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Uncomplicated urogenital and concomitant oropharyngeal gonorrhea in 424 male and female patients was treated in a randomized comparative study with 0.5 g of cefodizime (89 men and 54 women), 1 g of cefodizime (87 men and 52 women), or 1 g of cefotaxime (86 men and 56 women). The cure rates were 100% for men and women in the group given 0.5 g of cefodizime, 100% for men and women in the group given 1 g of cefodizime, and 99% for men and 100% for women in the group given 1 g of cefotaxime. The MICs of cefodizime and cefotaxime for the isolate of Neisseria gonorrhoeae ranged from 0.004 to 0.06 micrograms/ml. Chlamydia trachomatis was isolated before treatment in 15% and after treatment in 13% of all patients. Side effects, such as nausea, diarrhea, abdominal pain, genital candidiasis, and pain at the site of injection, developed in 4% of the patients given cefodizime. Side effects, such as vertigo, genital candidiasis, fatigability, and diarrhea, developed in 4% of the patients treated with cefotaxime. In both groups of patients, the side effects were mild and transient. Cefodizime and cefotaxime are safe and effective agents in the treatment of uncomplicated urogenital gonorrhea.
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PMID:Randomized comparative study of 0.5 and 1 g of cefodizime (HR 221) versus 1 g of cefotaxime for acute uncomplicated urogenital gonorrhea. 337 56

Directed to the health care professional, this review covers the current concepts of pelvic inflammatory disease (PID) affecting adolescent and young adult women. It defines PID and discusses the magnitude of the problem, risk factors (sexual activity, age, method of contraception, history of previous PID, history of gonococcal of chlamydial lower genital tract infection, and uterine instrumentation), etiologic agents (N. gonorrhea, aerobic and anaerobic bacteria, chlamydia trachomatis, genital mycoplasmas, and other pathogens), pathogenesis, clinical and laboratory features, diagnostic evaluation, differential diagnosis, treatment, and sequelae. The Centers for Disease Control define acute PID as "the acute clinical syndrome (unrelated to pregnancy or surgery) attributed to the ascent of microorganisms from the vagina and endocervix to the endometrium, fallopian tubes, and/or contiguous structures." The true incidence and prevalence of PID in women is uncertain. Recent data show an increase to 267,200 in the average annual number of hospitalizations for PID during the 1975-81 period for women 15-44 years of age. PID occurs rarely in sexually inactive women. The large number of PID cases among adolescents reflects in part the high proportion of sexually active females in that group. The risk of developing PID in sexually active females is inversely related to age; 1/3 of all patients in Westrom's series were 19 years of age or younger at the time of their 1st PID episode, and 69% of all women with PID were younger than 25 years. Women who have had 1 episode of PID have a 20-25% chance of developing subsequent episodes. A large series of PID cases verified by laparoscopy has shown that only a small proportion of patients (3%) present with a severe clinical illness. Low abdominal pain is the most common symptom and may be present for variable periods of time prior to diagnosis. Other common symptoms include vaginal discharge (55%), irregular vaginal bleeding (36%), urinary symptoms (19%), nausea and vomiting (10%), and proctitis symptoms (7%). The major goals of therapy in PID are to prevent infertility and other long-term sequelae. About 15% of patients fail to respond to initial antibiotic therapy, 20% experience recurrences, 20% develop involuntary infertility, and 8% of post-PID patients who conceive have an ectopic pregnancy. Early diagnosis and treatment reduces the risk of residual tubal damage.
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PMID:Acute pelvic inflammatory disease. 360 34

Despite the magnitude of the clinical and economic impact of pelvic inflammatory disease (PID), little is known about its outpatient presentation. We compared retrospectively the clinical and epidemiologic characteristics of 70 women with gonococcal PID, 44 women with nongonococcal PID, and 8,576 control women without PID seen in a clinic for sexually transmitted diseases. Gonococcal PID was associated with black race (P less than .002) and a shorter period of abdominal pain (P less than .02). Nongonococcal PID was associated with white race (P less than .005) and a history of previous gonococcal infection (P less than .02). There were no significant differences between groups in age, parity, number of sexual partners, contraceptive use, or febrility. PID seen in women attending our outpatient clinic is often mild, and the diagnosis uncertain. We found few reliable indicators to aid in the clinical diagnosis or to distinguish etiology. More studies are needed to improve the outpatient management of PID and limit its impact.
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PMID:Comparison of the clinical and epidemiologic characteristics of gonococcal and nongonococcal pelvic inflammatory disease seen in a clinic for sexually transmitted diseases, 1978-1979. 376 22

Rates of genital infection with Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis were determined prospectively in 396 sexually active female adolescents from three ethnically different urban teen clinics. The organisms were identified respectively in cultures of specimens from 21%, 7% and 6% of all adolescents; 28%, 16% and 20% of blacks; 23%, 4% and 2% of Hispanics, and 14%, 2% and 1% of whites. C trachomatis was identified in specimens from 27% of pregnant adolescents and from 42% of adolescents who had gonorrhea or trichomoniasis. Of 85 Chlamydia-positive adolescents, 47 (55%) were asymptomatic. Physical findings significantly associated (P <.001) with chlamydial infection were vaginal discharge, cervical inflammation and mucopurulent endocervical discharge. Not significantly associated (P >.05) with Chlamydia were the use of oral contraception or symptoms of lower abdominal pain, vaginal discharge or dysuria. Because in sexually active female adolescents C trachomatis is three times more common than N gonorrhoeae, care givers need to consider routine screening or epidemiologic treatment (or both) for both pathogens.
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PMID:Epidemiologic and clinical factors of Chlamydia trachomatis in black, Hispanic and white female adolescents. 403 12

This report presents a case of pelvic actinomycotic infection that was accurately diagnosed preoperatively by means of fine needle aspiration. The patient was a 40-year-old black female, gravida 6, para 6, who presented to the emergency room complaining of intermittent, crampy lower abdominal pain of approximately 1 month's duration. She also complained of a recent onset of urinary frequency and urgency without dysuria as well as a change in bowel habits, with recent constipation. Review of the patient's medical history was notable for the placement of a Dalkon Shield IUD 10 years before without subsequent removal, a history of irregular menses in the past year, and treatment for gonorrhea 10 years previously. The patient's last menstrual period was 2 weeks prior to admission. She denied fever and night sweats but had lost 20 pounds in the past 2-3 months. Vital signs were normal. Pelvic examination revealed a firm, fixed uterus, approximately the size of a 14-week pregnancy, and an associated mass extending to the left and inferiorly into the rectovaginal septum. An intravenous pyelogram showed left hydronephrosis and hydroureter, with compression of the ureter at the level of the sacrum. Sigmoidoscopy revealed extrinsic compression of the rectum at 12 cm, the some mucosal edema. A CT scan of the pelvis disclosed an 8 cm mass in continuity with the uterus extending into the lower pelvis, with possible focal erosion of the sacrum. The clinical impression was advanced cervical carcinoma. Transvaginal fine needle aspiration was performed using a 21-gauge spinal needle and a Franzen needle guide. Following a diagnosis of actinomycotic abscess, the patient was placed on tetracycline, due to her penicillin allergy, and taken to surgery. The abdomen was opened and revealed a slightly enlarged uterus. The uterus and cervix were adherent to the left pelvic wall and posteriorly to the rectum by firm, friable tissue. The left fallopian tube and ovary were adherent to this . With some difficulty the uterus was freed, and a total hysterectomy and bilateral salpingo-oophorectomy were performed. The postoperative course was unremarkable, and the patient was discharged on tetracycline. A morphologic diagnosis of actinomycotic infection with abscess formation was made. Sections of the left parametrium revealed multiple microabscesses and sinus tracts surrounded by abundant granulation tissue. Some of the abscesses contained actinomycotic organisms. Chronic endometritis and cervicitis as well as acute and chronic left salpingitis were documented.
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PMID:Diagnosis of pelvic actinomycosis by fine needle aspiration. A case report. 620 95

The experience of performing a conseceutive series of 1092 tubal sterilizations, using a local anesthesia, at a free standing outpatient clinic in the US between 1976-81 is reported. The clinic's experience demonstrated that low cost sterilizations could be performed safely in a facility lacking a general anesthesiologist, a blood bank, and a laporatomy set-up. Initially, unipolar forceps and closed laporscope tocar insertion was used, but in 1977 clinic personnel began using Kleppinger bipolar forceps to reduce the risk of ectopic burns and Hasson's open laparoscopy method to reduce the risk of extraperitoneal gas insufflation and vascular injury. Patient were initially screened over the telephone for cardiopulmonary disorders and other contraindications. 72 hours before the operation, they were counseled and informed of the risks. Preliminary laboratory examinations included blood counts, urinalyses, Papanicolaou smears, and gonorrhea cultures. In performing the sterilizations the local anesthestic, Xylocaine, was used. Surgical procedures included 1) administering a tranquilizing agent and an analgesic intravenously, 2) performing a paracervical block using a local anesthestic; 3) achieving uterine elevation; 4) infiltrating the subumbilical layers of the anterior abdominal wall with local anesthestic; 5) making a 1.5 cm incision; 6) inserting a 10 mm operating laparoscope; 6) creating pneumoperitoneum with nitrous oxide; 7) spraying and infiltrating the isthmic portion of the fallopian tubes with the local anesthestic; 8) cauterizing the tubes at 3 sites; and 9) releasing the pneumoperitoneum and closing up. Operating time is 15 minutes. The patient is observed for an hour and then discharged. The 1092 patient treated at the clinic had a median age of 31.7, a mean gravidity of 2.9, and a mean parity of 2.0. 17% had never delivered, 12.1% had never married, and 36% used no previous method of contraception. At the time of sterilization, 87 of the patients had IUDs removed, and 100 had abortions performed. Between 1976-81, complications associated with the sterilizations included 1) 2 cases of pelvic infection; 2) 7 cases of abdominal pain; 3) 6 cases each of incision bleeding, incision hematoma, and dysmenorrhea; and 4) 1 case each of vaginocervical laceration, vaginal bleeding, and paralytic ileus. 4 pregnancies were reported following sterilization, and 2 of these were ectopic pregnancies. 3 of the pregnancies occurred during the 1st 2 years of clinic operation, and only 1 during the last 3 years.
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PMID:Laparoscopic sterilization in a free-standing clinic: a report of 1,092 cases. 624 61

This discussion of acute pelvic inflammatory disease (PID) -- usually a spontaneous infection that occurs among sexually active, menstruating, nonpregnant women -- covers: pathophysiology; microbial etiology (gonorrhea, chlamydia, genital mycoplasmas, and aerobic and anerobic bacteria); epidemiology (number of sexual partners, age, IUDs, previous PID, previous gonorrhea, untreated male sexual contacts, and perihepatitis associated with PID); diagnosis (physical examination, laboratory examination, culdocentesis, examination of the male partner, cultures, and ultrasonography); treatment; and sequelae (recurrent PID, infertility, ectopic pregnancy, and pain). The majority of infections are caused by bacteria and a polymicrobial bacterial infection is common. Neisseria gonorrhea, Chlamydia trachomatis, and a wide variety of aerobic and anerobic bacteria are most frequently isolated from women with PID. Primary PID is usually and acute infection in which organisms ascend into the uterus and fallopian tubes from the cervix. Chronic active infections are unusual except in neglected cases and in Actinomyces infection, but sterile chronic inflammatory adhesions are common residuals of acute infection. Except for women who have an IUD in place or the 15% who have had uterine instrumentation, spontaneous PID is almost totally confined to women who are sexually active. There is a much higher PID rate among younger than older women. Women who use an IUD for contraception are at least 2-4 times more likely to develop PID than nonusers. Women who have had PID are twice as likely to develop the infection as those who have never had it. A history of a prior uncomplicated gonococcal infection is more common among women with PID than among women without disease. Untreated males with urethral N. gonorrhea and possibly with C. trachomatis infection are an important source of infection both for the initial and for recurrent episodes of PID. Abdominal pain is the most common symptom although the pain may be mild or even absent in at least 5% of patients with PID verified by laparoscopy. In patients who have overt PID, it is possible to establish the diagnosis with reasonable certainty by a combination of history, physical examination, Gram stain of cervical secretions, culdocentesis, and examination of the male sexual partner. Adequate treatment of salpingitis includes an assessment of the severity of the infection, administration of appropriate antibiotics, employment of other health measures, close patient follow-up, and treatment of the male sexual patner. 25% of women with 1 episode of salpingitis develop a subsequent episode.
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PMID:Acute pelvic inflammatory disease. 636 7

Paired sera from 60 consecutive patients with acute salpingitis, confirmed by laparoscopy, were examined for serum antibodies to Chlamydia trachomatis, Mycoplasma hominis, and Neisseria gonorrhoeae. By a microimmunofluorescence (MIF) test IgM or IgG antibodies to C trachomatis or both were present in sera from 80% of the patients' by indirect haemagglutination (IHA) tests antibodies to M hominis and N gonorrhoeae pilar antigens were present in 40% and 18% respectively. In a control group of 50 pregnant women antibodies to the same three organisms occurred in 8%, 8%, and 6%. Evidence of current chlamydial infection was found in 35 (58%) and of current gonococcal infection in five (8%) of the 60 patients by culture or serological tests or both. The results of chlamydial antibody tests correlated with the severity of the tubal inflammation (as shown by laparoscopy) and the duration of the lower abdominal pain before attendance. The predictive values of a positive and a negative MIF test result were 44% and 83% respectively and of the IHA gonococcal antibody test 36% and 100% respectively. Significant rises in titre of antibodies to M hominis were found in 12% of patients. A four-fold or greater rise in titre indicated probable double infections with chlamydia and mycoplasmas in 7% of patients. Thus, at present gonococcal salpingitis appears to form only a small proportion of all cases of salpingitis in southern Sweden, and in patients with nongonococcal salpingitis infections with C trachomatis and M hominis commonly occur.
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PMID:Antibodies to Chlamydia trachomatis, Mycoplasma hominis, and Neisseria gonorrhoeae in sera from patients with acute salpingitis. 678 61

Teso District in eastern Uganda with low fertility (crude birth rate in 1969 was 37/1000), and Ankole District in western Uganda with high fertility (55/1000), were selected to study malaria, nutrition, gonorrhea, and syphilis. The gonorrhea methodology for women included genital examination and endocervical smears and cultures. Husbands of gonococcal-negative fertile and infertile women also were examined for the presence of gonorrhea and evidence of infection in the past. Three hundred and forty-three women in Teso and 250 in Ankole underwent medical examination. In the Teso District, 84 (25%) of the women, as compared with 22 (8.9%) in Ankole, complained of lower abdominal pain (p 0.001). Seven women in Teso but none in Ankole had signs of bartholinitis. Mucopurulent discharge in the vagina was found in 56 (19%) of the Teso women as compared with 17 (10%) of the Ankole women (p 0.02). 90 (30.5%) of the women in Teso but only 21 (12.5%) women in Ankole had an eroded and/or infected cervix (p 0.001). Evidence of salpingitis was obtained in 56 (19%) of the Teso women as compared with 10 (5.9%) Ankole women (p 0.001). A tender adnexal mass was felt in 23 (7.8%) of the Teso sample but in only one (0.6%) in Ankole. Among the women in Teso, 54 (18.3%) had a positive cervical smear or culture for gonorrhea, but only four (2.4%) in Ankole had similar positive tests (p 0.001). Evidence of pelvic inflammatory disease was present in 17% of the infected Teso women. None of the infected Ankole women, however, had PID. Cervical secretions showed gonococci in only 10% of the infertile women as compared with 23% of the fertile women. However, 24.5% of husbands of the gonococcal-negative infertile women, as compared with 6.7% of husbands of the gonococcal-negative fertile women, were found to have active gonorrhea (p 0.01). In this group 75.5%, and 57.7% of husbands, respectively, had a past history of urethral discharge (p 0.05), while 18.4% and 5.8%, respectively, had bilaterally thickened epididymides (p 0.05).
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PMID:Gonorrhea and female infertility in rural Uganda. 746 80

During 1992-1993 in 12 rural health centers in Mwanza region, Tanzania, a baseline survey was conducted of 964 women attending a prenatal clinic to determine the prevalence of sexually transmitted diseases (STDs) and to evaluate various screening methods to identify those infected with Neisseria gonorrhoeae and Chlamydia trachomatis. Only 2.7% had ever used condoms. 66% had symptoms (vaginal discharge, genital itching, lower abdominal pain, painful or difficult urination, difficult or painful intercourse) associated with genital tract infection. 37% had abnormal vaginal discharge. 39% had a laboratory-confirmed STD. 49% had a reproductive tract infection. 10.1% had syphilis. 8.4% had gonorrhea and/or chlamydia. Sociodemographic factors associated with gonorrhea/chlamydia included age less than 25 (odds ratio [OR] = 2.2), unmarried status (OR = 3.2;), polygamous marriage (OR = 2.3), last child born more than 5 years earlier (OR = 3.2), and more than 1 sexual partner during the last year (OR = 1.7). When the researchers adjusted for these factors, the only signs or symptoms associated with gonorrhea/chlamydia were painful intercourse (OR = 2.1; p 0.02) and cervical discharge (OR = 3.2; p 0.06). The syndromic approach (based on vaginal discharge and/or genital itching and other symptoms related to the genital tract but not necessarily indicative of gonorrhea/chlamydia in pregnancy) had a higher sensitivity than the recommended syndromic approach based only on vaginal discharge and/or genital itching (72% vs. 43%). The risk score approach based on sociodemographic and other factors associated with gonorrhea/chlamydia infection had a higher sensitivity and lower cost/true case treated than other approaches. Yet, its positive predictive value was no greater than about 20%. A combination of case management using the World Health Organization syndromic approach for women with self-recognized genital infections together with screening for gonorrhea/chlamydia using a score-driven approach may be the most cost-effective approach to diagnosing and treating STDs.
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PMID:Risk assessment and other screening options for gonorrhoea and chlamydial infections in women attending rural Tanzanian antenatal clinics. 884 88


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