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2.  Effect of Butoconazole Nitrate 2% Vaginal Cream and Miconazole Nitrate 2% Vaginal Cream Treatments in Patients with Vulvovaginal Candidiasis 
In a multicenter, randomized, invesgtigator-blind, parallel study, 398 patients were dispensed topical butoconazole nitrate 2% cream for 3 days (n = 199) or miconazole nitrate 2% cream for 7 days (n = 199) for vaginal use. Efficacy analyses included 254 patients with culture-confirmed Candida (119 butoconazole and 135 miconazole users). Of the 398 patients issued study medication, 9 were lost to follow-up. Therefore, safety analyses included 389 patients (197 butoconazole and 192 miconazole users). Evaluations upon admission and approximately 8 and 30 days post-treatment included Candida cultures, potassium hydroxide (KOH) wet mounts, and vulvovaginal examinations, with rating of vulvovaginal signs and symptoms using a 4-point scale. Rates of clinical cure (based on sign/symptom scores), microbiologic cure (based on cultures and wet mounts), and therapeutic cure (both clinical and microbiologic cures) were assessed and were to be similar between the regimens. Therapeutic cure rates were 57.8% and 61.4% for butoconazole and miconazole, respectively. Three-day butoconazole treatment was as safe and effective as 7-day miconazole therapy in treating vulvovaginal candidiasis.
PMCID: PMC2364522  PMID: 18476119
3.  The Evolution of a Journal 
PMCID: PMC2364521  PMID: 18476115
4.  Antibiotic Prophylaxis for Presumptive Group B Streptococcal Infection in Preterm Premature Rupture of the Membranes: Effect on Neonatal and Maternal Infectious Morbidity 
Objective: The purpose of this study was to determine if the prevalence of neonatal and maternal infectious morbidity in patients with preterm premature rupture of membranes (PROM) who received ampicillin prophylaxis for presemptive group B streptococcal colonization is increased compared to those who received no prophylaxis.
Methods: The charts of all patients with preterm PROM who delivered between January 1988 and December 1993 were retrospectively reviewed. The routine use of ampicillin prophylaxis was initiated in January 1991. Patients with singleton gestations were included in the analysis only if chorioamnionitis was excluded on admission. Variables used in the final analysis included gestational age at the time of preterm PROM, gestational age at delivery, duration of rupture of membranes, birth weight, method of delivery, use of steroids, tocolytics, or antibiotics for group B streptococcus prophylaxis, neonatal sepsis, neonatal mortality, and postpartum endomyometritis. Data were analyzed using Student's t-test, chi-square test, Fisher's exact test, and stepwise logistic regression analysis to evaluate the effect of chemoprophylaxis for group B streptococcus on the incidence of neonatal sepsis and maternal postpartum endomyometritis. A two-tailed P < 0.05 was used to denote statistical significance.
Results: The charts of 206 patients were reviewed; 146 patients received ampicillin for group B streptococcal prophylaxis and 60 patients did not. There was a significantly higher incidence of postpartum endomyometritis among the patients who received ampicillin (62% vs. 22%; P < 0.01). The association between postpartum endomyometritis and chemoprophylaxis remained significant even after controlling for other confounding variables. There was no significant difference in the incidence of neonatal sepsis (5% vs. 7%; P = 0.7) or death (5% vs. 3%; P = 0.9) between both groups.
Conclusions: Group B streptococcal prophylaxis with a short course of intravenous ampicillin increases the risk of postpartum endomyometritis in patients with premature PROM.
PMCID: PMC2364520  PMID: 18476117
5.  Role of Genital Mycoplasmas in Bacteremia: Should We Be Routinely Culturing for These Organisms? 
Objective: The purpose of this study was to examine the role of the genital mycoplasmas Mycoplasma hominis and Ureaplasma urealyticum as causes of bacteremia in a tertiary referral obstetrical, gynecological, and neonatal intensive care facility, over a period of 12 years from 1983 to 1994 inclusively.
Methods: All clinically significant blood cultures were reviewed and the percentage of septicemic episodes for genital mycoplasmas was compared to the total isolation rate, including conventional bacteria.
Results: The overall positivity rate for all pathogenic organisms isolated from the blood cultures of infants ranged from 4.5% to 7.7% per annum. U. urealyticum represented 0.8% of these positive isolates and M. hominis 0.4%. For adults, the overall positivity rate from blood cultures ranged from 6.5% to 13.5%, with U. urealyticum representing 9.6% of these positive isolates and M. hominis 9.9%.
Conclusions: With M. hominis having an established role in such clinical entities as postabortal and postpartum fever and U. urealyticum strongly implicated with chronic lung disease in low birth weight infants, it is appropriate to examine blood cultures for genital mycoplasmas in an obstetric institution.
PMCID: PMC2364519  PMID: 18476120
6.  Ex Vivo Human Placental Transfer of Rifampin and Rifabutin 
Objective: The purpose of this study was to determine the ex vivo human placental transfer of rifampin and rifabutin.
Methods: Seven placentas from uncomplicated term vaginal or cesarean deliveries were studied utilizing the ex vivo single cotyledon perfusion system. Antipyrine was used for the reference compound in the determination of the clearance indices of rifampin and rifabutin.
Results: The clearance indices of rifampin at maternal concentrations of 1.0 and 10.0 μg/ml were 0.12 ± 0.05 and 0.12 ± 0.11, respectively. The clearance indices of rifabutin at maternal concentrations of 1.0 and 10.0 μg/ml were 0.44 ± 0.11 and 0.37 ± 0.15, respectively.
Conclusions: Because of its greater lipophilicity, rifabutin was found to have a greater clearance than rifampin. However, because of rifabutin's trend toward greater deposition in tissue, there was proportionately less accumulation of rifabutin in the fetal circulation when compared to rifampin.
PMCID: PMC2364518  PMID: 18476118
7.  Varicella Pneumonia Complicating Pregnancy: A Report of Seven Cases 
Background: Pneumonia is the most common complication of varicella-zoster infection in adults and has potentially devastating effects when complicating pregnancy. Due to the significant morbidity and mortality associated with this complication during pregnancy and the small number of reported cases in the literature, we present this report to help educate physicians who care for pregnant women.
Cases: Seven patients are presented in this report. These patients presented at various stages in pregnancy, from 17 to 31 weeks of gestation. Three of the patients had unremarkable hospital courses. Three of the patients had hospital stays over 21 days in duration. One patient died from complications of varicella pneumonia after 31 days of hospitalization. The obstetric outcomes of the 7 patients described include 1 non-viable delivery at 20 weeks gestation, 3 term deliveries, 2 preterm deliveries, and 1 patient who has not yet delivered. All of the patients presented were treated with intravenous acyclovir therapy. Of the patients described, 3 required intubation and ventilatory support. Other complications encountered include disseminated intravascular coagulation (DIC), adult respiratory distress syndrome (ARDS), metabolic encephalopathy, pneumothorax, superimposed bacterial pneumonia, and sepsis.
Conclusion: The course and treatment of varicella pneumonia complicating pregnancy are discussed. Current recommendations regarding the use of varicella-zoster immune globulin (VZIG) are also reviewed.
PMCID: PMC2364517  PMID: 18476122
8.  Norplant™ Cellulitis 
PMCID: PMC2364516  PMID: 18476116
9.  Randomized Clinical Trial of Azithromycin vs. Erythromycin for the Treatment of Chlamydia Cervicitis in Pregnancy 
Objective: The purpose of this study was to prospectively test the null hypothesis that there is no difference in the clinical effectiveness of azithromycin and erythromycin for the treatment of chlamydia cervicitis in pregnancy.
Methods: All antepartum obstetrical patients underwent routine screening for chlamydia cervicitis using a DNA probe assay (Gen-Probe Pace, San Diego, CA). Women who tested positive for chlamydia cervicitis were prospectively randomized to receive either azithromycin 1 g orally at enrollment, or erythromycin 500 mg orally 4 times a day for 7 days. Sexual partners were referred to the county health department for evaluation and treatment. A test of cure was repeated in 2 weeks. Results were analyzed by chi-square analysis and Fisher's exact test when indicated.
Results: One hundred forty women tested positive for chlamydia cervicitis and agreed to randomization. There were 4 (6.2%) treatment failures in the azithromycin group and 18 (27.7%) in the erythromycin group (P = 0.005). Gastrointestinal side effects were reported by 42 (65.5%) of the women taking erythromycin, but only 12 (19.4%) of those taking azithromycin (P < 0.002). Gastrointestinal side effects and resultant noncompliance were significantly related to treatment failure with erythromycin.
Conclusions: The findings of this study support the conclusion that a single dose of azithromycin is a significantly more effective and better tolerated treatment regimen for chlamydia cervicitis in pregnancy than erythromycin which is currently recommended.
PMCID: PMC2364515  PMID: 18476121
10.  Vulvar Vestibulitis—A Complex Clinical Entity 
Objective: This study aims to determine the pathophysiology of vulvar vestibulitis and to evaluate currently used treatment options.
Methods: Two hundred twenty women with vulvar vestibulitis were seen between October 1987 and March 1995. Every patient had vulvar pain when they attempted intercourse, 75% had excessive vaginal discharge, 36.4% had constant or recurring vulvar burning, and 10.9% had symptoms suggestive of cystitis. All were cultured for the presence of Candida albicans. One hundred sixty-one (73.2%) were also tested for vaginal IgE and prostaglandin E2 (PGE2); 72 (32.7%) had a vulvar biopsy performed as well.
Results: A wide range of variants were noted: 53 (24.1%) had a human papilloma virus (HPV) infection, 25 (11.4%) had a Candida vulvovaginitis, 43 (19.5%) had a vaginal allergy, 15 (6.8%) had vaginal PGE2 present, 14 (6.4%) had elevated urinary oxalate excretion, and 29 (13.2%) had a variety of diagnosed variants. In 81 (36.8%) no underlying diagnosis was made. This understates the numbers and varieties of vulvar vaginal diagnoses, for not all patients received a vaginal fluid analysis, a vulvar biopsy, or a 24 h urine screen for oxalates. A variety of medical and operative interventions was used. Symptoms were relieved in 65.9% of patients. The degree of sueeess varied. Successful outcomes were achieved in 14.3% of patients using a low oxalate diet and calcium citrate supplementation, 16% with anti-Candida treatment, 48.1% with antihistamines, 77% with vulvar injection of interferon, 83% with operative removal of inflamed vulvar tissue, and a posterior colporrhaphy used to cover the cutaneous defect.
Conclusions: The diagnosis of vulvar vestibulitis is easy to make. An etiology for this chronic condition will not be achieved in every patient. A majority of patients can get relief by a variety of medical and operative interventions.
PMCID: PMC2364514  PMID: 18476106
11.  Intra-amniotic Infection Caused by Capnocytophaga Species 
Background: Capnocytophaga species are common oral pathogens and infrequent causes of systemic infection in patients with compromised host. The isolation of this organism suggests an oral source of infection.
Case: A 32-year-old woman was admitted at 23 weeks gestation in preterm premature rupture of the membranes. She subsequently developed signs of clinical intra-amniotic infection, including fever, fetal tachycardia, and uterine tenderness. Bacteriologic studies of the amniotic fluid by trans-abdominal amniocentesis and subchorionic placental cultures yielded Capnocytophaga species. On review of the patient's history, a temporal relation was noted between orogenital contact and onset of clinical infection. Thorough evaluation of the patient, including dental examination with periodontal cultures, did not reveal an obvious source of infection. However, significant periodontal disease was identified in her partner and Capnocytophaga species were isolated from her partner.
Conclusion: This case suggests that intra-amniotic infection may have been due to an ascending infection after orogenital contact.
PMCID: PMC2364513  PMID: 18476112
12.  Desquamative Inflammatory Vaginitis 
PMCID: PMC2364512  PMID: 18476103
13.  Ultrasound-guided Transvaginal Aspiration in the Management of Actinomyces Pelvic Abscess 
Background: Increasing reports of intrauterine device (IUD)-related abdominopelvic actinomycosis have been described recently. Surgical therapy has been the usual treatment when tubo-ovarian abscess is identified.
Case: A 38-year-old woman suffering from Actinomyces pelvic abscess unresponsive to medical treatment underwent transvaginal ultrasound-guided needle aspiration. It resulted in marked improvement and avoided surgical treatment.
Conclusion: Transvaginal needle aspiration of Actinomyces pelvic abscess may be an alternative to surgical therapy, thereby allowing the preservation of pelvic organs.
PMCID: PMC2364511  PMID: 18476111
14.  Letter to the Editor 
PMCID: PMC2364510  PMID: 18476114
15.  New Faces and Affiliations 
PMCID: PMC2364509  PMID: 18476102
16.  Screening for Human Immunodeficiency Virus in Inner City Females With Abnormal Cervical Cytology 
Objective: This report evaluates the acceptance, results, and predictors of human immunodeficiency virus (HIV) infection in inner city women referred to a colposcopy clinic for abnormal cervical cytology.
Methods: HIV testing results of 1,908 inner city women referred for abnormal cervical cytology were analyzed retrospectively with respect to acceptance, race, ethnicity, Pap smear results, sexually transmitted diseases (STDs), HIV exposures, and final histologic findings.
Results: HIV testing was accepted by 50.4% of patients. Women who agreed to screening were significantly more likely to admit exposure to HIV or to be Hispanic, foreign-born, or have a history of multiple STDs. Of those screened, 3.3% were found to be HIV seropositive. Although higher grades of referral Pap smears were noted in the women found to be HIV seropositive, final histologic findings were not different. The only predictors of unknown HIV seropositivity were admitted HIV exposure and external condyloma.
Conclusions: Fifty percent of inner city women of unknown HIV status referred for abnormal cervical cytology will accept HIV serotesting and 3.3% are found to be positive. Most HIV-seropositive women can be detected based on either a history of exposure to HIV or the presence of external condyloma.
PMCID: PMC2364508  PMID: 18476108
17.  Immunohistochemical Characterization of Leukocytic Subpopulations in Chronic Endometritis 
Objective: We analyzed the histologic and immunohistochemical changes in the endometrial leukocytic subpopulations to determine which of them are characteristic of chronic endometritis.
Results: Endometrial biopsies from 25 cases of chronic endometritis and 35 controls were studied. Characteristic morphologic findings included the presence of a plasma cell infiltrate, and a prominent, albeit non-specific, lymphocytic infiltrate in all patients with endometritis. A neutrophilic infiltrate was also noted in 90% of the patients. Other non-specific histologic findings included occasional prominent lymphoid aggregates, stromal edema, hemorrhage, and necrosis and cystic dilation of some glands in endometria of patients with chronic endometritis. Endometrial immune cells were investigated immunohistochemically using antibodies to CD3 (pan-T), CD20 (pan-B, L26), and Ham-56 (macrophage). In control patients, endometrial immune cells were predominantly composed of CD3 and Ham-56 positive cells. CD20 positive cells comprised <2% of immune cells in control patients [mean: <2 cells/high power field (HPF)]. Large numbers of CD20 and CD3 lymphocytes were seen in endometria of patients with chronic endometritis. A semiquantitative analysis showed that the numbers of CD20 and CD3 positive cells in patients with chronic endometritis were increased 50- and 3-fold, respectively, when compared to those of control patients (mean B cells: 49 vs. 2 cells/HPF; mean T cells: 149 vs. 45 cells/HPF). CD20 positive cells were predominantly seen in subepithelial and periglandular aggregates. CD3 positive cells had a predominant stromal distribution and an occasional intra- or subepithelial localization. There was no difference in the number and distribution of Ham-56 positive cells in patients with or without endometritis.
Conclusions: These findings suggest that CD20 cells may have a significant role in the pathogenesis of chronic endometritis and that immunostaining for B and T lymphocytes could be used in confirming the diagnosis of endometritis or in diagnosing subclinical or progressing endometritis in which plasma cells could not be detected or are rarely identified.
PMCID: PMC2364507  PMID: 18476109
18.  Cholecystitis in Pregnancy 
Biliary tract disease is a relatively uncommon, heterogenous disease in pregnancy. Specifically, acute cholecystitis can be especially difficult to recognize in pregnancy. However, once diagnosed, the initial management plan should be conservative and include antibiotic therapy. Subsequent management depends on the gestational age at diagnosis. Surgical therapy, when indicated, should not be delayed and a planned intervention during the second trimester appears to offer a better outcome than surgery performed under emergent conditions.
PMCID: PMC2364506  PMID: 18476113
19.  Polymerase Chain Reaction Assay With Urine Specimens in the Diagnosis of Acute Chlamydia trachomatis Infection in Women 
Objective: The purpose of this study was to evaluate the benefits achievable by Amplicor polymerase chain reaction (PCR) (F. Hoffmann-LaRoche Ltd., Basel, Switzerland) with urine specimens in addition to PACE 2 (Gen-Probe, Inc., San Diego, California) assay with cervical swab specimens in the diagnosis of Chlamydia trachomatis in women.
Methods: Cervical and urine specimens from 286 women were tested for C. trachomatis by PACE 2 and Amplicor PCR, respectively. All urine specimens were analyzed undiluted and diluted 1:10 to detect and eliminate possible PCR inhibition. A confirmatory PCR assay using major outer membrane protein-based primers (MOMP-PCR) was used on urine specimens that were positive by PCR from women who were negative by PACE 2 with cervical swab specimens.
Results: Of the endocervical specimens, 26 were positive by the PACE 2 assay. The PCR with urine was positive in 21 of these patients. When the urine specimens were analyzed diluted 1:10, 4 of the 5 PCR-negative specimens from PACE 2-positive patients turned positive by the PCR. Additionally, 4 urine specimens from PACE 2-negative women were positive by the PCR with urine, and 3 of them could be confirmed by MOMP-PCR. Altogether, 29 women were found to be positive for C. trachomatis by either of the two assays.
Conclusions: By using the PCR with urine specimens, an 11% increase in sensitivity could be achieved in addition to that obtained by PACE 2 assay with cervical swab specimens. In the present material, however, the increased sensitivity was reversed by the presence of PCR inhibitors in 14% of the female urine specimens. Amplicor PCR with urine specimens can undoubtedly be recommended for the diagnosis of chlamydial infections in women. However, constant monitoring of the PCR inhibition seems highly advisable to obtain full benefit of the sensitivity of the PCR.
PMCID: PMC2364505  PMID: 18476107
20.  Piperacillin/Tazobactam (ZOSYN) 
PMCID: PMC2364504  PMID: 18476104
21.  Significance of Genital Mycoplasmas in Pelvic Inflammatory Disease: Innocent Bystander! 
Objective: Our objective was to determine the role of Mycoplasma hominis and Ureaplasma urealyticum in pelvic inflammatory disease (PID).
Methods: The clinical and microbiologic variables in 114 patients with a clinical diagnosis of PID were compared prospectively according to the isolation of M. hominis and U. urealyticum from their endometrial cavities.
Results: The groups were epidemiologically well matched. Clinical parameters such as temperature, leukocyte count, erythrocyte count, and C-reactive protein on admission and length of hospital stay were similar in the patients, regardless of their mycoplasma status. A significant percentage of the patients either continued or started to harbor genital mycoplasmas after the resolution of PID without any significant clinical sequelae.
Conclusions: The presence of genital mycoplasmas does not change the clinical presentation and course of PID. Both M. hominis and U. urealyticum can persist or colonize the endometrium after complete recovery from PID. Therefore, the genital mycoplasmas do not seem to have a dominant pathogenic role in PID.
PMCID: PMC2364503  PMID: 18476105
22.  Randomized Clinical Trial of Antibiotic Therapy for Antenatal Pyelonephritis 
Objective: The aim of this study was to prospectively evaluate the efficacy of a therapeutic course of intravenous antibiotics followed by oral antibiotics vs. intravenous antibiotics alone to prevent recurrent urinary tract infection.
Methods: Pyelonephritis was documented by strict criteria in 67 pregnant women who were then treated with appropriate intravenous antibiotics until afebrile and asymptomatic for 48 h. Women were then randomized to completion of a 10-day course of oral nitrofurantoin 100 mg qid or no further antibiotic therapy. Urine cultures (UC) were obtained 2 and 6 weeks after discharge, and at delivery. A positive UC or readmission for pyelonephritis was considered endpoints for participation in the study. Antibiotic suppression was not used.
Results: Readmission for pyelonephritis prior to the 2-week follow-up visit occurred in 2/36 (5.6%) women randomized to the oral therapy group compared to 4/31 (12.9%) in the no oral treatment group (P = 0.29). At the 2-week follow-up visit, 6/31 (19.4%) women had a positive UC in the oral therapy compared to 8/26 (30.1%) in the no oral treatment group but this difference was not statistically significant (P = 0.31).
Conclusions: Completion of 10 days of antibiotic therapy with oral medication does not significantly reduce the risk of recurrent pyelonephritis immediately post-parenteral treatment. Women in the no oral treatment group had a non-significant increase in positive UC at the 2-week follow-up visit. The high rates of recurrent urinary tract infection during pregnancy in both groups underscore the need for regular UC and for the possible role of oral antibiotic suppression.
PMCID: PMC2364502  PMID: 18476110
23.  Investigations by Cell-Mediated Immunologic Tests and Therapeutic Trials With Thymopentin in Vaginal Mycoses 
Objective: According to unsatisfactory therapeutic results in patients with chronically recurrent vaginal candidosis, we investigated if immunologic patient factors could be found and treated.
Methods: In 42 women with chronically recurrent and 20 women with acute Candida albicans vulvovaginitis, as well as 14 women with C. glabrata vaginitis, the following investigations were carried out: identification of yeast species; quantification of T lymphocytes and their subpopulations in sera; proliferation tests of T lymphocytes in vitro; treatment of 18 patients with chronically recurrent vaginal candidosis with the synthetic T-lymphocyte- stimulator thymopentin; and, finally, control of the above-mentioned parameters in the clinical course.
Results: Women with C. albicans vulvovaginitis showed fewer T lymphocytes and subpopulations in the peripheral blood than healthy women. Only the number of non-specific killer (NK) cells, however, was significantly lower in cases of acute C. albicans vulvovaginitis. In women with C. glabrata vaginitis, the number of T lymphocytes in the blood was within the normal range. In vitro proliferation tests using mitogens, bacterial antigens, and commercially available candida antigens with and without addition of thymopentin were carried out on the T lymphocytes of women with chronically recurrent C. albicans vulvovaginitis. These tests revealed no significant differences compared with the other patients with C. albicans infections. The patients were treated with thymopentin. Those women who revealed an increase of initially low numbers of T-helper cells recovered from vaginal candidosis after thymopentin treatment.
Conclusions: The peripheral T lymphocytes may be diminished in patients with chronically recurrent C. albicans vaginitis, and immunologic treatment can reduce the relapse rate.
PMCID: PMC2364501  PMID: 18476097
24.  Treatment of Recurrent Eczema Herpeticum in Pregnancy With Acyclovir 
Background: Eczema herpeticum is an uncommon manifestation of an infection with herpes simplex virus (HSV). The disease is primarily seen in patients with histories of atopic eczema. Eczema herpeticum may be a life-threatening illness, but the mortality is felt to be <10% with modern antiviral and antibacterial agents. The use of acyclovir for other viral infections secondary to herpesvirus in pregnancy has been well documented. The authors now present a case report of eczema herpeticum treated with acyclovir during pregnancy.
Case: A patient with a history of eczema herpeticum presented in pregnancy with a recurrence. She was successfully treated with intravenous (IV) acyclovir with good maternal and fetal outcome.
Conclusion: Acyclovir may be utilized in pregnancy for several manifestations of HSV including eczema herpeticum.
PMCID: PMC2364500  PMID: 18476099
25.  Azithromycin (Zithromax®) 
Azithromycin (Zithromax®, Pfizer, Inc., New York, NY) is a 15-membered-ring macrolide and the first azalide antibiotic. It is distinguished from other macrolides by its rapid and extensive penetration into intracellular and interstitial tissue compartments, accompanied by prolonged tissue and serum half-lives. Azithromycin shares the gram-positive activity of erythromycin but is more potent against gram-negative organisms. For urethritis and cervicitis caused by Chlamydia trachomatis, azithromycin is effective and well tolerated in a single dose of 1 g, a regimen recommended by the CDC. A 5-day dosage regimen is available for the treatment of community-acquired respiratory-tract and skin and skin-structure infections caused by susceptible organisms. Azithromycin provides short-duration, high-compliance, cost-effective regimens that should improve outcomes.
PMCID: PMC2364499  PMID: 18476095

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