Gynecologic disease in women infected with human immunodeficiency virus.
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Acquired Immunodeficiency Syndrome↗
Biomedical subjects
R L Sweet
Publications and source records attributed to R L Sweet.
Evaluation of the polymerase chain reaction test for detecting chlamydial DNA in adult chlamydial conjunctivitis.
PURPOSE: A new polymerase chain reaction (PCR) test (Amplicor, Diagnostics, Branchburg, NJ) was evaluated for its ability to detect chlamydial DNA from previously obtained adult conjunctival specimens. METHODS: The sensitivity of this PCR test was determined on 42 adult conjunctival specimens that were culture-positive for Chlamydia. The specificity was determined by testing 40 true-negative specimens that included 10 normal conjunctival samples and 20 ocular specimens that were culture-positive for herpes simplex virus or adenovirus. The remaining ten samples consisted of ocular bacterial pathogens in chlamydial transport media. RESULTS: Amplicor was 88% (37/42) sensitive and 100% (40/40) specific. CONCLUSIONS: The authors conclude that PCR testing for chlamydial DNA from ocular specimens may be useful, especially when conditions in transport might reduce the yield of positive cultures.
Adenovirus Infections, Human↗
Role of bacterial vaginosis in pelvic inflammatory disease.
Pelvic inflammatory disease (PID) is a frequent infection in sexually active young women and results in adverse sequelae, including tubal-factor infertility and ectopic pregnancy. In the 1970s investigations using culdocentesis demonstrated that anaerobic bacteria played an important role in the etiology of PID. This finding has subsequently been confirmed by studies utilizing laparoscopy and/or endometrial biopsy to obtain specimens directly from the upper genital tract (uterine cavity and fallopian tube) of patients with acute PID. Recently, several investigations have shown an association between bacterial vaginosis and the development of acute PID. The microorganisms associated with bacterial vaginosis include anaerobes such as Prevotella bivia, other Prevotella species, and Peptostreptococcus species. These studies that have demonstrated the presence of bacterial vaginosis-associated bacteria in addition to the sexually transmitted organisms Neisseria gonorrhoeae and Chlamydia trachomatis suggest that treatment of acute PID must be broad spectrum in nature and effective against anaerobic bacteria as well as N. gonorrhoeae and C. trachomatis.
Female↗
Consensus development of quality standards.
Explore the source record for details and available documents.
Consensus Statements as Topic↗
Quality standard for antimicrobial prophylaxis in surgical procedures. The Infectious Diseases Society of America.
OBJECTIVE: The objectives of this quality standard are 1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and 2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice. OPTIONS: We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis. OUTCOMES: The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help. EVIDENCE: Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these--rather than an exhaustive list of original references--are cited. VALUES: We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighed against the cost and potential morbidity associated with excessive use of antimicrobial agents. BENEFITS, HARMS, AND COSTS: More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics. RECOMMENDATIONS: All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended. VALIDATION: More than 50 experts in infectious disease and 10 experts in surgical infectious disease and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists. SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Disease Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Disease Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Contr
Anti-Bacterial Agents↗
Quality standard for the treatment of bacteremia. The Infectious Diseases Society of America.
OBJECTIVE: The objective of this quality standard is to optimize the treatment of bacteremia in hospitalized patients by ensuring that the antibiotic given is appropriate in terms of the blood culture susceptibility of the pathogen. Although this standard may appear to be minimal in scope, it is needed because appropriate antimicrobial treatment is not given in 5% to 17% of cases. To implement the standard, physicians, pharmacists, and microbiologists will need to devise a coordinated strategy. OPTIONS: We considered criteria for appropriate dosing, most cost-effective selection, proper antibiotic levels in serum, least toxicity, narrowest spectrum, specific clinical indications, and optimal duration of treatment. All these criteria were rejected as the basis for the standard because they were too controversial and too difficult to be applied by a nonphysician chart reviewer. In contrast, the selection of an antibiotic to which the pathogen is sensitive is a noncontroversial criterion and easy for a chart reviewer to apply. OUTCOMES: The standard is designed to reduce the incidence of adverse outcomes of septicemia such as renal failure, prolonged hospitalization, and death. EVIDENCE: Several well-designed clinical trials without randomization as well as case-controlled studies have confirmed the benefit of using an antibiotic that is appropriate in light of the susceptibility of the isolate in blood culture. Prospective, randomized, placebo-controlled trials are not available. VALUES: Our premise is that the presence of bacteremia is a risk factor for serious adverse outcomes. We also believe that the administration of antibiotics must always be guided by the susceptibility report for the pathogen(s) obtained from blood cultures. This concern is more critical for pathogens from the blood than for those from most other body sites. We had evidence that susceptibility reports for pathogens from positive blood cultures were not always used properly. We used group discussion to reach a consensus among the members of the Quality Standards Subcommittee. BENEFITS, HARMS, AND COSTS: Through the implementation of this standard, at least 5% of bacteremias could be treated more appropriately. An unknown number of deaths would likely be prevented, and mortality from bacteremia treated inappropriately would probably be reduced. The primary undesirable feature of the standard is an increased workload of pharmacists and microbiologists. RECOMMENDATIONS: Treatment of bacteremia with an antibiotic that is appropriate in terms of the pathogen's blood-culture susceptibility is a minimal standard of care for all patients. VALIDATION: We consulted more than 50 experts in infectious diseases from the fields of medicine, surgery, pediatrics, obstetrics and gynecology, nursing, epidemiology, pharmacology, and government. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists and were tested by one of the members of the Quality Standards Subcommittee. SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Diseases Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. This standard is endorsed by the IDSA.
Anti-Bacterial Agents↗
Quality standard for assurance of measles immunity among health care workers. The Infectious Diseases Society of America.
OBJECTIVE: The objective of this quality standard is to prevent nosocomial transmission of measles by assuring universal measles-mumps-rubella (MMR) vaccination of all health care workers who lack immunity to measles. Although the primary emphasis is on health care workers in hospitals, those at other sites, such as clinics, nursing homes, and schools, are also included. It will be the responsibility of designated individuals at these institutions to implement the standard. OPTIONS: We considered advocating the use of measles vaccine rather than MMR but chose the latter because it also protects against mumps and rubella and because it is more readily available. OUTCOMES: The desired outcome is a reduction in the nosocomial transmission of measles. EVIDENCE: Although direct comparative studies are lacking, nosocomial outbreaks of measles have been reported (as recently as 1992) in institutions where measles immunization of nonimmune health care workers is not universal, whereas such outbreaks have not been reported in institutions with universal immunization. VALUES AND VALIDATION: We consulted more than 50 infectious-disease experts in epidemiology, government, medicine, nursing, obstetrics and gynecology, pediatrics, and surgery. In light of disagreement regarding the implementation of the standard, we used group discussions to reach a consensus. BENEFITS, HARMS, AND COSTS: The consequences of the transmission of measles (and of mumps and rubella) in a health care institution include not only the morbidity and mortality attributable to the disease, but also the significant cost of evaluating and containing an outbreak and the serious disruption of regular hospital routines when control measures are instituted. The potential harm to health care workers after the implementation of the standard consists of untoward effects of MMR vaccine, although the reactions of vaccines should be minimal with adherence to recommended vaccination procedures. Implementation of the standard should entail no expense to health care workers; the precise cost to institutions is unknown, but the expense would be mitigated by prevention of measles outbreaks. RECOMMENDATIONS: We recommend MMR vaccination of all health care workers who lack immunity to measles. SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (Drs. Gross and McGowan), the Society for Hospital Epidemiology of America (Dr. Wenzel), the Surgical Infection Society (Dr. Dellinger), the Pediatric Infectious Diseases Society (Dr. Krause), the Centers for Disease Control and Prevention (Dr. Martone), the Obstetrics and Gynecology Infectious Diseases Society (Dr. Sweet), and the Association of Practitioners of Infection Control (Ms. Barrett). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.
Cross Infection↗
Purpose of quality standards for infectious diseases. Infectious Diseases Society of America.
Explore the source record for details and available documents.
Humans↗
Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America.
OBJECTIVE: The objectives of this quality standard are (1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and (2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice. OPTIONS: We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis. OUTCOMES: The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection in conjunction with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help. EVIDENCE: Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these--rather than an exhaustive list of original references--are cited. VALUES: We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighted against the cost and potential morbidity associated with excessive use of antimicrobial agents. BENEFITS, HARMS, AND COSTS: More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics. RECOMMENDATIONS: All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended. VALIDATION: More than 50 experts in infectious diseases and 10 experts in surgical infectious diseases and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists. SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.
Anti-Bacterial Agents↗
Quality standard for the treatment of bacteremia. Infectious Diseases Society of America.
OBJECTIVE: The objective of this quality standard is to optimize the treatment of bacteremia in hospitalized patients by ensuring that the antibiotic given is appropriate in terms of the blood culture susceptibility of the pathogen. Although this standard may appear to be minimal in scope, it is needed because appropriate antimicrobial treatment is not given in 5%-17% of cases. To implement the standard, physicians, pharmacists, and microbiologists will need to devise a coordinated strategy. OPTIONS: We considered criteria for appropriate dosing, most cost-effective selection, proper antibiotic levels in serum, least toxicity, narrowest spectrum, specific clinical indications, and optimal duration of treatment. All these criteria were rejected as the basis for the standard because they were too controversial and too difficult to be applied by a nonphysician chart reviewer. In contrast, the selection of an antibiotic to which the pathogen is sensitive is a noncontroversial criterion that is easy for a chart reviewer to apply. OUTCOMES: The standard is designed to reduce the incidence of adverse outcomes of septicemia, such as renal failure, prolonged hospitalization, and death. EVIDENCE: Several well-designed clinical trials without randomization as well as case-controlled studies have confirmed the benefit of using an antibiotic that is appropriate in light of the susceptibility of the isolate in blood culture. Prospective, randomized, placebo-controlled trials are not available. VALUES: Our premise is that the presence of bacteremia is a risk factor for serious adverse outcomes. We also believe that the administration of antibiotics must always be guided by the susceptibility report for the pathogen(s) obtained from blood cultures. This concern is more critical for pathogens from the blood than for those from most other body sites. We had evidence that susceptibility reports for pathogens from positive blood cultures were not always used properly. We used group discussion to reach a consensus among the members of the Quality Standards Subcommittee. BENEFITS, HARMS, AND COSTS: Through the implementation of this standard, at least 5% of cases of bacteremia could be treated more appropriately. An unknown number of deaths would likely be prevented, and mortality from bacteremia treated inappropriately would probably be reduced. The primary undesirable feature of the standard is an increased workload for pharmacists and microbiologists. RECOMMENDATIONS: Treatment of bacteremia with an antibiotic that is appropriate in terms of the pathogen's blood-culture susceptibility is a minimal standard of care for all patients. VALIDATION: We consulted more than 50 experts in infectious diseases from the fields of medicine, surgery, pediatrics, obstetrics and gynecology, nursing, epidemiology, pharmacology, and government. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists and were tested by one of the members of the Quality Standards Subcommittee. SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.L.B.). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.
Anti-Bacterial Agents↗
Quality standard for assurance of measles immunity among health care workers. Infectious Diseases Society of America.
OBJECTIVE: The objective of this quality standard is to prevent nosocomial transmission of measles by assuring universal measles-mumps-rubella (MMR) vaccination of all health care workers who lack immunity to measles. Although the primary emphasis is on health care workers in hospitals, those at other sites, such as clinics, nursing homes, and schools, are also included. It will be the responsibility of designated individuals at these institutions to implement the standard. OPTIONS: We considered advocating the use of measles vaccine rather than MMR vaccine but chose the latter because it also protects against mumps and rubella and because it is more readily available. OUTCOMES: The desired outcome is a reduction in the nosocomial transmission of measles. EVIDENCE: Although direct comparative studies are lacking, nosocomial outbreaks of measles have been reported (as recently as 1992) in institutions where measles immunization of nonimmune health care workers is not universal, whereas such outbreaks have not been reported in institutions with universal immunization. VALUES AND VALIDATION: We consulted more than 50 infectious-disease experts from the fields of epidemiology, government, medicine, nursing, obstetrics and gynecology, pediatrics, and surgery. In light of disagreement regarding the implementation of the standard, we used group discussions to reach a consensus. BENEFITS, HARMS, AND COSTS: The consequences of the transmission of measles (and of mumps and rubella) in a health care institution include not only the morbidity and mortality attributable to the disease but also the significant cost of evaluating and containing an outbreak and the serious disruption of regular hospital routines when control measures are instituted. The potential harm to health care workers after the implementation of the standard consists of untoward effects of MMR vaccine, although the reactions of vaccinees should be minimal with adherence to recommended vaccination procedures. Implementation of the standard should entail no expense to health care workers; the precise cost to institutions is unknown, but the expense would be mitigated by the prevention of measles outbreaks. RECOMMENDATIONS: We recommend MMR vaccination of all health care workers who lack immunity to measles. SPONSORS: The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.L.B.). Funding was provided by the IDSA and the other cooperating organizations. The standard is endorsed by the IDSA.
Cross Infection↗
Comparison of three regimens recommended by the Centers for Disease Control and Prevention for the treatment of women hospitalized with acute pelvic inflammatory disease.
This six-center, prospective, open-label clinical trial compared the efficacy and safety of three regimens recommended by the Centers for Disease Control and Prevention (CDC) for the treatment of women hospitalized for acute pelvic inflammatory disease (PID). The study focused on the response to inpatient therapy, not on long-term prevention of sequelae. A severity score was used for objective comparison of the degree of illness before and after therapy. Women were randomly assigned (in a 1:1:1 ratio) to treatment with cefoxitin plus doxycycline, clindamycin plus gentamicin, or cefotetan plus doxycycline. Two hundred seventy-five (94.2%) of 292 evaluable women required no alteration in therapeutic regimen. The three regimens produced almost identical cure rates. No serious adverse clinical or laboratory events were observed. In short, the three regimens recommended by the CDC for inpatient therapy of acute PID were similarly effective and safe.
Acute Disease↗
Comparison of EIA, culture, and polymerase chain reaction for Chlamydia trachomatis in a sexually transmitted disease clinic.
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Chlamydia Infections↗
A survey of practices in infectious diseases by obstetrician-gynecologists.
OBJECTIVE: To survey current practices among obstetricians and gynecologists concerning a wide range of infectious diseases to guide future efforts in continuing medical education. METHODS: A survey questionnaire of multiple-choice questions was mailed to 2500 physicians, under age 65, randomly selected from the American Medical Association specialty list of obstetrician-gynecologists. The first 500 returns constituted the data set and were analyzed by computer. RESULTS: We found many clinical areas in which practice patterns were deemed appropriate, including antibiotic selection, universal screening for hepatitis B, and follow-up of urinary tract infection in pregnancy. In other areas, marked by controversy among "experts," practice patterns varied widely. These areas included management of premature rupture of the membranes and premature labor, and universal screening for group B streptococci. Areas in need of further continuing medical education efforts include management of perinatal viral infections and diagnosis and treatment of sexually transmitted diseases. CONCLUSIONS: Although this survey indicated that practice patterns of American obstetricians and gynecologists are appropriate in many clinical areas relevant to infectious diseases, there are other clinical conditions requiring future efforts in continuing medical education.
Female↗
Risk factors associated with pelvic inflammatory disease of differing microbial etiologies.
OBJECTIVE: To compare the prevalences of demographic, historic, and behavioral risks for pelvic inflammatory disease among women with sexually transmitted disease (STD) pelvic inflammatory disease versus those with non-STD pelvic inflammatory disease. METHODS: Subjects included patients diagnosed with acute pelvic inflammatory disease at San Francisco General Hospital between January 1, 1981 and August 20, 1989, who had been entered into clinical treatment trials. At a minimum, endocervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis were required for study eligibility. All but nine women also had upper reproductive tract cultures for N gonorrhoeae, C trachomatis, and anaerobic and facultative bacteria. Five hundred eighty-nine patients were included in this analysis. The medical records of study subjects enrolled between January 1981 and October 1986 were abstracted (n = 321). Subjects recruited after October 1986 were interviewed during hospitalization using a standardized data base instrument (n = 268). Independent variables examined included age, race, insurance status, education, pregnancy history, menstrual history, contraceptive history, sexual history, douching history, STD history, and pelvic inflammatory disease history. Both univariate associations and multivariate (multiple logistic regression) analysis were performed. RESULTS: An STD organism was present in 65% of pelvic inflammatory disease cases. Neisseria gonorrhoeae and C trachomatis were recovered from 324 (55%) and 129 (22%) of the patients, respectively. In 30% of cases only anaerobic and/or facultative bacteria were isolated. In univariate analysis of STD versus non-STD pelvic inflammatory disease, statistically significant increases in STD risks were found for the following: black race (relative risk [RR] 1.76; 95% confidence interval [CI] 1.39-2.24), two or more sexual partners in the past 30 days (RR 1.25; 95% CI 1.08-1.45), no contraception (RR 1.36; 95% CI 1.18-2.57), N gonorrhoeae with previous episode of pelvic inflammatory disease (RR 1.97, 95% CI 1.39-2.80), and reported duration of pain 3 days or less (RR 1.17; 95% CI 1.02-1.35). Risks associated with non-STD pelvic inflammatory disease included: current intrauterine device (IUD) use (RR 0.25; 95% CI 0.11-0.61), history of IUD use (RR 0.82; 95% CI 0.68-0.98), and pelvic surgery in the past 30 days (RR 0.48; 95% CI 0.30-0.76). Multivariate analysis of the risks found that black race was associated with STD pelvic inflammatory disease (odds ratio 2.56; 95% CI 1.68-3.90), and current IUD use was associated with non-STD pelvic inflammatory disease (odds ratio 3.87; 95% CI 1.30-11.53). Neither univariate nor multivariate analysis identified douching as a risk differentiating STD from non-STD pelvic inflammatory disease. CONCLUSIONS: Pelvic inflammatory disease is a complex polymicrobial disease. This study demonstrates that risk factors associated with pelvic inflammatory disease cases can be differentiated by microbial etiology. We found that black race was associated with STD pelvic inflammatory disease and recent IUD use was associated with non-STD pelvic inflammatory disease.
Acute Disease↗
Randomized comparison of ampicillin-sulbactam to cefoxitin and doxycycline or clindamycin and gentamicin in the treatment of pelvic inflammatory disease or endometritis.
OBJECTIVE: To evaluate the efficacy and safety of ampicillin-sulbactam (3 g every 6 hours) in patients with pelvic inflammatory disease or postpartum endometritis using a randomized, comparative, multicenter study of parallel design. METHODS: Eligible patients with pelvic inflammatory disease were randomized to receive either ampicillin-sulbactam or cefoxitin (2 g every 6 hours) plus doxycycline (100 mg every 12 hours). Those with endometritis were randomized to ampicillin-sulbactam or clindamycin (900 mg every 8 hours) plus gentamicin (1.5 mg/kg every 8 hours). In the ampicillin-sulbactam group, chlamydia-positive patients also received oral doxycycline. RESULTS: For pelvic inflammatory disease, the clinical response rates (cure or improvement) were 85.5% (47 of 55) and 89.6% (43 of 48) in the ampicillin-sulbactam and cefoxitin and doxycycline groups, respectively (chi 2 = 0.10, P = .76). For endometritis, the clinical response rates were 88.7% (141 of 159) and 90.8% (139 of 153) in the ampicillin-sulbactam and clindamycin and gentamicin groups, respectively (chi 2 = 0.15, P = .70). The percentages of patients with pelvic inflammatory disease who had adverse experiences were not significantly different in the cefoxitin and doxycycline group (47% [29 of 62]) than in those receiving ampicillin-sulbactam (33% [22 of 66]) (P = .12). These adverse effects were mostly mild or moderate. In the endometritis subjects, the incidence of adverse experiences in the ampicillin-sulbactam group (11% [20 of 179]) was comparable to that during treatment with clindamycin and gentamicin (12% [22 of 180]). These adverse experiences were also mostly mild to moderate. CONCLUSION: Ampicillin-sulbactam is as effective and well tolerated as combination regimens using cefoxitin plus doxycycline and clindamycin plus-gentamicin for the treatment of pelvic inflammatory disease or endometritis, respectively.
Adult↗
Torulopsis glabrata pelvic abscess and fungemia.
BACKGROUND: Serious infections caused by Torulopsis glabrata, once rarely encountered, have become common over the last 3 decades. The most frequent manifestations of serious fungal infections include septicemia, endocarditis, hepatosplenic infections, and meningitis. We report a case of fungemia and pelvic abscess caused by T glabrata following gynecologic surgery. CASE: A 43-year-old woman developed fever, abdominal pain, and abdominal distention following a total abdominal hysterectomy and right salpingo-oophorectomy. Empirical treatment with broad-spectrum antimicrobial agents was not successful. Three sets of blood cultures were positive for T glabrata, and radiologic investigations revealed pelvic and lesser sac fluid collections. Cultures of the pelvic abscess grew T glabrata. Treatment was changed to amphotericin B, with complete clinical recovery. CONCLUSION: Serious T glabrata infections are rare following gynecologic surgery, especially in immunocompetent patients. Given the morbidity and mortality associated with these infections, aggressive treatment with amphotericin B and drainage of abscesses is warranted.
Abscess↗
Piperacillin and tazobactam versus clindamycin and gentamicin in the treatment of hospitalized women with pelvic infection. The Piperacillin/tazobactam Study Group.
OBJECTIVE: To compare the efficacy and safety of a combination of piperacillin and tazobactam with that of clindamycin and gentamicin in the treatment of hospitalized women with infections of the upper genital tract. METHODS: This was a randomized open-label trial in hospitalized women with infections of the upper genital tract. Patients were recruited at 12 hospitals in the United States and two hospitals in Canada and were randomly assigned to one of two regimens in a 2:1 ratio. One group received piperacillin, 3 g every 6 hours, and tazobactam, 375 mg every 6 hours; the other group received clindamycin, 900 mg every 8 hours, and gentamicin, 2.5-5.0 mg/kg/day in three divided doses. Therapy with the assigned regimen was to be administered for a minimum of 3 days. Cultures for aerobic and anaerobic bacteria were obtained from the site of infection before initiation of therapy. Cultures for Chlamydia trachomatis were also obtained from patients with endometritis or pelvic inflammatory disease. Subjects were evaluated for clinical and bacteriologic response at 24-72 hours and 2-4 weeks after completing therapy. RESULTS: Two hundred ninety-nine patients were enrolled; 196 were in the piperacillin-tazobactam group and 103 were in the clindamycin-gentamicin group. The most common diagnoses were endometritis (146) and pelvic inflammatory disease (115). The most common microorganisms recovered included: Peptostreptococcus sp (99), Prevotella sp (87), black pigmented Bacteroides (29), B fragilis (11), enterococci (64), group B streptococcus (26), Escherichia coli (31), Neisseria gonorrhoeae (49), and C trachomatis (19). A favorable clinical response occurred in 84.7% (166 of 196) of piperacillin-tazobactam patients and 87.3% (90 of 103) of clindamycin-gentamicin patients. Among those evaluable for bacteriologic response, 78% (67 of 86) and 82% (23 of 28), respectively, had a favorable response. Diarrhea occurred significantly more frequently in the piperacillin-tazobactam group (9.7 versus 2.9%; P = .04), but the majority of episodes were mild to moderate. None of the adverse experiences in either treatment group were considered life-threatening and drug-related. CONCLUSION: The combination of piperacillin and tazobactam is an effective and well-tolerated antibiotic regimen for the treatment of infections of the upper genital tract in women.
Bacterial Infections↗