Optimum therapy for acute pelvic inflammatory disease

Study of usage pattern of nonsteroidal anti-inflammatory drugs (NSAIDs) among different practice categories in Indian clinical setting

OBJECTIVE

The aim of the study was to evaluate the usage pattern of nonsteroidal anti-inflammatory drugs (NSAIDs) in diverse clinical practice settings in India.

METHODS

The study was conducted in Mumbai city and its suburbs, involving 1,916 doctors from among general practice to specialist practice. The data were collected with the help of a semi-structured questionnaire and were analysed statistically to bring out differences in NSAID usage among different groups of prescribers.

RESULTS

All the 1,916 doctors prescribed NSAIDs frequently with prescriptions ranging from 1 to 15 daily; they short-listed and prescribed only two to five NSAIDs from among a plethora of drugs available including fixed-dose combinations (FDCs). It is significant that FDCs were prescribed by more than 39% of doctors in all the categories, the highest prescribers being orthopaedic surgeons (76%) and lowest general practitioners (GPs; 39%). Apart from recommended usage, NSAIDs such as ibuprofen, diclofenac and aspirin were used for pelvic inflammatory disease, and indomethacin for pre-term labour and patent ductus arteriosus. Dosage variation, both in terms of dose and frequency of administration, has been observed for several NSAIDs in the GPs category as well as in the specialist categories-except that of paediatricians. In patients suffering from bronchial asthma, there has been significant use of aspirin and ibuprofen by GPs despite contra-indication for their use in such patients. Most prescribers perceived that NSAIDs are associated with mild gastrointestinal (GI) adverse events. Ibuprofen, a drug with reportedly better gastric tolerance, was perceived to cause GI adverse events, though to a lesser extent than aspirin; fewer prescribers perceived that diclofenac and piroxicam cause GI adverse events when compared with aspirin and ibuprofen. There were significant differences among the five practice categories with regard to preferences for NSAIDs. The first choice NSAIDs were ibuprofen, aspirin, diclofenac, paracetamol, piroxicam and ibuprofen+paracetamol FDC.

CONCLUSIONS

This study has shown that there exist significant differences in the usage pattern and preferences of NSAIDs among different practice categories in India. The data have also revealed that there is a need for awareness programmes on rational prescribing of NSAIDs towards optimal therapeutics and improved patient care in India.

Tubo-ovarian abscess presenting as pneumoperitoneum

BACKGROUND

Tubo-ovarian abscess (TOA), a serious complication of pelvic inflammatory disease, often require the antibiotic administration, surgical resection or the transvaginal aspiration. Pneumoperitoneum is often associated with the bowel perforation. We reported one case with TOA and pneumoperitoneum that have been mistaken for a perforated bowel with concomitant adnexal mass.

CASE

A 30-year-old diabetic Chinese woman was transferred for diffused abdominal pain, mild fever, nausea, and low-grade fever for 5 days. The sonography revealed a 5-cm adnexal mass. The chest X-rays revealed the pneumoperitoneum. Under the impression of bowel perforation and concomitant adnexal cyst, the emergent laparotomy was performed and the TOA was resected. No evidence of gastrointestinal perforation was present. Culture studies showed Escherichia coli without other bacteria flora. The postoperative course was uneventful.

CONCLUSION

We concluded that, beside the bowel perforation, TOA should be considered when a diabetic woman presents with pneumoperitoneum and adnexal mass.

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.

Gynaecological infections and strategies for treatment

Frequently, encountered gynaecologic infections and pathogens involved are presented. A review is given of bartholinitis, vulvovaginitis-bacterial vaginosis, candidiasis, trichomoniasis cervicitis and pelvic inflammatory disease: Neisseria gonorrhoeae, Chlamydia trachomatis and herpes simplex virus 2. Of each infection a thorough description of clinical symptoms and diagnostic criteria is followed by up-to-date treatment advices. For vulvovaginitis, cervicitis and pelvic inflammatory disease antifungal and antimicrobial agents, route of administration, the required daily dosage and time of administration are presented in an overview table.