Biomedical subjects
Publications and source records attributed to S Faro.
The development of postoperative infections is influenced by both host and external factors. The present report focuses on the influence of prophylactic agents on the apparent cause of infection after cesarean section and vaginal hysterectomy. The correlation between in vitro susceptibility patterns of potential pathogens and normal flora and in vivo response is also considered.
In a multicenter trial involving 11 centers, 160 women were enrolled to evaluate the safety and effectiveness of 1 or 2 gm of cefotetan administered every 12 hours in the treatment of obstetric and gynecologic infections. The 133 evaluable patients generally were under 25 years of age, were nonwhite, and had hospital-acquired endometritis or pelvic inflammatory disease caused by both aerobic and anaerobic bacteria. Escherichia coli, Neisseria gonorrhoeae, group D streptococci, Bacteroides sp., and Peptococcus sp. were among the most frequently isolated pathogens. The patients were treated for a mean of 5.6 +/- 1.6 days and received a total dose of 19.27 gm. The signs and symptoms of infection were cleared or improved in 93% of the 133 patients evaluable for clinical response. Of the 116 evaluated bacteriologically, 95% had a satisfactory or presumed satisfactory response; only six patients (5%) were considered to be bacteriologic failures. Differences in the results of several clinical laboratory tests performed before and after treatment were statistically, but not clinically, significant (p less than 0.05). Safety was evaluated in the 158 patients who received cefotetan, and only four (3%) had adverse reactions considered related to the drug. Cefotetan was clearly effective and produced no untoward reactions in these women with obstetric and gynecologic infections caused by both aerobic and anaerobic organisms when administered at 1 or 2 gm every 12 hours.
A multiinstitutional review of 10 pregnancies complicated by septic shock was undertaken to identify the clinical characteristics and hemodynamic alterations associated with this condition. Prolonged rupture of membranes with the subsequent development of chorioamnionitis or postpartum endometritis were risk factors that commonly preceded the diagnosis of septic shock. The majority of septic shock cases occurred during the puerperium. There were two maternal deaths in this selected series. Associated complications included pulmonary edema, adult respiratory distress syndrome, disseminated intravascular coagulation, pulmonary emboli, and cardiac arrest. The primary hemodynamic derangements were reduced systemic vascular resistance with depressed myocardial function. The mean initial systemic vascular resistance index in eight surviving women was 885 +/- 253 dyne.sec/cm5.m2. Despite an overall presenting cardiac index of 4.20 +/- 2.01 L/min/m2, five patients (50%) had evidence of myocardial depression based on analysis of their left ventricular function curves. Mean arterial pressure, systemic vascular resistance, and left ventricular stroke work index all showed significant improvement after therapy. A hemodynamic algorithm based on volume therapy, inotropic agents, and peripheral vasoconstrictors is offered. This therapeutic approach is designed to optimize cardiac performance and maintenance of organ perfusion in the critically ill patient with septic hypotension during pregnancy.
A new direct fluorescent antibody reagent, Monofluor, was evaluated for detecting Chlamydia trachomatis in fresh specimens. Monofluor was compared with Micro Trak and with cultivation in McCoy cells. Both direct systems were slightly less sensitive than culture, but no significant differences in specificity or sensitivity were noted between culture, Monofluor, or Micro Trak results.
Patients delivered by cesarean section are at risk for postoperative infectious morbidity, especially those patients who have labored with ruptured membranes for a long period of time. The bacteria involved in these infections are predominantly those of the patient's lower genital tract, both aerobes and anaerobes. Antibiotic prophylaxis has reduced the risk of postpartum infection but has also resulted in selection of resistant bacteria. Treatment of postpartum endometritis has classically been with clindamycin plus an aminoglycoside. However, the newer beta-lactam antibiotics have proved to be just as efficacious. A significant advance in the treatment of postpartum endometritis is the use of beta-lactamase inhibitors combined with beta-lactams, such as clavulanic acid plus ticarcillin or ampicillin plus sulbactam. Regardless of which antibiotic is chosen for treatment, it is important to know the weakness of each antibiotic. For example, cephalosporins such as cefoxitin or cefotetan do not have activity against Strep. faecalis, Ent. cloacae, or Pseudomonas aerugenosa; mezlocillin, ticarcillin, or piperacillin tend to be weakest against the gram-negative facultative anaerobes; and combinations such as clindamycin plus gentamicin do not provide coverage against Strep. faecalis. This knowledge of the weakness of the different antibiotics permits appropriate additions to the antibiotic regimen and avoids irrational changes in antibiotic therapy.
The need for antimicrobial prophylaxis in patients undergoing vaginal hysterectomy is well recognized, and the benefits of prophylaxis in cesarean section are relatively clear-cut. In contrast, only those patients at risk of serious complications from postoperative infection are considered candidates for prophylaxis after abdominal hysterectomy. This paper addresses the following questions: Does the patient need prophylaxis? If so, how should the most suitable antibiotic be selected?
One hundred patients undergoing vaginal hysterectomy were enrolled in a randomized double-blind comparative antibiotic prophylaxis study. Forty-six patients received mezlocillin and 54 patients received cefoxitin. No significant difference was found among patients who developed febrile morbidity. Failure rate for mezlocillin was 17 per cent and for cefoxitin, 15 per cent. There was an increase in colonization of Streptococcus faecalis and Enterobacter species in patients receiving three doses of cefoxitin prophylaxis.
Postoperative soft-tissue pelvic infections in women most commonly are polymicrobial and mixed aerobic and anaerobic. Antibiotic prophylaxis has been advocated to reduce the risk of postcesarean endometritis and post-vaginal hysterectomy pelvic infection. The use of antibiotic prophylaxis has a tendency to select for resistant bacteria, and many of those bacteria produce beta-lactamase. A new approach to the treatment of those infections is to employ beta-lactamase inhibitors in conjunction with a broad-spectrum antibiotic, such as ticarcillin disodium plus clavulanate potassium (Timentin).
Ticarcillin disodium/clavulanate potassium was compared to clindamycin/gentamicin in the treatment of post-cesarean-section endometritis in 133 evaluable patients. All patients received three 1-g doses of cefazolin for prophylaxis. There was no statistically significant difference in the cure rates between the ticarcillin disodium/clavulanate potassium group (84%) and the clindamycin/gentamicin group (81%). Bacteremia occurred in 21% of the patients, with Mycoplasma the most frequent isolate. Ticarcillin disodium/clavulanate potassium was found to be as efficacious as clindamycin/gentamicin in the treatment of postpartum endometritis.
The moderate impairment of cell-mediated immunity that occurs in pregnancy justifies concern when a pregnant woman develops influenza. We treated a woman for influenza pneumonia with respiratory failure at 33 weeks' gestation with oral amantadine and ribavirin inhalation therapy in conjunction with evacuation of the uterus and delivery.
Mycoplasma hominis was isolated in pure culture from a wound infection following delivery by cesarean section. The importance of recognizing this organism as a potential pathogen of the female genital tract is emphasized. Two commercially available isolation systems that allow the recovery of this organism are also described.
Two patients with chorioamnionitis due to Gardnerella vaginalis are described. Institution of tocolytic therapy for preterm labor is associated with maternal complications of septic hypotension and pulmonary edema in one patient. Diagnostic modalities, specifically culturing techniques, are discussed, as well as suspected pathophysiologic mechanisms.
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Sixty women with the diagnosis of puerperal endometritis were randomized to receive either moxalactam (n = 29) or the combination of clindamycin and tobramycin (n = 31) as therapy for their infection. Endometrial bacteriology consisted of mixed flora, both aerobic and anaerobic gram-positive and gram-negative organisms. Clinical cure was achieved in 27 (93%) of the moxalactam-treated patients and 28 (90%) of those given combination therapy. The two failures of moxalactam therapy were associated with enterococcal infection. Failures of clindamycin/tobramycin therapy were due to enterococcal infection, abscess formation, and moderately severe diarrhea. This study indicates that moxalactam is as effective and safe as the combination of clindamycin/tobramycin for the treatment of postpartum endometritis.
The postpartum patient experiences numerous physiologic alterations, which may affect the pharmacokinetics of certain drugs. Six patients received either piperacillin or mezlocillin intravenously immediately after delivery. Serum half-life and clearance were, respectively, 82.4 min and 202 +/- 105 ml/min for mezlocillin and 32.9 min and 456 +/- 88 ml/min for piperacillin. The data revealed that mezlocillin and piperacillin have significantly different pharmacokinetic reactions in the postpartum patient at the doses used.
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Vaginitis is a complex syndrome that is probably the most common outpatient disease seen by the gynaecologist. The specific aetiologies of vaginitis are many. One of the most common entities, however, is "non-specific vaginitis" which can be subdivided into: Gardnerella vaginitis, anaerobic vaginosis, and vaginitis of undetermined aetiology. The role of Gardnerella as a causative agent for vaginitis has been studied in depth but its specific role remains controversial. Anaerobic vaginosis can be diagnosed by noting on microscopic examination the presence of clue cells, free-floating bacteria and numerous white blood cells (WBC's). Culturing an aliquot of the vaginal discharge reveals a high number of anaerobes. In addition, this condition responds to antibiotics effective against anaerobes, e.g., metronidazole. Vaginitis of undetermined aetiology is more complex and is characterized by a purulent vaginal discharge, a pH of 4.0-4.6, numerous WBC's, and a high concentration of bacteria. The microbiology of this vaginitis includes many facultative Gram-negative rods and Gram-positive cocci. Anaerobes may be present but do not make up a large component of the endogenous microflora. This condition does not respond to the usual antibiotic therapies employed in treating bacterial vaginitis. Since this condition appears to be primarily an inflammatory reaction, it may be responsive to topical antiinflammatory agents such as benzydamine.
We present a case of pyelonephritis associated with respiratory distress and elevated liver enzymes in a pregnant patient.