Biomedical subjects
W J Ledger
Publications and source records attributed to W J Ledger.
Management of postpartum cesarean section morbidity.
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Listeria monocytogenes chorioamnionitis: diagnosis by transabdominal amniocentesis.
Two cases of Listeria monocytogenes chorioamnionitis are presented in which transabdominal amniocentesis was used to confirm the diagnosis and to obtain reliable intrauterine culture material free from lower genital tract contamination. The mechanisms of infection with Listeria monocytogenes in the pregnant patient are discussed.
Prevention, diagnosis, and treatment of postoperative infections.
Discontinuation of routine use of plastic surgical adhesive drapes, the electrocautery surgical knife, routine preoperative shaving, and routine intraoperative placement of wound drains may reduce the incidence of postoperative wound infection. Other potentially helpful measures include hot conization of the cervix before hysterectomy, delayed wound closure, and minimization of preoperative hospitalization time. Microbiologic cultures and the standard temperature definition of morbidity help but little in diagnosing postoperative infection; needed is careful physical examination of the patient before antibiotics are given. Drainage of abscesses and delay of wound closure may help one avoid the use of antibiotics. To prevent infections, an appropriate antibiotic should be in the tissues within 3 hours after surgery; its use should end in the recovery room. Prospective comparison studies are needed to help physicians choose among today's antibiotics.
Identification of the high risk mother and fetus--does it work?
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The role of anaerobic bacteria in postpartum endomyometritis.
To evaluate the role of anaerobic bacteria in postpartum endomyometritis, intravenous metronidazole was used as the sole initial therapy in 25 women with clinical signs of infection. This agent has not been shown to have activity against aerobic pathogens in soft tissue pelvic infections. A clinical cure was obtained in 21 of 25 (84%) with oral metronidazole utilized after the patient had been afebrile for at least 24 hours. The mean fever index of the 21 successfully treated women was 35.9 degree hours with a SD of +/-30 hours. The four patients with treatment failure required alternate antibiotics and the mean fever index of these patients was 138.0 degree hours. Transcervical endometrial cultures were obtained prior to therapy in 24 women. Anaerobes were recovered in every instance with a total of 67 isolates, a mean of 2.8 per patient. The most common isolates were peptococcus and Bacteroides species. A culdocentesis was performed concurrently in 23 women. Anaerobes were recovered in 20 (87%) with a total of 55 isolates. The most frequent isolates were peptococcus and Bacteroides fragilis. In 23 women in whom paired transcervical endometrial and cul-de-sac cultures were obtained, at least one common organism was isolated in 18 (78%). Both the successful clinical response to metronidazole and the paired culture results suggest that anaerobic organisms have an important role in endomyometritis following vaginal delivery.
A comparison of clindamycin-gentamicin and penicillin-gentamicin in the treatment of post-cesarean section endomyometritis.
A random comparison of clindamycin-gentamicin (C-G) and penicillin-gentamicin was made in 200 women who developed endomyometritis following cesarean section. All pretreatment profiles indicated similar populations. The clinical response was more favorable in the women receiving clindamycin-gentamicin. The implications of these results upon clinical practice is discussed.
Failure of surgical prophylaxis.
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Premature rupture of membranes and maternal-fetal infection.
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Management of obstetric and gynecologic infections resulting from trauma.
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The changing perinatal and maternal outcome in chorioamnionitis.
Chorioamnionitis is difficult to detect clinically, but its recognition in those at risk is essential. A retrospective study of 140 patients from among 26,129 deliveries was conducted over a 2-year period. The findings suggest that in modern obstetric practice, both perinatal and maternal complications associated with chorioamnionitis (particularly sepsis) are infrequent problems. Four neonatal deaths occurred but no infants died of sepsis. There were no maternal deaths, but 38 patients developed postpartum infections. Cesarean section did not appear to improve either perinatal or maternal outcome. With the use of appropriate modern antibiotics, extraperitoneal cesarean section and cesarean hysterectomy are probably no longer indicated. Not all neonates born out of a microbiologically contaminated intrauterine environment required antibiotic therapy, however, and individualization is recommended.
Cefoxitin: single-agent treatment of mixed aerobic-anaerobic pelvic infections.
Cefoxitin (mefoxin), a new semisynthetic cephamycin antibiotic, resistant to degradation by beta-lactamase enzymes produced by bacteria. In vitro, cefoxitin is active against virtually all clinically important gram-negative facultative bacteria other than Pseudomonas and Enterobacter spp., gram-positive aerobic bacteria other than the enterococcus, and clinically important anaerobic organisms, including Bacteroides fragilis. This broad antibacterial spectrum suggested that cefoxitin might be an effective single antibiotic agent for the treatment of mixed aerobic-anaerobic infections in obstetric and gynecologic patients. In this investigation, the efficacy and safety of cefoxitin was evaluated in 109 patients--68 with salpingitis, 25 with endomyometritis, 9 with pelvic cellulitis, and 7 with pelvic abscesses. An average of 2.5 bacteria were isolated from each patient. Aerobic bacteria alone was isolated in 38% of patients, anaerobic bacteria alone in 25%, and a combination of aerobic and anaerobic bacteria was isolated in 37% of patients. Overall, 100 of 109 (92%) infections responded to treatment with cefoxitin alone. The major cause of treatment failure was the presence of abscesses requiring surgical drainage. In addition to being an effective single agent for the management of pelvic infections, cefoxitin proved to be safe and well tolerated by patients.
Failure of immune serum globulin to prevent hepatitis B virus infection in infants born to HBsAg-positive mothers.
Twelve infants, born to mothers with hepatitis B virus infection, were inoculated within 7 days of birth with immune serum globulin containing antibody to hepatitis B surface antigen (HBsAg) titers of 1:32 to 1:64 as measured by passive hemagglutination. Six of nine infants (66.7%) born to HBsAg-positive carrier mothers became HBsAg-positive within 3 mo of age. In addition, two of three treated infants born to mothers with acute hepatitis B during the delivery period also developed HBsAg. The hepatitis e antigen was detected in four of five carrier mothers and in two mothers with acute hepatitis, whose infants subsequently became HBsAg positive. In addition, hepatitis B-specific DNA polymerase activity was detected in the seven HBsAg-positive mothers who transmitted the virus to their infants. All eight infants have remained persistently HBsAg positive. Thus, the immune serum globulin containing low-titer antibody to HBsAg is not protective when given to infants born to HBsAg carrier mothers or to mothers with acute hepatitis B during the delivery period.
The use of intravenous cefoxitin sodium in patients with obstetric/gynaecologic infections.
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Bacterial infections complicating pregnancy.
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Prophylactic use of cefazolin in monitored obstetric patients undergoing cesarean section.
Prophylactic cefazolin was evaluated in high-risk obstetric patients who had invasive fetal monitoring and subsequent cesarean section. A three-dose regimen of either cefazolin or placebo was administered randomly in a double-blind manner to 93 patients, 48 receiving cefazolin and 45 placebo, with the first dose given when the cord was clamped. In the placebo group, 51% of the patients were treated for endomyometritis compared to 29% in the cefazolin group. The incidence of urinary tract and wound infections was similar in the 2 groups. One patient in the active drug group was diagnosed as having septic pelvic thrombophlebitis and received multiple antibiotics and heparin before she recovered. One patient in the placebo group required triple antibiotic therapy. Operation to control infection was not required in any patients and there were no maternal deaths. The cefazolin patients had fewer degree-hours of morbidity as calculated by the quantitative fever index (P less than 0.002). The perioperative use of cefazolin was efficacious in reducing the incidence of endomyometritis, but did not prevent serious postoperative pelvic infection.
Hospital infections: gynecologic, obstetric, and perinatal infections.
Increased perinatal use of invasive monitoring techniques and a higher rate of cesarean section have led to an increase in the rate of maternal infection and to new types of infections in newborns. Control measures for maternal infections include antibiotic prophylaxis, direct administration of antibiotics to the amniotic fluid, extraperitoneal cesarean section, and cesarean hysterectomy. New types of infections in newborns include abscess resulting from use of electrodes to monitor fetal heart rate and the development of group B beta hemolytic streptococci infection, particularly in association with prolonged rupture of maternal membranes. Prospective studies are needed of preventive measures and proper management of maternal and perinatal infections. Obstetric and gynecologic problems that need further investigation include pelvic infection after vaginal hysterectomy, salpingooophoritis, and antibiotic dosages for pregnant women.