Comparison of ceftizoxime versus combination therapy in the treatment of pelvic inflammatory disease (PID).
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Anti-Bacterial Agents↗
Biomedical subjects
D L Hemsell
Publications and source records attributed to D L Hemsell.
Endometrial bacteria in asymptomatic, nonpregnant women.
The existence of normal lower reproductive tract flora has been recognized for many years. A study was conducted to identify the possible existence of upper reproductive tract (endometrial) bacteria in asymptomatic women with no history of previous pelvic infection and a normal pelvic examination. Bacteria were recovered from the endometria of 55 women with a double-lumen-catheter-protected brush; six cultures were sterile. Two hundred thirty-one bacterial species were present in 54 endocervical cultures. Type of contraception and phase of the menstrual cycle had no significant effect on the bacterial species recovered. Although contamination by cervical bacteria was possible, there was evidence of separate endometrial flora.
Adolescent↗
Infections after gynecologic surgery.
Infections observed after gynecologic surgical procedures are polymicrobial and require parenteral broad-spectrum antimicrobial therapy until the patient has been afebrile 24 to 72 hours. Therapy should be tailored to the specific infection and patient response thereto. When the infections are complicated by abscess or infected hematoma, combination therapy appears to be effective in a shorter period of time, and surgical drainage is infrequently necessary other than drainage of those in the supravaginal, extraperitoneal space. Administration of antibiotics immediately before surgery to women at high risk for postoperative infection has essentially eliminated pelvic infections. These infections range from cuff cellulitis through pelvic abscess and include pelvic thrombophlebitis. Pelvic infections and those in an abdominal, perineal, or vaginal incision can occur during the immediate postoperative period or after discharge from the hospital. As many as 50 per cent of these infections may occur after the patient is discharged from the hospital. Without question, the most appropriate means of objectively identifying infection rates, appropriate and inappropriate use of antimicrobials, and trends in morbidity is with an infection control program, usually consisting of an epidemiologist or specially trained nurses. Their contribution to appropriate patient care is significant. Information uncovered may put some clinicians on the defensive. This need not happen if gynecologic surgeons participate in and define criteria to be used for various infection diagnoses and similar situations. These diagnoses must be based on physical examination evidence, not "presumptive evidence." Antimicrobial administration and selection has an emotional component; objective evaluation avoids this bias. Optimal and efficient patient care is the goal and these programs should be established with that as their only goal. Several synergistic polymicrobial infections involve skin, subcutaneous tissue, and perhaps fascia; these are infrequently observed but require prompt recognition and antimicrobial therapy as well as wide surgical excision to healthy tissue to effect a cure. Clinical presentation extends to both ends of the spectrum with respect to degree of illness. These infections also occur spontaneously in gynecologic sites, and do so only in patients at high risk, such as those with diabetes, delibitating disease, advanced age, or evidence of arteriosclerotic disease. Another infection that was diagnosed and managed only surgically (that is, septic pelvic thrombophlebitis) can now be accurately diagnosed without surgery and can be adequately treated medically.(ABSTRACT TRUNCATED AT 400 WORDS)
Anti-Bacterial Agents↗
Multicenter clinical trials comparing cefotetan with moxalactam or cefoxitin as therapy for obstetric and gynecologic infections.
The clinical efficacy and safety of cefotetan was assessed in two multicenter clinical trials involving 335 evaluable patients hospitalized with obstetric and gynecologic infections. In Study I, cefotetan was compared with moxalactam and in Study II, cefotetan was compared with cefoxitin. The clinical response rate in Study I was 67 of 70 patients for cefotetan (96 percent) and 33 of 34 patients (97 percent) for moxalactam. In Study II, the clinical response rate was 138 of 147 patients in the cefotetan group (94 percent) and 76 of 84 patients in the cefoxitin group (91 percent). For the patients with bacteriologic response data, 196 of 205 cefotetan patients (96 percent), 23 of 24 moxalactam patients (96 percent), and 70 of 75 cefoxitin patients (93 percent) had a satisfactory bacteriologic response. Cefotetan was well tolerated and produced no major adverse reactions. The mean amount of cefotetan given was lower than that of moxalactam or cefoxitin.
Adult↗
Multicenter comparison of cefotetan and cefoxitin in the treatment of acute obstetric and gynecologic infections.
Two hundred eighty-seven women were treated in a multicenter, randomized, comparative study to compare the safety and efficacy of cefotetan every 12 hours with that of cefoxitin every 6 or 8 hours in the treatment of acute obstetric and gynecologic pelvic infections. The most frequent primary diagnoses in both groups were endometritis and pelvic inflammatory disease; 24 of these patients were also bacteremic. The mean duration of treatment was 5.2 and 5.4 days for the cefotetan and cefoxitin groups, respectively, and the total doses administered were 18.1 and 32.1 gm, respectively. The rate of clinical failure for the cefotetan group was 8.5% and 12.2% for the cefoxitin group. Laboratory and clinical adverse reactions were infrequent and none was serious; both antimicrobials were well tolerated. These results suggest the administration of cefotetan provided adequate clinical and bacteriologic effectiveness in the treatment of hospital- and community-acquired, polymicrobial obstetric and gynecologic pelvic infections.
Acute Disease↗
Alterations in lower reproductive tract flora after single-dose piperacillin and triple-dose cefoxitin at vaginal and abdominal hysterectomy.
There are no current data regarding the effect of a newer, broad-spectrum penicillin on lower reproductive flora at hysterectomy. To identify any existing differential effect on species and their susceptibilities, we obtained pre- and postoperative lower reproductive tract culture material from 209 women who were given single-dose piperacillin, then placebo or triple-dose cefoxitin, intravenously for prophylaxis at vaginal and abdominal hysterectomy in a prospective, randomized, blinded clinical trial. Significantly more preoperative endocervical bacteria were susceptible to piperacillin. Piperacillin caused less alteration in the numbers of lower reproductive tract flora when preoperative species were compared with postoperative species. More resistance to cefoxitin was identified postoperatively in bacteria recovered from the vaginal cuff of women who remained uninfected.
Bacteria↗
Sulbactam/ampicillin versus cefoxitin for uncomplicated and complicated acute pelvic inflammatory disease.
In this study, 17 women were treated for uncomplicated acute pelvic inflammatory disease requiring hospitalisation for therapy, and 5 women were treated for the same infection complicated by pelvic abscesses. Treatment regimens were sulbactam 1g plus ampicillin 2g (14 women) or cefoxitin 2g (8 women) given by intravenous infusion every 6 hours. On the third day of therapy, a rash developed in 1 woman who was being successfully treated for uncomplicated disease with sulbactam/ampicillin. The other 21 women were cured. No other adverse clinical reactions and no significant abnormal laboratory results were observed with either regimen. Bacteriological efficacy, 98% for sulbactam/ampicillin and 94% for cefoxitin, closely paralleled clinical efficacy. Sulbactam, a suicide-type beta-lactamase inhibitor, appears to have restored and expanded the antibacterial activity of ampicillin.
Acute Disease↗
Upper and lower reproductive tract bacteria in 126 women with acute pelvic inflammatory disease. Microbial susceptibility and clinical response to four therapeutic regimens.
To more clearly understand the microbiology of acute salpingitis in our patients and to evaluate the clinical efficacy and safety of recommended and new therapeutic regimens, 126 women who met clinical diagnostic criteria for acute community-acquired pelvic inflammatory disease underwent endocervical and endometrial cultures prior to random intravenous therapy with cefoxitin plus doxycycline, ceftizoxime plus doxycycline or ceftizoxime alone (two regimens). Nine women (7%) had Chlamydia, and 70 (56%) had gonococci in endometrial specimens (P less than .001). Only two women (3.4%) given monotherapy required altered medical therapy, and none required surgery. Parenteral combination therapy was associated more frequently with adverse clinical and laboratory events.
Acute Disease↗
Single-dose antimicrobial prophylaxis at abdominal hysterectomy. Cefamandole vs. cefotaxime.
Two hundred twenty-three women were given a single, 1-g, intravenous dose of cefamandole or cefotaxime at elective abdominal hysterectomy in a multicenter, prospective, randomized, blind clinical trial of efficacy and safety. The demographic, surgical, efficacy and safety variables were statistically similar. Prior to discharge from the hospital, 12 women (5.3%) developed major postoperative pelvic infections that required parenteral antimicrobial therapy; no wound infections occurred. There was no correlation between a depressed antimicrobial development of significant postoperative infection. An expanded spectrum of antibacterial activity and a longer serum half-life did not improve clinical efficacy, and single-dose intravenous cephalosporin prophylaxis before abdominal hysterectomy was associated with a low incidence of pelvic infection.
Adult↗
Acute pelvic inflammatory disease. Etiologic and therapeutic considerations.
Acute pelvic inflammatory disease (PID) is a community-acquired bacterial infection presumed to be initiated by sexual activity. The therapeutic goals in its treatment are to treat the symptoms, preserve fertility when desired and prevent the development of sequelae. PID should be diagnosed early and accurately, and appropriate antimicrobial therapy should be initiated immediately. Cost-effective parenteral therapy should include antibiotics that can be administered in as few daily doses as possible without sacrificing efficacy.
Acute Disease↗
Efficacy and safety of single-dose ceftizoxime vs. multiple-dose cefoxitin in preventing infection after vaginal hysterectomy.
The efficacy, safety and effect of a single, 1-g dose of ceftizoxime on the return of vaginal flora were compared to those of the standard regimen of three 2-g doses of cefoxitin for prophylaxis in 99 randomized women undergoing vaginal hysterectomy. Thirty-four were studied in Dallas and 65 in Los Angeles. Surgical procedures were comparable for all the antibiotic groups, although proportionately more simple hysterectomies were performed in Dallas. The patients received a povidone-iodine vaginal preparation immediately before surgery; vaginal packs, when used, contained no antimicrobial agents. Primary prophylactic failure (operative site infection) occurred in 1 of 52 (1.9%) and 4 of 47 (8.5%) of the ceftizoxime- and cefoxitin-treated patients, respectively, for a nonsignificant difference. All five primary prophylactic failures occurred in the Los Angeles patients. One patient in each antibiotic group developed a urinary tract infection and was classified as a secondary prophylactic failure. Febrile morbidity, length of hospital stay and incidence of adverse effects did not differ by antibiotic. The enterococcus was commonly found in the postoperative vaginal flora and was of no value in predicting operative-site infection. Enterobacter species and Pseudomonas aeruginosa were isolated more commonly in patients who received cefoxitin. Diphtheroids, Staphylococcus epidermidis and Peptostreptococcus species were isolated more commonly in patients treated with ceftizoxime.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Single-dose cephalosporin for prevention of major pelvic infection after vaginal hysterectomy: cefazolin versus cefoxitin versus cefotaxime.
Antimicrobial overutilization accelerates the development of bacterial resistance. A prospective, randomized, blinded clinical trial of vaginal hysterectomy prophylaxis was designed to compare the efficacy, safety, and costs of cefazolin with those of cefoxitin and cefotaxime. Sixteen women (7.5%) developed febrile morbidity only, 10 (4.7%) developed major pelvic infection requiring parenteral antimicrobial therapy, and neither clinical nor laboratory adverse reactions of significance were observed. Anemia, diabetes, and additional surgical procedures were associated with a significantly increased incidence of postoperative infection; no regimen was more protective for women with or without these risk factors. Infections almost doubled hospital stay and the charges for health care. Diagnosis-related group reimbursement would have been more than $1,300 less than the mean hospital charge for women who developed infection. Utilizing cefazolin for prophylaxis and reserving cefoxitin and cefotaxime for therapy is cost and antimicrobial efficient.
Adult↗
Induction of beta-lactamase enzymes: clinical applications for the obstetric-gynecologic patient.
The emergence of bacteria resistant to antibiotics has resulted in intensive research for new and improved beta-lactam antibiotics. Many improvements in antimicrobial agents are based on a knowledge of the mechanism responsible for resistance. This has led to the development of new extended-spectrum antibiotic compounds. However, several features have been noted since the development of extended-spectrum antibiotics, such as the rapid development of bacterial resistance, the induction of beta-lactamase enzyme activity by these stable antibiotics, failure to detect induced enzyme activity and resistance in the laboratory, and beta-lactam antagonism. The resistance of bacteria to antimicrobial agents has obvious impact on the selection of appropriate therapy against infections caused by these pathogens. Gram-negative anaerobic bacteria, such as Bacteroides fragilis and Bacteroides bivius, are organisms frequently recovered from women whose initial therapy for pelvic infection failed. The transfer of antimicrobial resistance in bacteria indicates that these organisms have a system for the spread of such resistance. Therefore determination of antimicrobial susceptibilities and prompt eradication of isolates from infected patients are necessary to delay the emergence of resistant organisms.
Bacteria↗
Single-agent therapy for women with acute polymicrobial pelvic infections.
Pathogens that cause acute polymicrobial female pelvic infections usually do not differ from those that compose the normal flora of the lower reproductive tract. Accurate identification of these bacteria is difficult because cultures obtained via the lower tract can easily be contaminated. Although use of a double-lumen catheter-protected brush culture cannot completely eliminate the risk of contamination, it is the least invasive method for obtaining culture material from the upper reproductive tract. Compounding the problem of accurately identifying pathogens that cause acute upper tract infections is the fact that bacteria appear to be present in the upper tracts of asymptomatic women with normal examinations. Because of these problems and because of the polymicrobial nature of these infections, empiric therapy frequently includes more than one antimicrobial agent. Newer, semisynthetic penicillins and cephalosporins have expanded spectrums of in vitro activity against most of the bacteria frequently recovered from pelvic infection sites. Comparative clinical trials have shown these agents to be as effective when used alone as is combination therapy. With few exceptions, empiric monotherapy with one of these newer antimicrobials will be curative for women with acute upper tract infection, will have less potential toxicity, will require less space, materials, and manpower to administer, and will be less expensive.
Anti-Bacterial Agents↗
Single-dose prophylaxis for vaginal and abdominal hysterectomy.
The practice of administering perioperative antimicrobials to uninfected patients undergoing elective surgical procedures has been subjected to careful prospective investigative scrutiny during the past two decades. A wound classification system was developed, helping to identify procedures for which prophylaxis did not provide benefit to the patient. Guidelines for prophylaxis in hysterectomy were proposed and risk factors were sought. Pharmacokinetics and spectrum of antibacterial activity, although variables of paramount importance in predicting success in the treatment of established infections, were discovered to have questionable impact on prophylactic efficacy. Duration of antimicrobial administration has gradually diminished from the total length of hospital stay to a single preoperative dose without increased risk of infection; efficacy may be related to route of administration. The wisdom of using newer agents for prophylaxis is addressed and questioned.
Anti-Bacterial Agents↗
Piperacillin and a combination of clindamycin and gentamicin for the treatment of hospital and community acquired acute pelvic infections including pelvic abscess.
Therapy for acute polymicrobial pelvic infections is empiric and must include predictable anaerobic coverage. Single agent therapy, if effective, is advantageous for the patient, nurses, pharmacy and hospital. Piperacillin sodium was compared with a combination of clindamycin and gentamicin as therapy for 63 female patients who were hospitalized with acute pelvic infections including pelvic abscess complicating community acquired salpingitis. Over-all clinical efficacy with piperacillin was 96.8 per cent and 90.3 per cent for clindamycin and gentamicin. Fewer bacteria demonstrated in vitro resistance to piperacillin (p = 0.008) and the cost of treatment for these infections was significantly less with piperacillin (p less than 0.05). Serious adverse reactions were not observed with either regimen. Piperacillin provides effective, cost-efficient therapy for women with acute polymicrobial pelvic infections.
Abscess↗
Sulbactam/ampicillin for treatment of polymicrobial pelvic infections.
The increasing number of beta-lactam antibiotic-resistant bacteria observed in many strains of aerobic and anaerobic Gram-positive and Gram-negative bacteria, including Bacteroides species, has been well documented. Semisynthetic synthesis of penicillins and cephalosporins with increased resistance to beta-lactamase enzyme hydrolysis has not solved the problem. An alternative to therapy with newer agents is combination of an irreversible, suicide-type, beta-lactamase enzyme inhibitor such as sulbactam with a beta-lactam antibiotic such as ampicillin. Women with a variety of acute polymicrobial pelvic infections have been treated with the above combination, metronidazole or clindamycin combined with aminoglycoside, or cefoxitin in prospective trials. The clinical efficacy of 92.4%, in vitro bacteriological efficacy of 96.6%, and safety of sulbactam/ampicillin were comparable to that observed in women given comparative therapy. Penetration of pelvic tissues by sulbactam and ampicillin was excellent. Sulbactam/ampicillin is a viable alternative for the treatment of women with acute pelvic infections.
Ampicillin↗
Preoperative cefoxitin prophylaxis for elective abdominal hysterectomy.
Fifty women were randomly given one, two, or three 2 gm parenteral doses of cefoxitin with placebo blinding perioperatively at abdominal hysterectomy. A single preoperative intramuscular dose was more efficient, less frequently associated with the development of bacterial resistance, and less expensive than two or three doses.
Bacterial Infections↗