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1.  Species Distribution and Susceptibility to Azoles of Vaginal Yeasts Isolated Prostitutes 
Objective. We investigated the use of miconazole among female prostitutes in Costa Rica as well as the distribution of vaginal yeasts and the susceptibility pattern to azoles of strains obtained from this population. Our intention was to relate a frequent use of miconazole to occurrence of vaginal yeasts resistant to azoles. Methods. Vaginal samples were taken from 277 patients that have previously used azoles. Vaginal swabs were obtained for direct microscopy and culture. Yeast isolates were identified by germ tube test and assimilation pattern. Susceptibility testing was determined using a tablet diffusion method. Results. The number of clinical Candida isolates (one from each patient) was 57 (20.6%). C. albicans was the predominant species (70%), followed by C. parapsilosis (12%), C. tropicalis (5.3%), C. glabrata and C. famata (3.5% each), C. krusei, C. inconspicua and C. guilliermondii (1.7% each). The majority of vaginal Candida isolates were susceptible to ketoconazole (91%), fluconazole (96.5%), and itraconazole (98%). A lower susceptibility of some isolates to miconazole (63%) was observed as compared to the other azoles tested. Moreover, the strains, nonsusceptible to miconazole, were more often obtained from patients that have used this antifungal at least four times within the last year before taking the samples as compared to those with three or less treatments (P<.01). Conclusion. An indiscriminate use of miconazole, such as that observed among female prostitutes in Costa Rica, results in a reduced susceptibility of vaginal yeasts to miconazole but not to other azoles.
PMCID: PMC2216416  PMID: 18273407
2.  Staphylococcus aureus and MRSA Colonization Rates among Gravidas Admitted to Labor and Delivery: A Pilot Study 
Objective. To determine colonization rates of Staphylococcus aureus given the potential for future intervention trials aimed at reducing surgical-site infectious morbidity, and to estimate methicillin-resistant Staphylococcus aureus (MRSA) rates in our patient population. Study design. Prospective pilot investigation comprising data from 104 gravidas admitted to an urban labor and delivery unit. All underwent anterior nares culture collection with a subset also undergoing vaginal culture collection. Results. Twenty-two percent of women were colonized in the anterior nares. Of the 28 women who had vaginal cultures collected, 4/28 (14.2%) demonstrated Staphylococcus aureus colonization. There was 82% concordance between the nares and vagina. Nine percent of isolates were MRSA strains. Overall, 2/96 (2.1%) of women were MRSA-colonized. Conclusions. Rates of Staphylococcus aureus colonization among gravidas entering labor and delivery are modest and consistent with the general population. MRSA rates among gravidas appear to be reassuringly low in this pilot study.
PMCID: PMC2216077  PMID: 18273405
3.  World Wide Web Resources on Obstetrical and Gynecological Infections 
Modern information and communications technology has provided medical students and practitioners around the world with a new, valuable, and easy-to-use way to retrieve potentially useful information. Using previously described by our research group methodology, we generated a list of 50 Internet resources in the field of obstetrical and gynecological infections. We believe that the availability of such a list will help in the education of students and clinicians interested in obstetrical and gynecological infections.
PMCID: PMC2216052  PMID: 18273403
4.  Vaginitis: Making Sense of Over-the-Counter Treatment Options 
Background. The FDA approved over-the-counter (OTC) use of vaginal antifungals in 1990. Subsequently, a plethora of OTC products have become available to women on drugstore shelves. Objectives. The purpose of this study was to determine the availability of OTC products marketed for the treatment of vaginitis and to determine if their efficacy had been confirmed by published prospective randomized control trials (RCTs). Materials and methods. The authors chose four retail locations frequented by women seeking vaginitis treatment. All products deemed a viable treatment option were purchased. Results. All intravaginal imidazoles purchased, regardless of treatment duration or active ingredient, were found to be of proven efficacy. We were unable to find an RCT confirming the effectiveness of vaginal anti-itch creams and homeopathic treatments for vaginitis. Conclusion. 45% of products available to women in the feminine hygiene section of the stores surveyed could not be confirmed to be effective for treating infectious vaginitis.
PMCID: PMC1986759  PMID: 18253469
5.  Lemierre's Syndrome Complicating Pregnancy 
Lemierre's syndrome is an anaerobic suppurative thrombophlebitis involving the internal jugular vein secondary to oropharyngeal infection. There is only one previous case report in pregnancy which was complicated by premature delivery of an infant that suffered significant neurological damage. We present an atypical case diagnosed in the second trimester with a live birth at term. By reporting this case, we hope to increase the awareness of obstetricians to the possibility of Lemierre's syndrome when patients present with signs of unabating oropharyngeal infection and pulmonary symptoms.
PMCID: PMC1939918  PMID: 17710241
6.  Rapid Determination of Macrolide and Lincosamide Resistance in Group B Streptococcus Isolated from Vaginal-Rectal Swabs 
Objective. Our objective was to assess the ability of real-time PCR to predict in vitro resistance in isolates of group B streptococcus (GBS). Methods. The first real-time PCR assays for the genes known to confer resistance to erythromycin and clindamycin in GBS were developed. Three hundred and forty clinical GBS isolates were assessed with these assays and compared with conventional disk diffusion. Results. The presence of an erythromycin ribosome methylation gene (ermB or ermTR variant A) predicted in vitro constitutive or inducible resistance to clindamycin with a sensitivity of 93% (95% CI 86%–97%), specificity of 90% (95% CI 85%–93%), positive predictive value of 76% (95% CI 67%–84%), and negative predictive value of 97% (95% CI 94%–99%). Conclusion. This rapid and simple assay can predict in vitro susceptibility to clindamycin within two hours of isolation as opposed to 18–24 hours via disk diffusion. The assay might also be used to screen large numbers of batched isolates to establish the prevalence of resistance in a given area.
PMCID: PMC1939917  PMID: 17710240
7.  Xanthogranulomatous Endometritis: A Challenging Imitator of Endometrial Carcinoma 
Xanthogranulomatous inflammation is a distinguished histopathological entity affecting several organs, predominantly the kidney and gallbladder. So far, only a small number of cases of xanthogranulomatous inflammation occurring in female genital tract have been described, most frequently affecting the endometrium and histologically characterized by replacement of endometrium by xanthogranulomatous inflammation composed of abundant foamy histiocytes, siderophages, giant cells, fibrosis, calcification and accompanying polymorphonuclear leucocytes, plasma cells and lymphocytes of polyclonal origin. We present a case of a 69-year-old female complained of post menopausal bleeding and weight loss. Clinical preliminary diagnoses were endometrial carcinoma or hyperplasia and ultrasound was supposed to be endometrial malignancy, hyperplasia or pyometra by radiologist. Histopathological examination of uterus revealed xanthogranulomatous endometritis. Since xanthogranulomatous endometritis may mimic endometrial malignancy clinically and pathologically as a result of the replacement of the endometrium and occasionally invasion of the myometrium by friable yellowish tissue composed of histiocytes, knowledge of this unusual inflammatory disease is needed for both clinicians and pathologists.
PMCID: PMC1939916  PMID: 17710239
8.  Survey of Obstetrician-Gynecologists about Giardiasis 
Giardiasis is one of the most common parasitic diseases in the United States with over 15 400 cases reported in 2005. A survey was conducted by The American College of Obstetricians and Gynecologists (ACOG) in collaboration with the Centers for Disease Control and Prevention (CDC) to evaluate the knowledge of obstetricians and gynecologists regarding the diagnosis and treatment of giardiasis. The questionnaire was distributed to a random sample of 1200 ACOG fellows during February through June of 2006. Five hundred and two (42%) responded to the survey. The respondents showed good general knowledge about diagnosis, transmission, and prevention; however, there was some uncertainty about the treatment of giardiasis and which medications are the safest to administer during the first trimester of pregnancy.
PMCID: PMC1939915  PMID: 17710238
9.  Blastomyces Antigen Detection for Monitoring Progression of Blastomycosis in a Pregnant Adolescent 
Although disseminated blastomycosis is a rare complication in pregnancy, delay in diagnosis and treatment can be fatal. We investigate the use of the Blastomyces urine antigen in diagnosis following disease progression in the intrapartum, postpartum, and neonatal periods. We describe a case of disseminated blastomycosis in a pregnant adolescent and review the pertinent literature regarding treatment and monitoring blastomycosis in pregnancy and the neonatal periods. This is the first reported case in which the Blastomyces urine antigen is utilized as a method of following disease activity during pregnancy confirming absence of clinically evident disease in a neonate. Urine antigen detection for blastomycosis can be useful for following progression of disease in patients with disseminated blastomycosis in both the intrapartum and postpartum periods.
PMCID: PMC1906866  PMID: 17641724
10.  The Superinfection of a Dermoid Cyst 
Mature cystic teratoma may be complicated by torsion, rupture, and malignant change, but is rarely complicated by infection. Here we report the case of a patient who presented with a tubo-ovarian abscess following a dilation and curettage (D&C) procedure in the setting of an ovarian dermoid cyst.
PMCID: PMC1906865  PMID: 17641723
11.  Postmenopausal Tuberculosis Endometritis 
Tuberculosis remains a global health problem, primarily in developing countries with inadequate health services. A significant portion of tuberculosis in these settings is extrapulmonary, including tuberculosis of the genitourinary tract. Patients with genital tuberculosis are usually young women detected during work up for infertility. After menopause, tuberculosis of the endometrium is a rare possibility probably because of the decreased vascularity of the tissues. We present a case of endometrial tuberculosis with postmenopausal vaginal bleeding.
PMCID: PMC1874669  PMID: 17541465
12.  High Titers ofChlamydia trachomatis Antibodies in Brazilian Women with Tubal Occlusion or Previous Ectopic Pregnancy 
Objective. To evaluate serum chlamydia antibody titers (CATs) in tubal occlusion or previous ectopic pregnancy and the associated risk factors.Methods. The study population consisted of 55 women wih tubal damage and 55 parous women. CAT was measured using the whole-cell inclusion immunofluorescence test and cervical chlamydial DNA detected by PCR. Odds ratios were calculated to assess variables associated withC. trachomatis infection.Results. The prevalence of chlamydial antibodies and antibody titers in women with tubal occlusion or previous ectopic pregnancy was significantly higher (P < .01) than in parous women. Stepwise logistic regression analysis showed that chlamydia IgG antibodies were associated with tubal damage and with a larger number of lifetime sexual partners.Conclusions. Chlamydia antibody titers were associated with tubal occlusion, prior ectopic pregnancy, and with sexual behavior, suggesting that a chlamydia infection was the major contributor to the tubal damage in these women.
PMCID: PMC1874668  PMID: 17541464
13.  Protective Effect of Vaginal Lactobacillus paracasei CRL 1289 against Urogenital Infection Produced by Staphylococcus aureus in a Mouse Animal Model 
Urogenital infections of bacterial origin have a high incidence among the world female population at reproductive age. Lactobacilli, the predominant microorganisms of the healthy vaginal microbiota, have shown a protective effect against the colonization and overgrowth of urogenital pathogens that increased the interest for including them into probiotics products assigned to restore the urogenital balance. In the present work, we determined in a mouse animal model the capability of Lactobacillus paracasei CRL 1289, a human vaginal strain with probiotic properties, to prevent the vaginal colonization of a uropathogenic strain of Staphylococcus aureus. Six-week-old female BALB/c mice, synchronized in their estral cycle, were intravaginally inoculated with two doses of 109 lactobacilli before challenging them with a single dose of 105 or 107 CFU of S. aureus. The vaginal colonization of both microorganisms and the effect on the vaginal structure were determined at 2, 5, and 7 days after pathogen inoculation. Control mice and those challenged only with the pathogen showed an insignificant lactobacilli population, whereas 105 lactobacilli/mL of vaginal homogenate were recovered at 2 days after challenge from the L. paracasei CRL 1289 and the probiotic + pathogen groups, decreasing this number on the following days. The treatment with L. paracasei CRL 1289 decreased significantly the number of staphylococci recovered at 2 and 5 days when mice were challenged only with 105 CFU of pathogen. The inoculation of S. aureus produced a remarkable inflammatory response and structural alterations in the vaginal mucosa that decreases in a significant manner when the mice were protected with L. paracasei CRL 1289. The results obtained suggest that this particular Lactobacillus strain could prevent the onset of urogenital infections by interfering with the epithelial colonization by uropathogenic S. aureus.
PMCID: PMC1868078  PMID: 17485818
14.  Pneumococcal Meningitis during Pregnancy: A Case Report and Review of Literature 
Background. Bacterial meningitis is a medical emergency for which prompt diagnosis and treatment are imperative to reducing the rate of death and long-term neurologic compromise. Few cases of meningitis have been reported during pregnancy, many of which had devastating outcomes for mother, neonate, or both. Case. A 38-year-old multigravida at 35 weeks of gestation presented with mental status changes, fever, and preterm contractions. Lumbar puncture revealed gram positive cocci consistent with S. pneumoniae. Patient was intubated and admitted to ICU where she was given antibiotics and adjunctive therapy with dexamethasone. Continuous fetal monitoring was utilized throughout her course of her hospitalization. Patient was discharged home after ten days in the hospital and had an uncomplicated vaginal birth after caesarean section (VBAC) at 38 weeks. Both she and the infant are doing well with no permanent neurologic sequelae. Conclusion. A review of literature indicates only isolated cases of pneumococcal meningitis being described during pregnancy. An extended period of time between onset of maternal illness and delivery appears to reduce the risk of neonatal transmission and improve both maternal and fetal outcomes.
PMCID: PMC1852901  PMID: 17485820
15.  Sonographically Diagnosed Vault Hematomas Following Vaginal Hysterectomy and Its Correlation with Postoperative Morbidity 
Objective. Our aim is to investigate sonographically detectable vault hematomas after vaginal hysterectomy and its relation to postoperative morbidity. Methods. We studied a group of 103 women who had undergone vaginal hysterectomy for benign causes apart from uterovaginal prolapse. Transabdominal ultrasound examinations were carried out 24 to 72 hours after surgery to assess the presence of vault hematomas. Ultrasound findings were correlated with clinical data and postoperative morbidity. Results. The incidence of vault hematoma was found 19.4% in present study. In these patients, 40% (8/20) had fever while only 2.4% (2/83) of cases without vault hematoma suffered from fever. Out of all women having vault hematoma, 70% (14/20) had small-sized hematoma and 30% (6/20) had large-sized hematoma. Fifty percent of patients (3/6) with large-sized hematoma, as compared to only 35% (5/14) with small-sized hematoma, suffered from febrile morbidity. Large-sized hematomas drained by vaginally, while all small-sized pelvic hematomas managed by watchful expectancy successfully. The significant difference was found mean hemoglobin drop and postoperative stay in the hematoma group or without hematoma group. Conclusion. Sonographic detection of vaginal vault fluid collection is common after hysterectomy, but such a finding rarely indicates additional treatment. Though febrile morbidity was more in cases with vault hematoma, the number of such patients was too small to be significant. Vaginal ultrasound examination should not be performed routinely after hysterectomy.
PMCID: PMC1847506  PMID: 17485823
16.  Abdominal Wall Mycetoma Presented as Obstructed Incisional Hernia of Cesarean Section in Eastern Sudan 
Mycetoma a worldwide disease frequently occurs in the tropics with the highest prevalence being in Africa. Madurella mycetomatis is the main causative organism of human eumycetoma in Sudan. The legs and feet were commonly the sites of the infection. A 22-year-old lady was presented with painful abdominal swelling around a previous caesarian section scar. A provisional diagnosis of obstructed incisional hernia was put. Histopathological examination revealed macroscopically four masses of soft tissue. Microscopic sections showed grains of Madurella mycetomatis.
PMCID: PMC1847505  PMID: 17485822
17.  Frequency of Chlamydia trachomatis in Women with Cervicitis in Tehran, Iran 
Chlamydia trachomatis (CT) is the most common cause of bacterial sexually transmitted infection (STI) worldwide, but current data concerning the prevalence of CT among women in Iran is scarce. Data regarding the frequency of CT infection among Iranian women can help to justify the implementation of a national CT screening program that can reduce the high morbidity associated with sequelae of CT infections by treating infected women. Endocervical secretions from 123 married women (20–55 years) with cervicitis were tested by a PCR-EIA method using primers to amplify a CT-specific plasmid. The digoxigenin-labeled amplicon was measured by hybridization to a biotin-labeled probe and a strepavidin-coated plate, followed by an enzyme-linked colorimetric analysis. Overall frequency of CT infection among women was 17% (21/123). The range of CT frequency among various age groups was 12–25%. The 31–40-year-age group comprised the majority (49%) of CT positive samples, followed by 20–30 year group (33%). Although the 20-to-30-year-old women reported the highest frequency of STI history, they had the lowest relative frequency of CT infection (12%). There is a high frequency of CT infection among women with cervicitis in Tehran, Iran, thus indicating a necessity to implement a routine CT screening program in the major cities of Iran and possibly nationwide. Identification of CT-infected women may prevent its spread, and thereby reduce the high morbidity associated with CT infections among women in Iran.
PMCID: PMC1803038  PMID: 17485821
18.  Cost Comparisons between Home- and Clinic-Based Testing for Sexually Transmitted Diseases in High-Risk Young Women 
Home testing for chlamydia and gonorrhea increases screening rates, but the cost consequences of this intervention are unclear. We examined the cost differences between home-based and clinic-based testing and the cost-effectiveness of home testing based on the DAISY study, a randomized controlled trial. Direct and indirect costs were estimated for home and clinic testing, and cost-effectiveness was calculated as cost per additional test performed. In the clinic testing group, direct costs were 49/test and indirect costs (the costs of seeking or receiving care) were 62/test. Home testing cost was 25/test. We found that home testing was cost saving when all testing for all patients was considered. However cost savings were not seen when only asymptomatic tests or when patient subgroups were considered. A home testing program could be cost saving, depending on whether changes in clinic testing frequency occur when home testing is available.
PMCID: PMC2216070  PMID: 18273404
19.  Genital Tract Interleukin-8 but not Interleukin-1β or Interleukin-6 Concentration is Associated with Bacterial Vaginosis and Its Clearance in HIV-Infected and HIV-Uninfected Women 
Genital tract infections and cytokine perturbations are associated with increased HIV acquisition and transmission. We measured the relationship between bacterial vaginosis (BV) and concentrations of Interleukin-8 (IL-8), Interleukin-1β (IL-1β), and Interleukin-6 (IL-6) in cervicovaginal lavage (CVL) specimens collected longitudinally from 16 HIV-infected and 8 HIV-uninfected high-risk women. CVL samples were analyzed when women presented with BV, and at their next visit, after successful treatment, when BV was cleared. A subset of participants had cytokine levels evaluated at three consecutive clinic visits: before developing BV, at the time of BV diagnosis, and after clearing BV. Significantly higher IL-8, but not IL-1β or IL-6 levels were present when women had active BV compared to when BV was absent. Trends in cytokine levels were similar for HIV-infected and HIV-uninfected women. BV in these women was associated with significantly higher concentrations of genital tract IL-8 which decreased 2.4 fold when BV was cleared.
PMCID: PMC2216434  PMID: 18273408
20.  Safety Study of an Antimicrobial Peptide Lactocin 160, Produced by the Vaginal Lactobacillus rhamnosus  
Objective. To evaluate the safety of the antimicrobial peptide, lactocin 160. Methods. Lactocin 160, a product of vaginal probiotic Lactobacillus rhamnosus 160 was evaluated for toxicity and irritation. An in vitro human organotypic vaginal-ectocervical tissue model (EpiVaginal) was employed for the safety testing by determining the exposure time to reduce tissue viability to 50% (ET-50). Hemolytic activity of lactocin160 was tested using 8% of human erythrocyte suspension. Susceptibility of lactobacilli to lactocin160 was also studied. Rabbit vaginal irritation (RVI) model was used for an in vivo safety evaluation. Results. The ET-50 value was 17.5 hours for lactocin 160 (4.9 hours for nonoxynol 9, N9). Hemolytic activity of lactocin 160 was 8.2% (N9 caused total hemolysis). Lactobacilli resisted to high concentrations of peptide preparation. The RVI model revealed slight vaginal irritation. An average irritation index grade was evaluated as “none.” Conclusions. Lactocin 160 showed minimal irritation and has a good potential for intravaginal application.
PMCID: PMC2216118  PMID: 18273406
21.  Phase I Trial of a Lactobacillus crispatus Vaginal Suppository for Prevention of Recurrent Urinary Tract Infection in Women 
Objectives: We performed a phase I trial to assess the safety and tolerance of a Lactobacillus vaginal suppository for prevention of recurrent UTI. Methods: Premenopausal women with a history of recurrent UTI were randomized to use L. crispatus CTV-05 or placebo vaginal suppositories daily for five days. Results: 30 women were randomized (15 to L. crispatus CTV-05). No severe adverse events occurred. Mild to moderate vaginal discharge and genital irritation were reported by women in both study arms. Seven women randomized to L. crispatus CTV-05 developed pyuria without associated symptoms. Most women had high concentrations of vaginal H202-producing lactobacilli before randomization. L. crispatus, L. jensenii, and L. gasseri were the most common Lactobacillus species identified, with stable prevalence over time. Conclusions: L. crispatus CTV-05 can be given as a vaginal suppository with minimal sideeffects to healthy women with a history of recurrent UTI. Mild inflammation of the urinary tract was noted in some women.
PMCID: PMC2216064  PMID: 18288237

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