Clinical Review

UPDATE: INFECTIOUS DISEASE

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Here is a practical look at 1 year’s advances in managing disseminated
gonococcal disease, infection associated with cesarean delivery,
hepatitis C, and chorioamnionitis


 

References

RELATED ARTICLES

Dr. Duff reports no financial relationships relevant to this article.

In this Update, I’ve highlighted four interesting articles about infectious disease management in obstetric and gyn practice that appeared in the medical literature over the past 12 months:

  • One describes a study that reminds physicians of the importance of an unusual manifestation of gonococcal infection
  • A second article demonstrates the importance of making a change in the prophylactic antibiotic regimen provided to morbidly obese patients who are having a cesarean delivery
  • A third describes an exciting development in the treatment of chronic hepatitis C virus infection
  • The final article makes interesting observations about the proper duration of treatment for patients who have chorioamnionitis.

N gonorrhoeae causes illness beyond the urogenital tract

Bleich AT, Sheffield JS, Wendel GD, Sigman A, Cunningham FG. Disseminated gonococcal infection in women. Obstet Gynecol. 2012;119(3):597–602.

This article describes a retrospective review of 112 women who were admitted to Parkland Memorial Hospital in Dallas, Texas, from January 1975 through December 2008 and given a diagnosis of disseminated infection with Neisseria gonorrhoeae. Eighty (71%) of these women were not pregnant and were cared for on the internal medicine service; 32 (29%) were pregnant and were treated by faculty members and residents on the ObGyn service.

Over the course of the study, the frequency of disseminated gonococcal infection decreased significantly. Among pregnant women, the rate of infection was 11 for every 100,000 deliveries before 1980 and, after 1985, five for every 100,000 deliveries.

The most common clinical manifestation of disseminated gonococcal infection was arthritis. The most commonly affected joints were the knee, wrist, elbow, and ankle.

Other common clinical manifestations included dermatitis, fever, chills, and a purulent cervical discharge. Notably, the frequency of a purulent joint effusion was 50% in pregnant women and 70% in nonpregnant women—reflecting the fact that the duration of symptoms was approximately 3 days shorter in pregnant women than in nonpregnant women. Otherwise, the clinical presentation in pregnant women did not differ significantly from that of nonpregnant women.

In addition, the clinical course and the response to intravenous (IV) antibiotic therapy did not differ significantly between pregnant and nonpregnant women.

The authors were unable to document that disseminated gonococcal infection had any deleterious effect on the outcome of pregnancy among the patients studied. Although four of the 32 women delivered preterm, in only one instance was delivery related temporally to the disseminated gonococcal infection.

Commentary

Because of their experience treating women who have gonorrhea, I would say that most ObGyns think of N gonorrhoeae as causing localized infection in the lower genital tract (urethritis, endocervicitis, inflammatory proctitis) or upper genital tract (pelvic inflammatory disease). We should recognize, however, that gonorrhea also can cause prominent extra-pelvic findings, such as severe pharyngitis (in patients who practice orogenital intercourse) and perihepatitis (Fitz-Hugh-Curtis syndrome).

In addition, always bear in mind that, in rare instances, gonorrhea can become disseminated, causing quite serious illness. The most common extra-pelvic manifestation of disseminated gonococcal infection is arthritis. As noted in this study of a series of patients, the arthritis is usually polyarticular and affects medium or small joints.

The second most common manifestation of disseminated gonococcal infection is dermatitis. Characteristic lesions are raised, red or purple papules. These lesions are not a simple vasculitis; rather, they contain a high concentration of microorganisms.

Other possible manifestations of disseminated infection include pericarditis, endocarditis, and meningitis.

The diagnosis of disseminated gonococcal infection is usually made by clinical examination and culture of specimens from the genital tract, blood, or joint effusion.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Disseminated gonococcal infection usually responds promptly to intravenous antibiotic therapy.

Recommended therapy is ceftriaxone:
• 25 to 50 mg/kg/d IV for 7 days
or
• a single, daily, 25 to 50 mg/kg intramuscular dose, also for 7 days.
Continue therapy for 10 to 14 days if the patient has meningitis.

An alternative regimen is cefotaxime:
• 25 mg/kg/d IV for 7 days
or
• 25 mg/kg IM every 12 hours, also for 7 days.
Extend treatment for 10 to 14 days if meningitis is present.1

Obesity curtails effectiveness of antibiotic prophylaxis in cesarean delivery

Pevzner L, Swank M, Krepel C, Wing DA, Chan K, Edmiston CE Jr. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol. 2011;117(4):877–882.

In this prospective study of the influence of an obese habitus on antibiotic prophylaxis during cesarean delivery, researchers divided 29 patients who were scheduled for cesarean into three groups, by body mass index (BMI):

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