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Biomedical subjects

D A Eschenbach

Publications and source records attributed to D A Eschenbach.

At least 55 records · Page 3Linked to original sources
PubMed1995

The inflammatory Papanicolaou smear: what does it mean?

OBJECTIVE: To determine the correlation between inflammation detected on Papanicolaou smear and specific lower genital tract agents, and, based on these findings, to develop recommendations for follow-up tests and treatment of young women with inflammation on smears. METHODS: A high-risk population of 779 randomly selected women attending a sexually transmitted disease (STD) clinic and a low-risk population of 1050 consecutive women presenting for annual examination at a university student health center underwent a standardized history and gynecologic examination. Univariate and multivariate analyses, focusing on the association between dense inflammation on Papanicolaou smear and specific lower genital tract pathogens or findings on cervical examination, were done for each population. RESULTS: Dense inflammation was present on the Papanicolaou smear of 256 (33%) of the 779 women in the STD clinic and 200 (19%) of 1050 students. Dense inflammation on Papanicolaou smear was independently associated with mucopus, cervical ectopy, cervical infection with Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus (HSV), and vaginal infection by Trichomonas vaginalis in the STD population; in the student population, it was associated with cervical ectopy, C trachomatis, and mucopus. CONCLUSION: Although dense inflammation on Papanicolaou smear was a common finding in both the high- and low-risk populations, about half of the inflammation detected in the high-risk setting was associated with a specific microbial organism (C trachomatis, N gonorrhoeae, HSV, or T vaginalis), whereas less than 10% of the dense inflammation detected in the low-risk setting was linked with a specific pathogen (C trachomatis). In both settings, a substantial population of sexually active women had dense inflammation associated with cervical ectopy but none of the specific organisms evaluated in this study.

Adult↗
PubMed1995

The genital flora of women with intraamniotic infection. Vaginal Infection and Prematurity Study Group.

The relationship of genital flora assessed at the end of the second trimester of pregnancy and intraamniotic infection diagnosed by clinical signs and symptoms during labor was evaluated. Women were enrolled at 23-26 weeks of gestation and followed through delivery in the multi-center Vaginal Infections and Prematurity Study (1984-1989). Among the cohort of 11,989 followed through delivery, 286 (2.4%) developed intraamniotic infection. The recovery of Gardnerella vaginalis (relative risk [RR] = 1.8; 95% confidence interval [CI] = 1.4-2.4), heavy growth of Bacteroides species (RR = 1.5; 95% CI = 1.1-2.1), and isolation of Mycoplasma hominis (RR = 1.7; 95% CI = 1.3-2.1) from the vagina at the end of the second trimester of pregnancy were associated with an increased risk of intraamniotic infection. Bacterial vaginosis was also associated with intraamniotic infection (RR = 1.5; 95% CI = 1.1-2.2). These findings extend prior studies by showing that prenatal cultures for microorganisms associated with bacterial vaginosis predicted an increased risk of intraamniotic infection.

Adolescent↗
PubMed1994

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↗
PubMed1994

Clinical manifestations of genital infection due to Chlamydia trachomatis in women: differences related to serovar.

The relationship between the infecting Chlamydia trachomatis serovar and the clinical manifestations of genital tract infection was evaluated in a study of 155 women attending a sexually transmitted diseases clinic; 99 women had lower genital tract infection and 56 had Chlamydia-associated pelvic inflammatory disease (PID). In the group with lower genital tract infection, women with serovar F differed from those with serovars of class B or C in that they exhibited fewer signs of cervical infection, including easily induced bleeding (P = .04), edema of the zone of cervical ectopy (P = .06), and colposcopic evidence of mucopurulent endocervical discharge (P = .007). Serovar F also produced fewer infections with inclusion counts of > or = 1,000 and fewer rectal infections (P = .04). There was no apparent association of any specific serovar with PID. Thus, in this population, serovar F was associated with fewer objective clinical manifestations of mucopurulent endocervical discharge, and the distribution of chlamydial serovars found in PID reflected that found in lower genital tract infection.

Adult↗
PubMed1994

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↗
PubMed1994

Genital flora in pregnancy and its association with intrauterine growth retardation.

A study of risk factors for intrauterine growth retardation (IUGR) was conducted among a cohort of 13,914 pregnant women enrolled in the multicenter Vaginal Infections and Prematurity Study. From 23 through 26 weeks of gestational age, cultures of specimens from the vagina and cervix were done for group B streptococci, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Candida albicans, Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, and anaerobic gram-negative rods belonging to the genera Bacteroides, Porphyromonas, and Prevotella. Newborns who were small for their gestational age were delivered by 1,251 women, and infants of the appropriate weight for their gestational age were delivered by 10,332 women. When controlling for ethnicity and smoking and excluding women treated with antibiotics, the Mantel-Haenszel adjusted relative risk of IUGR was 1.16 for Bacteroides, Prevotella, and Porphyromonas spp. (95% confidence interval [95% CI], 1.01 to 1.33), 1.16 for M. hominis (95% CI, 1.04 to 1.29), 1.20 for U. urealyticum (95% CI, 1.05 to 1.38), and 1.22 for T. vaginalis (95% CI, 1.05 to 1.42). There was also a strong and significant trend for an increasing risk of IUGR with the number of these four microbes recovered. Among women colonized with all four isolates, the adjusted odds ratio of IUGR was 1.79 (95% CI, 1.27 to 2.52) in comparison with women not colonized with any of these microorganisms. Group B streptococci, N. gonorrhoeae, C. trachomatis, and C. albicans were not significantly associated with IUGR. These results suggest that infection is associated with some cases of IUGR and that specific microorganisms, alone or in combination, are involved. Since genital isolates are highly correlated with each other, the relative contribution of each microbe is difficult to determine.

Bacteria↗
PubMed1994

Vaginitis including bacterial vaginosis.

Bacterial vaginosis is a common lower genital tract infection. Women with bacterial vaginosis have 100-1000 times more virulent bacterial per ml of vaginal flora than women without this infection. This tremendous increase in the concentration of bacteria has been recently associated with postpartum and posthysterectomy infection and preterm delivery.

Female↗
PubMed1993

History and review of bacterial vaginosis.

OBJECTIVES: Review publications that significantly impacted on the knowledge of bacterial vaginosis. STUDY DESIGN: Assessment of information on the epidemiology, bacteriology, and pathology of bacterial vaginosis. RESULTS: Bacterial vaginosis has a complex microbiology. Further information is required on the epidemiology. The large increase in the concentration of vaginal bacteria among patients with bacterial vaginosis is associated with postpartum and postsurgical infections and with preterm delivery. CONCLUSIONS: Bacterial vaginosis is the most important vaginal infection because of its potential to cause upper genital tract infection in specific settings.

Female↗
PubMed1993

The severity of fetal membrane infection and pregnancy complications.

The purpose of this report is to examine the association of histologic chorioamnionitis with microorganisms isolated from the fetal membranes and to evaluate whether microorganisms with or without inflammation are associated with labor characteristics and with pregnancy complications. Inflammation was more common among membranes that yielded pathogenic bacteria (47%, P = 0.002) or Urea-plasma urealyticum (34%, P = 0.03) than among membranes that yielded no growth or nonpathogenic bacteria (20%). Prolonged membrane rupture (P = 0.0001), infant birth weight less than 2500 g (P = 0.02), and intraamniotic infection (P = 0.001) occurred more frequently among those women whose membranes yielded pathogenic bacteria than among those whose membranes yielded no growth or nonpathogenic bacteria. Our findings suggest that placental membranes in which pathogenic bacteria are accompanied by inflammation are associated with the highest risk of pregnancy complications.

Adolescent↗
PubMed1993

The normal vaginal flora, H2O2-producing lactobacilli, and bacterial vaginosis in pregnant women.

In this study of the vaginal flora of 171 pregnant women in labor at term, the flora was categorized as normal (Lactobacillus predominant), intermediate, or representative of bacterial vaginosis (BV) on the basis of a vaginal smear. BV was diagnosed in 39 women (23%); the vaginal flora was classified as normal in 50% of cases and as intermediate in 27%. H2O2-producing lactobacilli were recovered from 5% of women with BV, 37% of those with an intermediate flora, and 61% of those with a normal flora. H2O2-negative lactobacilli were equally frequent (57%-65%) in all three groups. The microorganisms most frequently recovered from women with BV included Gardnerella vaginalis, Prevotella bivia/disiens, Bacteroides ureolyticus, Prevotella corporis/Bacteroides levii, Fusobacterium nucleatum, Mobiluncus species, Peptostreptococcus prevotii, Peptostreptococcus tetradius, Peptostreptococcus anaerobius, viridans streptococci, Ureaplasma urealyticum, and Mycoplasma hominis (P < .05 for each). The presence of all but three of these organisms was inversely related to vaginal colonization by H2O2-producing lactobacilli; the exceptions were B. ureolyticus, F. nucleatum, and P. prevotii. Other microorganisms were equally frequent among women with and without BV. We conclude that specific groups of anaerobes are associated with BV in this population and that a strong association exists between species associated with BV and those inhibited by H2O2-producing lactobacilli.

Adolescent↗
PubMed1993

Bacterial vaginosis and anaerobes in obstetric-gynecologic infection.

Anaerobic infections of the upper genital tract are common. Antibiotic regimens designed to inhibit anaerobes markedly reduce morbidity. A vaginal infection associated with an increased concentration of anaerobic bacteria (bacterial vaginosis) has been recently linked to a wide variety of upper genital tract infections. Bacterial vaginosis has an important role in the development of clinical chorioamnionitis, postpartum endometritis, posthysterectomy vaginal-cuff cellulitis, postabortion pelvic inflammatory disease, and upper genital tract infections such as amniotic fluid infection and chorioamnion infection associated with premature delivery.

Abortion, Spontaneous↗
PubMed1993

Ureaplasma urealyticum and premature birth.

Evidence related to the association of Ureaplasma urealyticum with premature birth is reviewed. U. urealyticum is a common inhabitant in the vagina of pregnant women. It is recovered from the vaginas of approximately 70% of pregnant women. The presence of U. urealyticum in the vagina is not associated with premature birth. Therapy to eradicate U. urealyticum from the vagina during pregnancy does not reduce the incidence of premature birth. Recovery of U. urealyticum from the amniotic fluid has not been associated with prematurity. However, in three of six reports, the recovery of U. urealyticum from the chorioamnion has been associated with prematurity, and U. urealyticum is rather consistently associated with histological chorioamnionitis. This review suggests that U. urealyticum in the lower genital tract is not associated with premature birth but that its presence in the chorioamnion is weakly associated with prematurity and strongly associated with histological chorioamnionitis.

Amniotic Fluid↗
PubMed1993

Characteristics of women in preterm labor associated with elevated C-reactive protein levels.

OBJECTIVE: To evaluate clinical, microbiologic, and histologic findings associated with elevated C-reactive protein levels among women in preterm labor or with preterm premature rupture of the membranes (PROM). METHODS: Obstetric data, serum C-reactive protein levels, and amniotic fluid (AF) and chorioamniotic membrane cultures and histology were obtained on 203 women presenting between 22-34 weeks' gestation in preterm labor or with PROM. RESULTS: Women with C-reactive protein greater than 1.5 mg/dL were more likely to deliver within 7 days of enrollment (54 of 68, 79%) than were women with normal C-reactive protein levels (45 of 135, 33%) (P < .001). The median C-reactive protein levels and association with rapid delivery did not differ between women with intact versus ruptured membranes. Elevated C-reactive protein levels were associated with a positive AF culture among women in preterm labor with intact membranes. To control for confounding by a long interval to delivery, only the group delivering within 7 days was considered for evaluation of C-reactive protein levels and placental and infant outcome. Among women delivering within 7 days, elevated C-reactive protein was associated with the development of clinical chorioamnionitis and with infant death before hospital discharge, but not with a positive membrane culture or histologic chorioamnionitis. CONCLUSIONS: Elevated C-reactive protein appears to be associated with AF infection, delivery within 7 days of admission, and infant death among women delivering preterm, but not with membrane infection or inflammation. Elevated C-reactive protein may be helpful in determining the need for AF culture and in targeting studies of antibiotic therapy among women in preterm labor or with preterm PROM.

Amniotic Fluid↗
PubMed1993

The relationship of amniotic fluid cytokines and preterm delivery, amniotic fluid infection, histologic chorioamnionitis, and chorioamnion infection.

OBJECTIVE: To assess the association between cytokines in the amniotic fluid (AF) and preterm delivery, the isolation of bacteria from the AF or chorioamnion, and histologic chorioamnionitis. METHODS: Fifty afebrile women with intact membranes in preterm labor at or before 34 weeks' gestation underwent amniocentesis. Cytokine levels were measured in AF, and cultures were performed. Placentas were cultured and examined histologically. RESULTS: Thirty-two (64%) of the 50 patients delivered at or before 34 weeks' gestation. Delivery at or before 34 weeks, compared with delivery after 34 weeks, was related to increased levels of interleukin-6 (IL-6) (88 versus 12%; P < .001), interleukin-1 (IL-1) alpha (50 versus 6%; P = .004), IL-1 beta (42 versus 0%; P = .002), and prostaglandin (PG) E2 (66 versus 22%; P = .008). Bacteria were recovered from the AF of nine (18%) of the 50 patients. All of the cytokines with increased levels, plus tumor necrosis factor (TNF)-alpha, were related to bacteria in the AF. Increased IL-6, IL-1 alpha, IL-1 beta, TNF-alpha, and PGE2 were also associated with histologic chorioamnionitis among women who delivered within 1 week of amniocentesis. Elevated cytokine levels were not related to chorioamnion infection. CONCLUSIONS: Elevated AF cytokines and PGE2 predicted delivery before 34 weeks' gestation and delivery within 7 days of the amniocentesis, as well as AF infection and histologic chorioamnionitis. These findings support the hypothesis that infection is one cause of preterm delivery, operating via a mechanism involving induction of cytokine production.

Adult↗
PubMed1993

Efficacy of intravaginal 0.75% metronidazole gel for the treatment of bacterial vaginosis.

OBJECTIVE: To assess the efficacy of 0.75% metronidazole vaginal gel, formulated at pH 4.0, for the treatment of bacterial vaginosis in a double-blind, placebo-controlled crossover trial. METHODS: Fifty-three women with bacterial vaginosis (clue cells of at least 20% plus vaginal pH of at least 4.7, amine odor, or homogeneous discharge) were enrolled. Women with concomitant infection by Candida, Trichomonas, Chlamydia trachomatis, or Neisseria gonorrhoeae were excluded. Five grams of metronidazole gel or placebo was inserted intravaginally twice daily for 5 days. Response to therapy was evaluated at 4-16 days and 1 month after treatment. RESULTS: Twenty-six of the 30 women (87%) who received metronidazole were free of bacterial vaginosis 9-21 days after enrollment, compared with only four (17%) of 23 placebo-treated women (P < .001). Women who were cured were followed prospectively. Those who had persistent bacterial vaginosis were crossed over to metronidazole gel in an open trial; bacterial vaginosis was eradicated in 21 of 23 (91%) of these women at the 2-week follow-up. Recurrent bacterial vaginosis developed within 1 month in four (15%) of 26 women who were initially cured after receiving metronidazole gel. Response to therapy was accompanied by a decrease in vaginal Bacteroides, Gardnerella vaginalis, and Mycoplasma hominis. CONCLUSIONS: Treatment with intravaginal metronidazole gel resulted in a clinical cure in 87% (placebo-controlled trial) to 91% (crossover trial) of women with bacterial vaginosis. The recurrence rate of 15% at 1 month after treatment is similar to that reported with oral metronidazole.

Administration, Intravaginal↗
PubMed1992

A review of premature birth and subclinical infection.

Premature birth causes high rates of neonatal morbidity and mortality. There are multiple causes of preterm birth. This article reviews the evidence linking subclinical infection and premature birth. Although maternal genital tract colonization with specific organisms has been inconsistently associated with preterm birth and/or premature rupture of membranes, some infections have been consistently associated with preterm delivery. The association of histologic chorioamnionitis with prematurity is a consistent finding, but the mechanisms require further study. The relationship between histologic chorioamnionitis infection and the chorioamnionitis of prematurity requires additional research. A varying number of patients in "idiopathic" preterm labor have positive amniotic fluid cultures (0% to 30%), but it is not clear whether infection preceded labor or occurred as a result of labor. Evidence of subclinical infection as a cause of preterm labor is raised by finding elevated maternal serum C-reactive protein and abnormal amniotic fluid organic acid levels in some patients in preterm labor. Biochemical mechanisms for preterm labor in the setting of infection are suggested by both in vitro and in vivo studies of prostaglandins and their metabolites, endotoxin and cytokines. Some, but by no means all, antibiotic trials conducted to date have reported decreases in prematurity. These results support the hypothesis that premature birth results in part from infection caused by genital tract bacteria. In the next few years, research efforts must be prioritized to determine the role of infection and the appropriate prevention of this cause of prematurity.

Anti-Bacterial Agents↗