treatment for Pelvic Inflammatory Disease, what is the best for Hong Kong?

Pelvic inflammatory disease is an important risk factor for infertility, ectopic pregnancy and chronic pelvic pain. Although the Centers for Disease Control and Prevention published treatment guidelines for pelvic inflammatory disease in 2002, the effectiveness of treatment has been affected by the emergence of quinolone-resistant Neisseria gonorrhoeae. The prevalence of quinolone-resistant Neisseria gonorrhoeae is highly variable with time and place. In Hong Kong, quinolone-resistant Neisseria gonorrhoeae is over 90%, thus ceftriaxone, doxycycline and metronidazole should be the treatment of choice. For patients sensitive to cephalosporins, azithromycin and metronidazole can be considered as alternative treatments.

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.

Proposal for shorter antibiotic therapies

OBJECTIVES

Reducing antibiotic consumption has now become a major public health priority. Reducing treatment duration is one of the means to achieve this objective. Guidelines on the therapeutic management of the most frequent infections recommend ranges of treatment duration in the ratio of one to two. The Recommendation Group of the French Infectious Diseases Society (SPILF) was asked to collect literature data to then recommend the shortest treatment durations possible for various infections.

METHODS

Analysis of the literature focused on guidelines published in French and English, supported by a systematic search on PubMed. Articles dating from one year before the guidelines publication to August 31, 2015 were searched on the website.

RESULTS

The shortest treatment durations based on the relevant clinical data were suggested for upper and lower respiratory tract infections, central venous catheter-related and uncomplicated primary bacteremia, infective endocarditis, bacterial meningitis, intra-abdominal, urinary tract, upper reproductive tract, bone and joint, skin and soft tissue infections, and febrile neutropenia. Details of analyzed articles were shown in tables.

CONCLUSION

This work stresses the need for new well-conducted studies evaluating treatment durations for some common infections. Following the above-mentioned work focusing on existing literature data, the Recommendation Group of the SPILF suggests specific study proposals.

Pelvic inflammatory disease: improving awareness, prevention, and treatment

Purpose

Pelvic inflammatory disease (PID) is a common disorder of the reproductive tract that is frequently misdiagnosed and inadequately treated. PID and its complications, such as infertility, ectopic pregnancy, and chronic pelvic pain, are preventable by screening asymptomatic patients for sexually transmitted infections (STIs) and promptly treating individuals with STIs and PID.

Recent findings

The rates of adverse outcomes in women with PID are high and disproportionately affect young minority women. There are key opportunities for prevention including improving provider adherence with national screening guidelines for STIs and PID treatment recommendations and patient medication adherence. Nearly half of all eligible women are not screened for STIs according to national quality standards, which may increase the risk of both acute and subclinical PID. Moreover, in clinical practice, providers poorly adhere to the Centers for Disease Control and Prevention recommendations for treatment of PID. Additionally, patients with PID struggle to adhere to the current management strategies in the outpatient setting.

Conclusion

Novel evidence-based clinical and public health interventions to further reduce the rates of PID and to improve outcomes for affected women are warranted. We propose potential cost-effective approaches that could be employed in real-world settings.

Diagnostic Value of Vaginal Discharge, Wet Mount and Vaginal pH - An Update on the Basics of Gynecologic Infectiology

The majority of uncomplicated vulvovaginal complaints (e.g. bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis) can be detected with uncomplicated basic infectiological tests and can usually be treated effectively without requiring further diagnostic procedures. Tests include measurement of vaginal pH, preparation and assessment of wet mount slides prepared from vaginal or cervical discharge, and the correct clinical and microbiological classification of findings. In Germany, at least in recent years, this has not been sufficiently taught or practiced. As new regulations on specialist gynecologic training in Germany are currently being drawn up, this overview provides basic information on gynecologic infectiology and summarizes clinically relevant aspects of recent microbiological findings on the physiology and pathology of vaginal flora. The clinical signs and symptoms of aerobic vaginitis, the pathogenesis of which is still not completely understood, are also reviewed. Finally, the symptoms, indications and risk factors for pelvic inflammatory disease (PID) are presented. In contrast to the above-listed infections, PID requires immediate culture of the pathogen from samples (e.g. obtained by laparoscopy) with microbiological diagnostic procedures carried out by specialist laboratories. A schematic summary of all pathologies discussed here is presented.

Time to manage Mycoplasma genitalium as an STI: but not with azithromycin 1 g!

PURPOSE OF REVIEW

Mycoplasma genitalium is a sexually transmitted infection that causes significant morbidity in men and women and is a co-factor in HIV transmission. However, commercial diagnostic tests are not generally available for M. genitalium and sub-optimal treatment is often given. We review the literature on the burden of infection, how it may present in clinical practice and the effectiveness of current treatment regimens.

RECENT FINDINGS

In-vivo and in-vitro data strongly suggest that M. genitalium is an important cause of urethritis, cervicitis, pelvic inflammatory disease and potentially asymptomatic proctitis. Studies now consistently demonstrate suboptimal eradication rates with the current treatment regimens recommended first line for the treatment of nongonococcal urethritis. Concurrently, there has been a rapid emergence of antibiotic resistance in M. genitalium, with macrolide resistance now appearing to be endemic in some centres, and quinolone resistance is beginning to emerge.

SUMMARY

In the absence of specific M. genitalium diagnostic and antimicrobial resistance testing, azithromycin 1 g should not be used for the management of patients with symptomatic disease potentially caused by M. genitalium. This review offers an alternative evidence-based approach to managing such patients that should, theoretically, reduce the risk of the development of antimicrobial resistance.

Laparoscopy for the management of acute lower abdominal pain in women of childbearing age

BACKGROUND

This is an updated version of the original review, published in Issue 1, 2011, of The Cochrane Library. Acute lower abdominal pain is common, and making a diagnosis is particularly challenging in premenopausal women, as ovulation and menstruation symptoms overlap with symptoms of appendicitis, early pregnancy complications and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications.

OBJECTIVES

To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age.

SEARCH METHODS

The Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINAHL were searched (October 2013). The International Clinical Trials Registry Platform (ICTRP) was also searched. No new studies were included in this updated version.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis were included. Trials were included if they evaluated laparoscopy with open appendicectomy, or laparoscopy with a wait and see strategy. Study selection was carried out by two review authors independently.

DATA COLLECTION AND ANALYSIS

Data from studies that met the inclusion criteria were independently extracted by two review authors and the risk of bias assessed. We used standard methodological procedures as expected by The Cochrane Collaboration. A summary of findings table was prepared using GRADE criteria.

MAIN RESULTS

A total of 12 studies including 1020 participants were incorporated into the review. These studies had low to moderate risk of bias, mainly because allocation concealment or methods of sequence generation were not adequately reported. In addition, it was not clear whether follow-up was similar for the treatment groups. The index test was incorporated as a reference standard in the laparoscopy group, and differential verification or partial verification bias may have occurred in most RCTs. Overall the quality of the evidence was low to moderate for most outcomes, as per the GRADE approach.Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (seven RCTs, 561 participants; odds ratio (OR) 4.10, 95% confidence interval (CI) 2.50 to 6.71; I(2) = 18%), but no evidence was found of reduced rates for any adverse events (eight RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) = 0%). A meta-analysis of seven studies found a significant difference favouring the laparoscopic procedure in the rate of removal of normal appendix (seven RCTs, 475 participants; OR 0.13, 95% CI 0.07 to 0.24; I(2) = 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. A significant difference favoured laparoscopy in terms of rate of specific diagnoses (four RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) = 79%), but no evidence suggested a difference in rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) = 0%).  

AUTHORS' CONCLUSIONS

We found that laparoscopy in women with acute lower abdominal pain, non-specific lower abdominal pain or suspected appendicitis led to a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared with open appendicectomy only. Hospital stays were shorter. No evidence showed an increase in adverse events when any of these strategies were used.

Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment

Pelvic inflammatory disease (PID) is characterized by infection and inflammation of the upper genital tract in women and can cause significant reproductive health sequelae for women. Although a definitive diagnosis of PID is made by laparoscopic visualization of inflamed, purulent fallopian tubes, PID is generally a clinical diagnosis and thus represents a diagnostic challenge. Therefore, diagnosis and treatment algorithms advise a high index of suspicion for PID in any woman of reproductive age with pelvic or abdominal pain. Antibiotic therapy should be started early, and given for an adequate period of time to reduce the risk of complications. Coverage for anaerobic organisms should be considered in most cases.

Poor provider adherence to the Centers for Disease Control and Prevention treatment guidelines in US emergency department visits with a diagnosis of pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) is commonly diagnosed in US emergency departments (EDs). We aimed to estimate national rates of provider adherence to the Centers for Disease Control and Prevention (CDC) treatment guidelines for PID among patient visits, with a diagnosis of acute PID in US ED settings.

METHODS

A multiyear cross-sectional analysis was performed on ED visits from females >12 years old, using the National Hospital Ambulatory Medical Care Survey database from 1999 to 2006. The ED diagnoses of acute PID were identified from the database. Specific antibiotics ordered or provided during ED visits diagnosed with PID were identified and compared to contemporary CDC treatment guidelines to determine provider adherence. Analyses were performed using procedures for multiple-stage survey data.

RESULTS

Overall, 1,605,000 discharged ED patient visits with a diagnosis of acute PID were identified. ED provider adherence to CDC treatment guidelines was 30.5% (95% confidence intervals [CI], 24.4%-36.7%). Doxycycline was the most commonly missing medication from the recommended regimens while azithromycin was the most prescribed antibiotic that was not recommended until 2006 CDC guidelines. Additionally, among the visits without being given any CDC-recommended antibiotics, 38.4% were prescribed neither antibiotics nor pain relievers. In multivariate analysis, those without specialty consultation during ED visits and those before the announcement of 2002 guidelines were 4.95 (95% CI, 1.71-14.29) and 1.93 (95% CI, 1.14-3.27) times less likely to receive CDC-recommended antibiotic regimens versus their counterparts.

CONCLUSIONS

Poor provider adherence to the CDC-recommended treatment guidelines for PID has been widespread in US EDs, especially for women who did not receive specialty consultation.

Assessing a potential role of host Pannexin 1 during Chlamydia trachomatis infection

Pannexin 1 (Panx1) is a plasma membrane channel glycoprotein that plays a role in innate immune response through association with the inflammasome complex. Probenecid, a classic pharmacological agent for gout, has also been used historically in combination therapy with antibiotics to prevent cellular drug efflux and has been reported to inhibit Panx1. As the inflammasome has been implicated in the progression of Chlamydia infections, and with chlamydial infections at record levels in the US, we therefore investigated whether probenecid would have a direct effect on Chlamydia trachomatis development through inhibition of Panx1. We found chlamydial development to be inhibited in a dose-dependent, yet reversible manner in the presence of probenecid. Drug treatment induced an aberrant chlamydial morphology consistent with persistent bodies. Although Panx1 was shown to localize to the chlamydial inclusion, no difference was seen in chlamydial development during infection of cells derived from wild-type and Panx1 knockout mice. Therefore, probenecid may inhibit C. trachomatis growth by an as yet unresolved mechanism.

Pelvic Inflammatory Disease: Current Concepts of Diagnosis and Management

Pelvic inflammatory disease (PID), one of the most common infections in non-pregnant women of reproductive age, remains an important public health problem. It is associated with major long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. In addition, treatment of acute PID and its complications incurs substantial health care costs. Prevention of these long-term sequelae is dependent upon clinicians having a high index of suspicion in order to make an early diagnosis and development of treatment strategies based on knowledge of the microbiologic etiology of acute PID. It is well accepted that acute PID is a polymicrobic infection. The sexually transmitted organisms, Neisseria gonorrhoeae and Chlamydia trachomatis, are present in many cases and microorganisms comprising the endogenous vaginal and cervical flora are frequently associated with PID. This includes anaerobic and facultative bacteria, similar to those associated with bacterial vaginosis. Genital tract mycoplasmas, most importantly Mycoplasma genitalium, have recently also been implicated as a cause of acute PID. As a consequence, treatment regimens for acute PID should provide broad spectrum coverage that is effective against these microorganisms.

Treatment of acute pelvic inflammatory disease

Pelvic inflammatory disease (PID), one of the most common infections in nonpregnant women of reproductive age, remains an important public health problem. It is associated with major long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. In addition, treatment of acute PID and its complications incurs substantial health care costs. Prevention of these long-term sequelae is dependent upon development of treatment strategies based on knowledge of the microbiologic etiology of acute PID. It is well accepted that acute PID is a polymicrobic infection. The sexually transmitted organisms, Neisseria gonorrhoeae and Chlamydia trachomatis, are present in many cases, and microorganisms comprising the endogenous vaginal and cervical flora are frequently associated with PID. This includes anaerobic and facultative bacteria, similar to those associated with bacterial vaginosis. Genital tract mycoplasmas, most importantly Mycoplasma genitalium, have recently also been implicated as a cause of acute PID. As a consequence, treatment regimens for acute PID should provide broad spectrum coverage that is effective against these microorganisms.

Recommendations and rationale for the treatment of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is one of the most common serious infections of nonpregnant women of reproductive age. Management of PID is directed at containment of infection. Goals of therapy include the resolution of clinical symptoms and signs, the eradication of pathogens from the genital tract and the prevention of sequelae including infertility, ectopic pregnancy and chronic pelvic pain. The choice of an antibiotic regimen used to treat PID relies upon the appreciation of the polymicrobial etiology of this ascending infection including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and other lower genital tract endogenous anaerobic and facultative bacteria, many of which are associated with bacterial vaginosis. Currently available evidence and the CDC treatment recommendations support the use of broad-spectrum antibiotic regimens that adequately cover the above named microorganisms. The outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline. Clinically severe PID should prompt hospitalization and imaging to rule out a tubo-ovarian abscess. Parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly Gram-negative aerobes and anaerobes, should be implemented.

Laparoscopy for the management of acute lower abdominal pain in women of childbearing age

BACKGROUND

Acute lower abdominal pain is common and making a diagnosis is particularly challenging in premenopausal woman as ovulation and menstruation symptoms overlap with the symptoms of appendicitis and pelvic infection. A management strategy involving early laparoscopy could potentially provide a more accurate diagnosis, earlier treatment and reduced risk of complications.

OBJECTIVES

To evaluate the effectiveness and harms of laparoscopy for the management of acute lower abdominal pain in women of childbearing age.

SEARCH STRATEGY

The  Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, LILACS and CINHAL were searched (to April 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) that included women of childbearing age who presented with acute lower abdominal pain, nonspecific lower abdominal pain or suspected appendicitis were included.

DATA COLLECTION AND ANALYSIS

Data from studies that met the inclusion criteria were independently extracted by two authors and the risk of bias assessed.

MAIN RESULTS

Laparoscopy was compared with open appendicectomy in eight RCTs. Laparoscopy was associated with an increased rate of specific diagnoses (7 RCTs, 561 participants; OR 4.10, 95% CI 2.50 to 6.71; I(2) 18%) but there was no evidence of reduced rate for any adverse event (8 RCTs, 623 participants; OR 0.46, 95% CI 0.19 to 1.10; I(2) 0%).Laparoscopic diagnosis versus a 'wait and see' strategy was investigated in four RCTs. There was a significant difference favouring laparoscopy in the rate of specific diagnoses (4 RCTs, 395 participants; OR 6.07, 95% CI 1.85 to 29.88; I(2) 79%) but there was no evidence of a difference in the rates of adverse events (OR 0.87, 95% CI 0.45 to 1.67; I(2) 0%).  

AUTHORS' CONCLUSIONS

The advantages of laparoscopy in women with nonspecific abdominal pain and suspected appendicitis include a higher rate of specific diagnoses being made and a lower rate of removal of normal appendices compared to open appendicectomy only. Hospital stays were shorter. There was no evidence of an increase in adverse events with any of the strategies.

Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is an infection-caused inflammatory continuum from the cervix to the peritoneal cavity. Most importantly, it is associated with fallopian tube inflammation, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. The microbial etiology is linked to sexually transmitted microorganisms, including Chlamydia trachomatis, Neisseria gonorrheae, Mycoplasma genitalium, and bacterial vaginosis-associated microorganisms, predominantly anaerobes. Pelvic pain and fever are commonly absent in women with confirmed PID. Clinicians should consider milder symptoms such as abnormal vaginal discharge, metrorrhagia, postcoital bleeding, and urinary frequency as potential symptoms associated with the disease, particularly in women at risk of sexually transmitted infection. The diagnosis of PID is based on the findings of lower genital tract inflammation associated with pelvic organ tenderness. The outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens with activity against the commonly isolated microorganisms associated with PID and usually consists of an extended spectrum cephalosporin in conjunction with either doxycycline or azithromycin. Clinically severe PID should prompt hospitalization and imaging to rule out a tuboovarian abscess. Parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly gram-negative aerobes and anaerobes, should be implemented. Screening for and treatment of Chlamydia infection can prevent PID.

Treatment strategies for pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) is one of the most common infections seen in nonpregnant reproductive-age women. It is a major public health problem associated with substantial medical complications (e.g., infertility, ectopic pregnancy, and chronic pelvic pain) and healthcare costs. Prevention of these long-term sequelae requires treatment strategies that are based on the microbiologic etiology of acute PID.

OBJECTIVE

To determine appropriate antimicrobial regimens for the treatment of acute PID based on published literature.

METHODS

Clinical trials published since 2002 were assessed conducting a systematic search of the literature on the treatment of acute PID using PubMed (National Library of Congress). The search was limited to articles written in English and published from 1 January 2002 to 30 June 2008.

RESULTS

Acute PID is a polymicrobic infection caused by both sexually transmitted organisms (primarily Neisseria gonorrhoeae and Chlamydia trachomatis) and microorganisms found in the endogenous flora of the vagina and cervix. The latter include anaerobic bacteria and facultative bacteria, many of which are associated with bacterial vaginosis. Genital tract mycoplasmas, most importantly Mycoplasma genitalium, may also be implicated in the etiology of acute PID. Because of this polymicrobial nature, currently available evidence, as well as recommendations by the CDC, support the use of broad-spectrum regimens (oral or parenteral) that provide adequate coverage against these microorganisms.

A randomized double-blind comparison of moxifloxacin and doxycycline/metronidazole/ciprofloxacin in the treatment of acute, uncomplicated pelvic inflammatory disease

This multicentre, double-blind study was undertaken to demonstrate non-inferiority of once-daily oral moxifloxacin compared with combination therapy in the management of acute, uncomplicated pelvic inflammatory disease (PID). Women aged ≥18 years with PID were randomized to receive moxifloxacin (400 mg once daily) for 14 days or comparator treatment (doxycycline [100 mg twice daily] plus metronidazole [400 mg three times daily] for 14 days, plus one single 500-mg ciprofloxacin dose). Of the 434 valid per protocol (PP) patients, the overall clinical success rates at 2–14 days post-therapy were 96.6% (moxifloxacin) and 98.0% (comparator); moxifloxacin was non-inferior to the comparator regimen both in the PP (95% confidence interval [CI]: −4.5, 1.6) and intent-to-treat (95% CI: −5.8, 6.9) populations. Clinical success rates at 21–35 days post-therapy were 93.8% (166/177; data missing for 47 patients) for moxifloxacin and 91.3% (147/161; data missing for 37 patients) for the comparator. Bacteriological success rates at 2–14 days post-therapy were 92.5% (moxifloxacin) and 88.2% (comparator). Once-daily dosing and proven efficacy suggest that moxifloxacin may be of value in acute, uncomplicated PID.

Diagnosis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease (PID), the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, largely resulting from varying signs and symptoms and a polymicrobial etiology that is not fully delineated. Owing to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. As PID has a multimicrobial etiology, including Neisseria gonorrhoeae, Chlamydial trachomatis and anaerobic and mycoplasmal bacteria, treatment of PID should consist of a broad spectrum antibiotic regimen. Recent treatment trials have focused on shorter duration regimens, such as azithromycin, and monotherapies including ofloxacin, but data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines.

Sexually transmitted infections and pelvic inflammatory disease in women

Sexually transmitted infections (STIs) are an important public health challenge in the United States. Primary care clinicians can contribute to decreasing these largely preventable causes of morbidity and mortality by integrating routine screening, testing, counseling, treatment, and partner management of STIs into their practice. Newer tests for chlamydia and gonorrhea that can be performed on urine specimens allow screening without a pelvic examination. The most recent edition of the Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines provides an evidence-based, reliable, and convenient set of recommendations for treating and caring for patients who have STIs.

Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines

Pelvic inflammatory disease (PID) is a substantial cause of reproductive morbidity in young women. A systematic review of the literature related to PID management was performed in preparation for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. This search was conducted using PubMed and was limited to articles written in English and published between 1 January 2002 and 31 January 2005 that were related to PID treatment. Studies were evaluated for new data on PID with regard to site, route, and timing of antimicrobial administration; regimen adherence; experience in adolescents and women >35 years of age; coinfection with human immunodeficiency virus; and management of sex partners. Strong evidence suggests that neither site nor route of treatment administration affects the short- or long-term major outcome of women with mild or moderate clinical presentations. Data on these outcomes in women with more severe clinical presentations are inadequate to provide guidance as to the preferred agents or route of administration. Important contributions to the literature that impact the 2006 guidelines are described in this article.

Comparing Ceftriaxone Plus Azithromycin or Doxycycline for Pelvic Inflammatory Disease

OBJECTIVE

To evaluate the equivalence of ceftriaxone plus doxycycline or azithromycin for cases of mild pelvic inflammatory disease (PID).

METHODS

Patients with PID received an intramuscular injection of 250 mg of ceftriaxone, and were randomly assigned to receive 200 mg/d of doxycycline for 2 weeks, or 1 g of azithromycin per week, for 2 weeks. The degree of pain was assessed on days 2, 7, and 14 and clinical cure was assessed on day 14.

RESULTS

From 133 patients eligible for the study, 13 were excluded for having conditions other than PID, 11 were lost on follow-up, and three had oral intolerance to the antibiotics, yielding 106 for protocol analysis. No significant difference was observed regarding the degree of pain between the doxycycline and azithromycin groups. Clinical cure per protocol was 98.2% (56 of 57; 95% confidence interval [CI], 0.9-0.99) with azithromycin, and 85.7% (42 of 49; 95% CI, 0.72-0.93) with doxycycline (P=0.02). In a modified intention to treat analysis, clinical cure was 90.3% (56 of 62; 95% CI, 0.80-0.96) with azithromycin, and 72.4% (42 of 58; 95% CI, 0.58-0.82) with doxycycline (P=.01); a relative risk of 0.35, and a number needed to treat of six for benefit with azithromycin.

CONCLUSION

When combined with ceftriaxone, 1g of azithromycin weekly for 2 weeks is equivalent to ceftriaxone plus a 14-day course of doxycycline for treating mild PID.

Could a simple antenatal package combining micronutritional supplementation with presumptive treatment of infection prevent maternal deaths in sub-Saharan Africa?

BACKGROUND

Reducing maternal mortality is a key goal of international development. Our objective was to determine the potential impact on maternal mortality across sub-Saharan Africa of a combination of dietary supplementation and presumptive treatment of infection during pregnancy. Our aim was to demonstrate the importance of antenatal interventions in the fight against maternal mortality, and to stimulate debate about the design of an effective antenatal care package which could be delivered at the lowest level of the antenatal health system or at community level.

METHODS

We collated evidence for the effectiveness of antenatal interventions from systematic reviews and controlled trials, and we selected interventions which have demonstrated potential to prevent maternal deaths. We used a model-based analysis to estimate the total reduction in maternal mortality in sub-Saharan Africa which could be achieved by combining these interventions into a single package, based on a WHO systematic review of causes of maternal deaths.

RESULTS

Severe hypertensive disorders, puerperal sepsis and anemia are causes of maternal deaths which could be prevented to some extent by prophylactic measures during pregnancy. A package of pills comprising calcium and iron supplements and appropriate anti-microbial and anti-malarial drugs could reduce maternal mortality in sub-Saharan Africa by 8% (range <1% to 20%). This estimate is based on Cochrane Review estimates for the effectiveness of daily calcium supplements in reducing the risk of death/serious morbidity due to hypertensive disorders (RR = 0.80, 95% CI 0.65-0.97), anti-microbial prophylaxis in reducing the odds of puerperal sepsis/postpartum endometritis (OR = 0.49, 95% CI 0.23-1.06), anti-malarial prophylaxis in reducing the risk of severe antenatal anemia (RR = 0.62, 95% CI 0.50-0.78), and iron supplementation in reducing the risk of iron deficiency anemia at term (RR = 0.33, 95% CI 0.16-0.69).

CONCLUSION

Maternal mortality could be reduced by a combination of micronutrient supplementation and presumptive treatment of infection during pregnancy. Such an approach could be adopted in resource-poor settings where visits to antenatal clinics are infrequent and would complement existing Safe Motherhood activities.

Newest Approaches to Treatment of Pelvic Inflammatory Disease: A Review of Recent Randomized Clinical Trials

Treatment of pelvic inflammatory disease (PID) should provide high rates of clinical and microbiological cure for a range of pathogens and should ultimately prevent reproductive morbidity. Between 1992 and 2006, 5 randomized clinical trials of moxifloxacin (1 trial), ofloxacin (1 trial), clindamycin-ciprofloxacin (1 trial), and azithromycin (2 trials) treatment among women with mild to moderate PID were found to have clinical cure rates of 90%-97%. Trials of ofloxacin and clindamycin-ciprofloxacin reported rates of cure of Neisseria gonorrhoeae and Chlamydia trachomatis infection of 100%, although microbiological cure data for other pathogens were not presented. One azithromycin trial reported a 98% eradication of C. trachomatis, N. gonorrhoeae, Mycoplasma hominis, and anaerobes. Moxifloxacin exhibited high eradication rates for N. gonorrhoeae, C. trachomatis, M. hominis, Mycobacterium genitalium, and gram-negative anaerobes. Clinical cure rates from 2 doxycycline-metronidazole trials were low (35% and 55%). Although a handful of studies have shown that monotherapies for PID achieve high rates of clinical cure, the efficacy of these regimens in treating anaerobic PID and in preventing adverse reproductive sequelae is not fully elucidated.

Epidemiology, pathogenesis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease, the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, due largely to a polymicrobial etiology which is not fully delineated. Signs and symptoms of this syndrome vary widely, further complicating diagnosis and treatment. Due to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. Since pelvic inflammatory disease has a multimicrobial etiology including Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic and mycoplasmal bacteria, treatment of pelvic inflammatory disease should be broad spectrum. Recent treatment trials have focused on shorter duration regimens such as azithromycin and monotherapies including ofloxacin, although data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines. Several promising short-duration and monotherapy antibiotic regimens should be evaluated in pelvic inflammatory disease treatment trials for compliance, microbiological and clinical cure, and reduction of subsequent adverse reproductive and gynecological morbidity.

Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial

OBJECTIVE

This multinational, multicentre, prospective, randomised, double blind, parallel group, non-inferiority study compared the efficacy and safety of moxifloxacin monotherapy with ofloxacin plus metronidazole in women with uncomplicated pelvic inflammatory disease.

METHODS

Women from hospitals throughout 13 countries received a 14 day course of either oral moxifloxacin, 400 mg once daily (n = 384), or oral ofloxacin, 400 mg twice daily plus oral metronidazole, 500 mg twice daily (n = 365).

RESULTS

Of the 741 patients in the intent to treat (ITT) population, 564 (74.2%) were valid for the per protocol (PP) analyses; 112 (19.9%) of these were included in the microbiologically valid population (MBV). Clinical resolution rates in the PP population at the test of cure visit (TOC, 5-24 days post-therapy, primary efficacy end point) were 90.2% (248/275) for moxifloxacin and 90.7% (262/289) for ofloxacin plus metronidazole (95% CI: -5.7% to 4.0%). At follow up (28-42 days post-therapy), resolution rates in the PP population were 85.8% (236/275) and 87.9% (254/289) for moxifloxacin and comparator, respectively (95% CI: -8.0% to 3.1%). Bacteriological success rates in the MBV population at TOC were 87.5% (49/56) for moxifloxacin and 82.1% (46/56) for comparator (95% CI: -8.3% to 18.8%). Against Chlamydia trachomatis and Neisseria gonorrhoeae, bacteriological success rates with moxifloxacin were 88.5% (23/26) and 100% (13/13) and for comparator 85.7% (18/21) and 81.8% (18/22), respectively. Drug related adverse events occurred less frequently with moxifloxacin (22.5% (85/378)) versus the comparator (30.9% (112/363)) (p = 0.01).

CONCLUSION

In uncomplicated PID, once daily moxifloxacin monotherapy was clinically and bacteriologically as efficacious as twice daily ofloxacin plus metronidazole therapy and was associated with fewer drug related adverse events.

Macrolides and ketolides: azithromycin, clarithromycin, telithromycin

The advanced macrolides, azithromycin and clarithromycin, and the ketolide telithromycin are structural analogues of erythromycin. They have several distinct advantages when compared with erythromycin including enhanced spectrum of activity, more favorable pharmacokinetics and pharmacodynamics, once daily administration, and improved tolerability. This article reviews the pharmacokinetics, antimicrobial activity, clinical use, and adverse effects of these antimicrobial agents.

Management of pelvic inflammatory disease in adolescents

Pelvic inflammatory disease (PID) is highly prevalent among sexually active adolescent females. The major organisms are N gonorrhoeae and C trachomatis. Diagnosis is based on historical information and clinical findings. Early diagnosis and treatment effectively reduce the incidence of complications associated with PID. Highly effective treatment regimens are available and main antimicrobials used include quinolones, cephalosporins, metronidazole, doxycycline, and azithromycin. Delay or inadequate treatment is associated with long term sequelae including tubal infertility and chronic pelvic pain. Prevention efforts should be directed towards routine screening and treatment for sexually transmissible infections, public education and provision of resources for treatment and follow-up.