Jorge D. Blanco

A prospective, controlled study of maternal and perinatal outcome after intra-amniotic infection at term

A study was made of the outcome for mothers and their neonates with both clinical and bacteriologic evidence of intra-amniotic infection at term. Samples of amniotic fluid from patients with intra-amniotic infection showed greater than 10(2) colony-forming units per milliliter of a high-virulence isolate, whereas samples from control patients showed no growth or low-virulence isolates only. Control patients were uninfected during labor and were matched on the basis of gestational age, interval from rupture of membranes to delivery, and mode of delivery. There were 67 matched pairs. The mean interval from diagnosis of intra-amniotic infection to delivery was 3.1 +/- 2.2 hours (+/- SD). Mothers with intra-amniotic infection had a significantly longer hospital stay and greater fever index after delivery than did control patients. Intrapartum bacteremia was documented in six of 50 (12%) women with intra-amniotic infection. The cesarean birth rate was 36%. There was one case of probable septic shock and one of postpartum hemorrhage among women with intra-amniotic infection. Infants in the intra-amniotic infection group had a significantly longer hospital stay than did the control infants. Among 59 infants for whom blood culture results were available, bacteremia was documented in five (8%) with intra-amniotic infection. Definite radiographic evidence of pneumonia was present in 4%; there were no cases of meningitis. There was one perinatal death in the intra-amniotic infection group. Overall, the maternal and perinatal outcome after intra-amniotic infection at term was excellent.

Sperm washing and swim-up technique using antibiotics removes microbes from human semen

Pelvic infections may follow intrauterine or intratubal insemination with washed semen. In this study, we determined whether sperm washing removes microorganisms from human semen. Before and after semen wash, we cultured 15 ejaculates for aerobic and anaerobic bacteria, genital mycoplasma, and chlamydia. All semen samples had from one to five organisms isolated (total, 40 isolates) before the semen wash preparation. The mean number (+/- standard deviation) of isolates per sample was 2.67 +/- 1.35. After the semen were prepared, none of the samples showed a positive culture. The decrease in the number of samples with positive cultures and the decrease in the number of isolates is significant (P less than 0.0001). After sperm washing, electronmicroscopic studies did not show any microbes attached to any portion of the spermatozoa. We conclude that the method of sperm wash preparation used is effective in removing microbes present in human semen.

Streptococcal infections in pregnancy

During a 4-year period, 48 obstetric patients with aerobic streptococcal bacteremia were identified. The isolates were group B (31); group D, enterococci (5); group A (4); group D, not enterococci (3); Streptococcus pneumoniae (3); and viridans streptococci (2). The most common diagnoses were endometritis (36) and chorioamnionitis (8). For all streptococcal genital infections, the clinical presentation included early-onset fever, often with few localizing signs. Only one patient had a chronic debilitating disease. There was an excellent correlation between genital and bloodstream isolates (36 of 42). Maternal response to therapy was good, with no deaths nor episodes of septic shock. Possible infectious complications developed in two fetuses and four neonates. The microbiologic and clinical features of aerobic streptococci were reviewed, and the outcome in obstetric patients and that in other adults were compared.

A double-blind, randomized comparison of moxalactam versus clindamycin-gentamicin in treatment of endomyometritis after cesarean section delivery

A double-blind comparison of clindamycin plus gentamicin versus moxalactam plus placebo was performed for the treatment of endomyometritis after cesarean section delivery. Entry criteria were uterine tenderness, temperature greater than or equal to 101 degrees F, and leukocytosis. Uterine specimens were obtained for culture via a single-lumen transcervical catheter. Bacteremia occurred in 10% of patients. Among the 57 patients treated with clindamycin plus gentamicin, there were two clinical failures and four side effect failures (diarrhea in two, allergic reaction in two). Among the 56 patients in the moxalactam group, there were four clinical failures and one side effect failure (diarrhea). Both regimens had good cure rates, with no significant differences in cures or postoperative hospital stay.

Therapy of obstetrical infections with moxalactam.

We evaluated moxalactam in 62 patients with puerperal or postabortal genital infections. In all patients, the initial dose was 6 g/day. In 84% of patients, we found anaerobes in genital specimens. Of aerobic isolates, only enterococci were resistant. Among anaerobes tested, only two isolates (a Clostridium leptum and a Bacteroides disiens) had minimal inhibitory concentrations of greater than or equal to microgram/ml. Good clinical responses occurred in 56 of 62 (90%). Moxalactam was well tolerated with little local irritation and minimal hepatic, renal, or hematological abnormalities.

The association between the absence of amniotic fluid bacterial inhibitory activity and intra-amniotic infection

We studied the relationship of amniotic fluid bacterial inhibition in 50 patients with intra-amniotic infection to that in 50 matched control patients. Amniotic fluid was collected through a transcervical intrauterine catheter. All infected patients had clinical signs of intra-amniotic infection and greater than or equal to 10 2 colony-forming units per milliliter of a high-virulence organism. None of the control patients became infected. The matching characteristics for the intra-amniotic infection group versus the control group were: interval from rupture of the membranes to delivery (14.30 +/- 7.96 versus 15.00 +/- 7.19 hours, NS), interval from rupture of the membranes to collection of amniotic fluid (12.41 +/- 6.37 versus 12.16 +/- 6.46 hours NS), and gestational age (40.3 +/- 1.6 versus 40.0 +/- 1.6 weeks, NS). All patients were in labor. We tested each sample of amniotic fluid for inhibitory activity to Escherichia coli by a plate-count technique. Thirty-five samples (70%) of intra-amniotic infection fluid were noninhibitory, whereas 16 samples (32%) of control fluid were noninhibitory. The conclusion was that amniotic fluid from patients with intra-amniotic infection was significantly less likely to be inhibitory to E. coli (p less than 0.001).

A double-blind, randomized comparison of clindamycin-gentamicin versus cefamandole for treatment of post—cesarean section endomyometritis

Among patients with endomyometritis after cesarean section, a double-blind comparison of clindamycin-gentamicin versus cefamandole-placebo therapy was performed. Study criteria were: exclusion--use of prophylactic antibiotics or allergy to the drugs used; entry--uterine tenderness, oral temperature greater than or equal to 101 degrees F, and leukocytosis. Uterine specimens for culture were obtained via a single-lumen transcervical catheter. Most common isolates were Bacteroides bivius, Escherichia coli, and anaerobic cocci. Bacteremia occurred in 9.0%. Therapy results were: [Chart: see text]. Therapeutic failures were defined as persistent fever despite 3 or more days of treatment. Among the six clindamycin-gentamicin therapeutic failures, one patient had a resistant organism, and one had a pelvic mass. Among the 13 cefamandole-placebo therapeutic failures, three patients had resistant organisms, and one had a pelvic mass. Cause of persistent fever was not evident in the other patients. Side effects that necessitated discontinuation of therapy were: clindamycin-gentamicin group--diarrhea (six), allergic response (one); cefamandole-placebo group--diarrhea (two), allergic response (one). If the common practice of excluding side-effect failures is followed, there were more cures in the clindamycin-gentamicin group (P = 0.06).

Correlation of quantitative amniotic fluid cultures with endometritis after cesarean section

At the time cesarean section, amniotic fluid was collected transabdominally from 60 patients, and quantitative cultures were performed on the amniotic fluid. A culture was defined as positive if greater than or equal to 10(2) colony-forming units per milliliter of a high-virulence organism were isolated. Any other result was defined as negative. In 24 patients with no labor or rupture of the membranes, no positive cultures were found, but there was a 25% incidence of endometritis. Among 36 patients with labor or rupture of the membranes, or both, 13 (36%) had a positive culture. Twelve of the 13 (92%) developed endometritis, whereas nine of the 23 (39%) patients with a negative culture had endometritis (p less than 0.002). The usual clinical risk factors for endometritis were not different between the positive and negative culture groups. However, the patients with positive cultures had a significantly shorter time interval from cesarean section to endometritis than did the patients with negative cultures (p less than 0.02). There was an excellent correlation between a positive amniotic fluid culture and endometritis after cesarean section.

Randomized comparison of ceftazidime versus clindamycin-tobramycin in the treatment of obstetrical and gynecological infections.

A randomized comparison of ceftazidime versus clindamycin-tobramycin was performed for the treatment of obstetrical and gynecological infections. Entry criteria were an oral temperature of greater than or equal to 38 degrees C and a clinical diagnosis of endometritis, salpingitis, or pelvic cellulitis after hysterectomy. All patients with endometritis had cultures of intrauterine material obtained via a transcervical single-lumen catheter. The patients with pelvic cellulitis had material from the vaginal apex aspirated for culture, and all patients with salpingitis had a culdocentesis for culture of intraperitoneal material. Of 38 patients who received ceftazidime, 34 had endometritis after cesarean section, 3 had endometritis after abortion, and 1 had pelvic cellulitis. Of 39 patients who received clindamycin-tobramycin, 35 had endometritis after cesarean section, 3 had salpingitis, and 1 had pelvic cellulitis. The most common bacterial isolates were Lactobacillus sp., Bacteroides bivius, Escherichia coli, other gram-negative aerobic bacilli, group B streptococci, and other aerobic streptococci. Bacteremia occurred in 9.0% of the patients. Of the patients receiving clindamycin-tobramycin and ceftazidime, 34 (87.2%) and 34 (89.5%), respectively, responded to therapy. All the clinical failures occurred in patients with endometritis after cesarean section. Clinical failures had persistent fever despite 3 or more days of treatment. One of the patients receiving clindamycin-tobramycin developed an urticarial rash after her infection had resolved. No patient in either group developed diarrhea. In these small groups of patients, there were no significant differences in cure rate, side effects, or length of hospital stay.

Chlamydia trachomatis isolation in patients with endometritis after cesarean section

Cervical specimens for Chlamydia were collected from 110 patients with endometritis after cesarean section and from 52 intrapartum patients without clinical infection. The C. trachomatis isolation rate was not statistically different between these groups.