William M. McCormack

Risk factors for prematurity and premature rupture of membranes a prospective study of the vaginal flora in pregnancy

Prematurity remains a major cause of perinatal mortality in the United States. Some research has indicated that infectious agents play a role in either initiating preterm labor, causing premature rupture of the membranes, or preventing tocolysis. This study attempted to determine if the presence of various vaginal pathogens in early pregnancy was associated with the subsequent development of premature rupture of membranes or preterm labor. We found that among 233 evaluable patients those with Trichomonas vaginalis were significantly more likely to have premature rupture of the membranes (p less than 0.03), and those with Bacteroides sp. were more likely to be delivered of their infants before 37 weeks (p less than 0.03) and to have infants weighing less than 2500 gm (p less than 0.05). Those with Ureaplasma urealyticum more frequently began preterm labor (p less than 0.05). Preterm premature rupture of the membranes was found significantly more often among patients with Bacteroides sp. Stepwise multiple logistic regression analysis indicated that those associations were not related to the number of previous abortions, deliveries, or preterm deliveries or to maternal age. We conclude that microbiologic screening in early pregnancy may aid in the assessment of patient risk for preterm delivery.

The Genital Mycoplasmas

IT has been seven years since human infections with genital mycoplasmas were reviewed in these pages.1 Interest in these organisms has increased considerably with a corresponding increase in our kn...

Effect of treatment regimens for Neisseria gonorrhoeae on simultaneous infection with Chlamydia trachomatis

We evaluated the effect of treatment of gonorrhea on simultaneous Chlamydia trachomatis infection by randomly assigning 293 heterosexual men and 246 heterosexual women with gonorrhea to receive one of the following treatment regimens: (1) 4.8 million units of aqueous procaine penicillin plus 1 g of probenecid, (2) nine tablets of trimethoprim-sulfamethoxazole daily for three days, or (3) 500 mg of tetracycline four times a day for five days. Among the men, gonococcal infection was cured in 99 per cent given penicillin plus probenecid, 96 per cent given trimethoprim-sulfamethoxazole, and 98 per cent given tetracycline. Among the women, only 90 per cent given tetracycline were cured, in contrast to 97 per cent given penicillin plus probenecid and 99 per cent given trimethoprim-sulfamethoxazole. Chlamydial infection, present in 15 per cent of the men and 26 per cent of the women, was cured in 30 of 32 patients given trimethoprim-sulfamethoxazole and 27 of 29 given tetracycline, but in only 10 of 23 given penicillin plus probenecid. Among chlamydia-positive patients, postgonococcal urethritis in men and cervicitis in women occurred more often in patients given penicillin plus probenecid. Salpingitis developed in 6 of 20 women given penicillin plus probenecid, but in only 1 of 26 given trimethoprim-sulfamethoxazole and in none of 24 given tetracycline. We conclude that the use of penicillin plus probenecid alone for gonorrhea in heterosexual patients carries an unacceptably high risk of postgonococcal chlamydial morbidity. Trimethoprim-sulfamethoxazole and tetracycline were highly effective against both pathogens and were well tolerated in men, but both drugs caused frequent side effects in women. The failure of tetracycline to cure gonorrhea in 10 per cent of women argues against its use alone; treatment with penicillin followed by tetracycline has been recommended for further trial.

Vaginal Swabs Are Appropriate Specimens for Diagnosis of Genital Tract Infection with Chlamydia trachomatis

ABSTRACT Because self-collected vaginal swabs (VS) are potentially very useful for screening asymptomatic women for Chlamydia trachomatis infection, a multicenter study evaluated that specimen with nucleic acid amplification tests (NAATs). The objective was to determine whether VS are equal to Food and Drug Administration (FDA)-cleared specimens (cervical swabs and first-catch urines [FCU]) for diagnosing genital chlamydial infection. All NAATs then commercially available (October 1996 to October 1999) were used (ligase chain reaction [LCx Probe System; Abbott Laboratories, Abbott Park, Ill.]; PCR [Amplicor; Roche Molecular Systems, Branchburg, N.J.]; and transcription-mediated amplification, [Amplified CT Assay; Gen-Probe Inc., San Diego, Calif.]). NAATs were performed on FCU, urethral, cervical, self- and clinician-collected VS. Sensitivity was compared to isolation using cervical and urethral swabs. Agreement of NAAT results between VS and cervical swabs or FCU was calculated. Specimens from 2,517 15- to 25-year-old asymptomatic women attending clinics at nine different centers were evaluated. Results with self- and clinician-collected VS were equivalent and were at least as good as results with FCU and cervical swabs. Across all sites, summary specificities for all specimens were >99%. Among culture-positive women, NAAT sensitivity with VS (93%) was as high as or higher than NAAT sensitivity with cervical swabs (91%) or FCU (80.6%) or culture of cervical swabs (83.5%). VS are appropriate specimens for diagnosing chlamydial genital tract infection by NAATs. That patients can efficiently collect them offers important benefits for screening programs. It would be beneficial for public health programs if the NAAT manufacturers sought FDA clearance for this specimen.

Sexual Behavior of College Women in 1975, 1986, and 1989

To compare sexual practices in college women before and after the start of the current epidemics of Chlamydia trachomatis, genital herpesvirus, and human immunodeficiency virus type 1 infection, we surveyed 486 college women who consulted gynecologists at a student health service in 1975, 161 in 1986, and 132 in 1989 at the same university. There were no statistically significant differences in age, age at menarche, or reason for visiting the gynecologist. The percentages of women in this population who were sexually experienced were the same in all three years (88 percent in 1975, 87 percent in 1986, and 87 percent in 1989). Oral contraceptives were used by 55 percent of the women in 1975, 34 percent in 1986, and 42 percent in 1989; the use of condoms as the usual method of birth control increased (6 percent in 1975, 14 percent in 1986, and 25 percent in 1989; P less than 0.001). In 1975, only 12 percent reported the regular use of condoms during sexual intercourse, in some cases in conjunction with other methods of contraception, as compared with 21 percent in 1986 and 41 percent in 1989 (P = 0.0014). No significant differences were found in the three surveys in the number of male sexual partners or the frequency of fellatio, cunnilingus, or anal intercourse. An additional sample of 189 college women who did not consult the health service was surveyed in 1989, and similar sexual behavior was reported by those who were sexually experienced (65 percent). We conclude that in this population there has been little change in sexual practices in response to new and serious epidemics of sexually transmitted diseases, with the exception of an increase in the use of condoms (which still does not reach 50 percent).

Quantitative determination of antibody to capsular polysaccharide in infection with type III strains of group B Streptococcus.

The development of antibody in response to invasive infection with type III strains of group B Streptococcus was studied in sera from 31 infants and 4 adults by means of a quantitative radioactive antigen-binding assay. Low concentrations of antibody were consistently found in the acute sera of patients who developed clinical illness. Although adults with puerperal sepsis and infants with bone or joint infection uniformly demonstrated significant rises in serum antibody concentration after recovery, much lower levels of antibody were detected in convalescent sera from infants recovering from meningitis or sepsis. The median antibody concentration in sera from 43 parturients with type III strains of group B Streptococcus isolated from vaginal cultures whose neonates failed to develop symptomatic disease was significantly greater than that in sera from 29 mothers of infants with invasive, type III, group B streptococcal infection. Study of paired maternal and cord sera demonstrated a significant correlation between the antibody concentration in a mothers serum and that in her neonate.

Chorioamnionitis and Colonization of the Newborn Infant with Genital Mycoplasmas

To study the role of Mycoplasma hominis and T-mycoplasmas (Ureaplasma urealyticum) in chorioamnionitis, we obtained culture from 249 puerperal women and their babies. The placentas were examined histologically. Infants whose placentas showed inflammation (chorioamnionitis) had cultures positive for T-mycoplasmas more frequently (37.5 per cent) than those with normal placentas (19.0 per cent) (P = 0.021). Colonization with M. hominis was found in 16.0 per cent of the babies and was not significantly associated with chorioamnionitis. Material colonization with mycoplasmas was more frequent (73.4 per cent) and was not correlated with placental inflammation. We conclude that a substantial proportion of cases of chorioamnionitis may be caused by prenatal infection with T-mycoplasmas. The fact that these organisms are not highly virulent could explain the frequent finding of inflammed placentas from otherwise normal pregnacies. No adverse clinical effects of the placental lesions or of mycoplasmal colonization could be detected in this small study.

Sexual experience and urethral colonization with genital mycoplasmas. A study in normal men.

Cultures for genital mycoplasmas and anonymous questionnaires on sexual experience were obtained from 191 normal male college students. Men who had not had sexual intercourse were virtually free of mycoplasmas whereas more than 26% of those who had had intercourse with 2 partners and 56.3% of those who had had intercourse with more than 14 partners were colonized with T-strain mycoplasmas. Mycoplasma hominis was less prevalent but followed the same general pattern. These data indicate that colonization with T-mycoplasmas is related to sexual experience and T-mycoplasmas are part of the urethral flora of many normal sexually active men. Moreover the rates of colonization among the more sexually active normal men are similar to those that have been reported for patients with nongonococcal urethritis. This raises some questions about the proposed causative role for T-mycoplasmas in this disorder. (authors)

Acute pelvic inflammatory disease: characteristics of patients with gonococcal and nongonococcal infection and evaluation of their response to treatment with aqueous procaine penicillin G and spectinomycin hydrochloride.

We studied 41 women with acute gonococcal pelvic inflammatory disease and 42 women with acute nongonococcal pelvic inflammatory disease. Women with gonococcal pelvic inflammatory disease were more likely to have become ill during the first 10 days of their menstrual cycle (P < 0.05), presented themselves for treatment sooner (P < 0.05), and were more severely ill than patients with nongonococcal pelvic inflammatory disease (P < 0.05). Patients were treated with aqueous procaine penicillin G or with spectinomycin hydro-chloride for five days. Most of the patients with gonococcal disease responded to treatment. Neither drug, in the dosage employed in this study, was highly effective in the treatment of acute nongonococcal pelvic inflammatory disease. In all, 10 of 21 women with nongonococcal pelvic inflammatory disease and only one of 19 women with gonococcal pelvic inflammatory disease required retreatment for pelvic inflammatory disease within 28 days (P < 0.05). Reexamination an average of 17 months following treatment showed that women who had been treated for nongonococcal pelvic inflammatory disease were more likely to develop recurrent pelvic inflammatory disease if the episode of pelvic inflammatory disease treated in the study was not their first. Women treated for nongonococcal pelvic inflammatory disease were also less likely to become pregnant (P < 0.05). These data, which show that gonococcal and nongonococcal pelvic inflammatory disease differ in initial clinical severity, response to treatment, and long-term complications, support the concept that gonococcal pelvic inflammatory disease and nongonococcal pelvic inflammatory disease are separate clinical entities.

A Comparison of Single-Dose Cefixime with Ceftriaxone as Treatment for Uncomplicated Gonorrhea

BACKGROUND Because of the widespread existence of Neisseria gonorrhoeae resistant to penicillin or tetracycline, ceftriaxone is now recommended for the treatment of gonorrhea. There is, however, a need for effective antibiotics that can be administered orally as an alternative to ceftriaxone, which requires intramuscular administration. Cefixime is an orally absorbed cephalosporin that is active against resistant gonococci and has pharmacokinetic activity suitable for single-dose administration. METHODS AND RESULTS In a randomized, unblinded multicenter study of 209 men and 124 women with uncomplicated gonorrhea, we compared three single-dose treatment regimens: 400 mg or 800 mg of cefixime, administered orally, and 250 mg of ceftriaxone administered intramuscularly. The overall cure rates were 96 percent for the 400-mg dose of cefixime (89 of 93 patients) (95 percent confidence interval, 93.5 percent to 97.8 percent); 98 percent for the 800-mg dose of cefixime (86 of 88 patients) (95 percent confidence interval, 94.6 percent to 100 percent); and 98 percent for ceftriaxone (92 of 94 patients) (95 percent confidence interval, 94.9 to 100 percent). The cure rates were similar in men and women, and pharyngeal infection was eradicated in 20 of 22 patients (91 percent). Thirty-nine percent of 303 pretreatment gonococcal isolates had one or more types of antimicrobial resistance; the efficacy of all three regimens was independent of the resistance pattern. Chlamydia trachomatis infection persisted in at least half the patients infected in each treatment group. All three regimens were well tolerated. CONCLUSIONS In the treatment of uncomplicated gonorrhea, a single dose of cefixime (400 or 800 mg) given orally appears to be as effective as the currently recommended regimen of ceftriaxone (250 mg given intramuscularly).