今日の臨床サポート

骨盤内炎症性疾患

著者: 佐藤麻希子 大館市立総合病院産婦人科

監修: 小林裕明 鹿児島大学大学院医歯学総合研究科生殖病態生理学

著者校正/監修レビュー済:2020/08/27
参考ガイドライン:
  1. 日本産科婦人科学会日本産婦人科医会:産婦人科診療ガイドライン 婦人科外来編2020
  1. 日本感染症学会日本化学療法学会:JAID/JSC感染症治療ガイド2014
  1. 日本性感染症学会:性感染症 診断・治療 ガイドライン2016(改訂版)
患者向け説明資料

概要・推奨   

  1. 軽・中等症例では外来での抗菌薬治療が勧められる。外科的緊急疾患が除外できない症例、妊婦、経口抗菌薬が無効な症例、経口投薬ができない症例、悪心嘔吐や高熱を伴う症例、卵管卵巣膿瘍を伴う症例では入院が勧められる(推奨度2)。
  1. 卵管留膿腫または卵巣膿瘍が存在する症例ではメトロニダゾールの投与追加など、嫌気性菌をカバーする処方が推奨される(推奨度2)。
  1. 軽症・中等症例にはセフェム系やニューキノロン系の内服薬を投与し、中等症ではセフェム系(第2世代まで)点滴静注を選択することができる(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 敗血症性ショックに陥ると死亡率は30~40%である。起炎菌がPseudomonas aeruginosaE. coli, Klebsiella属では死亡率が30%以上であることから、これらの十分なカバーを考えた抗菌薬投与を必要とする。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
佐藤麻希子 : 特に申告事項無し[2021年]
監修:小林裕明 : 講演料(中外製薬株式会社,アストラゼネカ株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2021年]

改訂のポイント:
  1. 産婦人科診療ガイドライン 婦人科外来編2020 に基づき、以下の改訂を行った。
  1. 診断基準の変更(「腹腔鏡による炎症の確認」の削除)
  1. 治療薬の推奨の変更(内服薬からβ-ラクタマーゼ阻害薬配合ペニシリン系の削除。併用薬からクリンダマイシン、ミノサイクリンの削除(耐性菌の増加に伴い))

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 骨盤内炎症性疾患(pelvic inflammatory disease、PID)は、広義には子宮付属器炎、子宮感染、子宮傍結合織炎および骨盤腔炎などを総括した総称である。一般的には子宮内膜炎、子宮筋層炎、卵管炎およびそれを起点とした骨盤腹膜炎と卵管卵巣膿瘍を指すことが多い。
  1. (A)下腹部痛・圧痛と子宮付属器および周囲の圧痛が必須診断基準である。加えて、(B)①38℃以上の発熱、②白血球数増多、③CRPの上昇の付加診断基準と、(C)特異的診断基準として、MRIや経腟超音波による膿瘍像確認を加味して診断を行う[1][2]
  1. 原因菌は特にクラミジア、淋菌が重要であるが、嫌気性菌や腟細菌叢の菌であるBV関連細菌(anaerobes, G. vaginalis, Haemophilus influenzae, enteric Gram-negative rods, Streptococcus agalactiae)の関与も報告されている[3]
  1. 全身状態が良好な膿瘍非形成例ではまずは外来で抗菌薬内服治療を行う。
  1. 全身状態不良例、内服不能症例、内服治療反応不良例、膿瘍形成例には、入院による抗菌薬の点滴治療を行う。膿瘍形成例では外科的治療を考慮する。
  1. 卵管留膿腫、卵巣膿瘍の破裂による敗血症性ショック(ショック)症例では、バイタルの安定を図った後、速やかな手術療法が必要となる。
  1. PID症例の約10%で卵管性不妊となり、子宮外妊娠の罹患率も上昇する[4]
問診・診察のポイント  
問診:
  1. 子宮内操作を伴う経腟的検査や処置について確認する(子宮内容除去術や子宮内膜細胞診、3週間以内のIUD挿入[5][6][7]など)。また、その際に使用した抗菌薬の種類について確認する。
  1. クラミジアなど性感染症の既往、卵管留水腫、子宮内膜症の既往について確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Roberta B Ness, Kevin E Kip, Sharon L Hillier, David E Soper, Carol A Stamm, Richard L Sweet, Peter Rice, Holly E Richter
雑誌名: Am J Epidemiol. 2005 Sep 15;162(6):585-90. doi: 10.1093/aje/kwi243. Epub 2005 Aug 10.
Abstract/Text Controversy surrounds the association between bacterial vaginosis (BV) and pelvic inflammatory disease (PID). Women (N = 1,140) were ascertained at five US centers, enrolled (1999-2001), and followed up for a median of 3 years. Serial vaginal swabs were obtained for Gram's stain and cultures. PID was defined as 1) histologic endometritis or 2) pelvic pain and tenderness plus oral temperature >38.8 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital infection. Exploratory factor analysis identified two discrete clusters of genital microorganisms. The first correlated with BV by Gram's stain and consisted of the absence of hydrogen peroxide-producing lactobacillus, Gardnerella vaginalis, Mycoplasma hominis, anaerobic gram-negative rods, and, to a lesser degree, Ureaplasma urealyticum. The second, unrelated to BV by Gram's stain, consisted of Enterococcus species and Escherichia coli. Being in the highest tertile in terms of growth of BV-associated microorganisms increased PID risk (adjusted rate ratio = 2.03, 95% confidence interval: 1.16, 3.53). Carriage of non-BV-associated microorganisms did not increase PID risk. Women with heavy growth of BV-associated microorganisms and a new sexual partner appeared to be at particularly high risk (adjusted rate ratio = 8.77, 95% confidence interval: 1.11, 69.2). When identified by microbial culture, a combination of BV-related microorganisms significantly elevated the risk of acquiring PID.

PMID 16093289  Am J Epidemiol. 2005 Sep 15;162(6):585-90. doi: 10.1093・・・
著者: L Weström, R Joesoef, G Reynolds, A Hagdu, S E Thompson
雑誌名: Sex Transm Dis. 1992 Jul-Aug;19(4):185-92.
Abstract/Text From 1960 10 1984, 2,501 women underwent diagnostic laparoscopy (index laparoscopy) because of a clinical suspicion of acute pelvic inflammatory disease (PID). Of these women, 1,844 had abnormal laparoscopic findings (patients) and 657 had normal findings (control subjects). The reproductive events after index laparoscopy of 1,732 patients and 601 control subjects were followed. The patients and control subjects were followed for a total of 13,400 and 3,958 woman-years, respectively. During the follow-up period, 1,309 (75.6%) of the patients and 451 (75.0%) of the control subjects attempted to conceive. Of these women, 209 (16.0%) of the patients and 12 (2.7%) of the control subjects failed to conceive. A total of 141 (10.8%) of the patients and 0 (0%) of the control subjects had confirmed tubal factor infertility, 21 (1.6%) of the patients and 3 (0.7%) control subjects had other causes of infertility, and 47 (3.6%) patients and 9 (2.0%) control subjects did not have a complete infertility evaluation. Additional information on tubal morphology (hysterosalpingography, laparoscopy, or laparotomy) in women from couples for whom evaluation was incomplete indicated that 165 (12.2%) patients and 4 (0.9%) of the control subjects had abnormal tubal function or morphology after index laparoscopy. Tubal factor infertility after PID was associated with number and severity of PID episodes. The ectopic pregnancy rate for first pregnancy after index laparoscopy was 9.1% among the patients and 1.4% among control subjects.

PMID 1411832  Sex Transm Dis. 1992 Jul-Aug;19(4):185-92.
著者: I Viberga, V Odlind, G Lazdane, J Kroica, L Berglund, S Olofsson
雑誌名: Infect Dis Obstet Gynecol. 2005 Dec;13(4):183-90. doi: 10.1080/10647440500097601.
Abstract/Text OBJECTIVE: To study the microbial characteristics of patients with pelvic inflammatory disease (PID) and the possible impact of an intrauterine device (IUD) on the microbial environment in women presenting with PID.
METHODS: Case-control study, investigating 51 women with acute PID and 50 healthy women. Endocervical specimens for microbiological investigation were obtained at gynaecological examination.
RESULTS: IUD users with PID had significantly more Fusobacteria spp. and Peptostreptococcus spp. than non-IUD users with PID. The finding of combinations of several anaerobic or aerobic microbes was associated with a significantly increased risk of PID and with complicated PID. In IUD users, the combinations of several anaerobic/aerobic microbes were associated with an increased risk of PID, irrespective of duration of IUD use. Long-term IUD use appeared to be associated with an increased risk of a PID being complicated.
CONCLUSION: The finding of several anaerobic or aerobic microbes appears to be associated with PID in users of IUD.

PMID 16338777  Infect Dis Obstet Gynecol. 2005 Dec;13(4):183-90. doi: ・・・
著者: T M Farley, M J Rosenberg, P J Rowe, J H Chen, O Meirik
雑誌名: Lancet. 1992 Mar 28;339(8796):785-8. doi: 10.1016/0140-6736(92)91904-m.
Abstract/Text The risk of pelvic inflammatory disease (PID) associated with use of an intrauterine device (IUD) has been an important concern that has dominated decisions on its use throughout the world, especially in the USA. Early research that suggested such an association led to both a dramatic decline in use of the method and its withdrawal from the US market by two manufacturers. However, factors other than use of an IUD are now thought to be major determinants of PID risk. To address these concerns, we have reviewed the World Health Organisation's IUD clinical trial data to explore the incidence and patterns of PID risk with use of an IUD. The overall rate of PID among 22,908 IUD insertions and during 51,399 woman-years of follow-up was 1.6 cases per 1000 woman-years of use. After adjustment for confounding factors, PID risk was more than six times higher during the 20 days after insertion than during later times (unadjusted rates, 9.7 vs 1.4 per 1000 woman-years, respectively); the risk was low and constant for up to eight years of follow-up. Rates varied according to geographical area (highest in Africa and lowest in China) and were inversely associated with age. PID rates were lower among women who had IUDs inserted more recently. Our findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of sexually transmissible disease. PID is an infrequent event beyond the first 20 days after insertion. Because of this increased risk with insertion, IUDs should be left in place up to their maximum lifespan and should not routinely be replaced earlier, provided there are no contraindications to continued use and the woman wishes to continue with the device.

PMID 1347812  Lancet. 1992 Mar 28;339(8796):785-8. doi: 10.1016/0140-・・・
著者: D A Grimes
雑誌名: Lancet. 2000 Sep 16;356(9234):1013-9. doi: 10.1016/S0140-6736(00)02699-4.
Abstract/Text Concern about upper-genital-tract infection related to intrauterine devices (IUDs) limits their wider use. In this systematic review I summarise the evidence concerning IUD-associated infection and infertility. Choice of an inappropriate comparison group, overdiagnosis of salpingitis in IUD users, and inability to control for the confounding effects of sexual behaviour have exaggerated the apparent risk. Women with symptomless gonorrhoea or chlamydial infection having an IUD inserted have a higher risk of salpingitis than do uninfected women having an IUD inserted; however, the risk appears similar to that of infected women not having an IUD inserted. A cohort study of HIV-positive women using a copper IUD suggests that there is no significant increase in the risk of complications or viral shedding. Similarly, fair evidence indicates no important effect of IUD use on tubal infertility. Contemporary IUDs rival tubal sterilisation in efficacy and are much safer than previously thought.

PMID 11041414  Lancet. 2000 Sep 16;356(9234):1013-9. doi: 10.1016/S014・・・
著者: I M Macintyre, A Millar, A N Smith, W P Small
雑誌名: Br J Surg. 1990 Jan;77(1):65-9.
Abstract/Text Highly selective vagotomy for duodenal ulcer was performed on 307 patients between 1973 and 1983 without operative mortality. Of these, 283 (92.2 per cent) were followed up prospectively for a minimum of 5 years. Recurrent ulcer was diagnosed in 49 (17.3 per cent). The recurrent ulcer rate increased from 13.2 per cent at 5 years to 19.4 per cent at 12 years. Age, length of history, previous haemorrhage or perforation and preoperative acid output were not associated with increased risk of recurrent ulceration. The risk in men and smokers was higher but not significantly so. The recurrence rate for individual surgeons varied from 5.3 to 25.6 per cent. Failure of healing with H2-receptor antagonists was not associated with a higher recurrent ulcer rate. Patients with a strong family history (more than one first degree relative affected) had a significantly higher recurrence rate (33.2 per cent at 10 years) than those without (13.5 per cent at 10 years). Of the 49 recurrent ulcer patients, 30 (61.2 per cent) required either an operation or regular H2-receptor antagonists. Of the 250 patients (81.4 per cent) available in 1988 for review of symptoms 5-15 years after operation, 5.4 per cent had dumping, 8.9 per cent epigastric pain, and 11.8 per cent heartburn every day or most days. H2-receptor antagonists were required by 10.7 per cent of patients on a frequent or regular basis. Of 239 patients who answered the question, 218 (91.2 per cent) felt that their symptoms had been cured or greatly improved and 203 (84.9) considered the operation a success. Despite the high recurrence rate, the operation was successful in controlling ulcer symptoms in around 90 per cent of patients and produced postvagotomy symptoms--none severe--in around 5 per cent of patients.

PMID 1967959  Br J Surg. 1990 Jan;77(1):65-9.
著者: G L Rubin, H W Ory, P M Layde
雑誌名: Am J Obstet Gynecol. 1982 Nov 15;144(6):630-5.
Abstract/Text To study the association of the use of oral contraceptives and pelvic inflammatory disease (PID), we analyzed data from a large multicenter case-control study of contraceptive use and serious gynecologic disorders. The analysis included data from interviews of 648 women hospitalized with an initial episode of PID and 2,516 hospitalized control subjects. The risk of PID for women using oral contraceptives in the 3 months prior to interview was 0.5 (95% confidence limits, 0.4 to 0.6) relative to women using no contraceptive method during this period. This association was not explained by differences between case subjects and control subjects in demographic variables, level of sexual activity, or medical history. The protective effect of current oral contraceptive use against PID was restricted to women using oral contraceptives for more than 12 months; past use of oral contraceptives did not exert a protective effect against PID. Annually, an estimated 50,000 initial cases of PID are prevented by oral contraceptive use; 12,500 hospitalizations are also averted by oral contraceptive use. Consequently, protection against PID is one of the most important noncontraceptive benefits of oral contraception.

PMID 7137247  Am J Obstet Gynecol. 1982 Nov 15;144(6):630-5.
著者: Hernando Gaitán, Edith Angel, Rodrigo Diaz, Arturo Parada, Lilia Sanchez, Cara Vargas
雑誌名: Infect Dis Obstet Gynecol. 2002;10(4):171-80. doi: 10.1155/S1064744902000194.
Abstract/Text OBJECTIVE: To evaluate the clinical diagnosis of pelvic inflammatory disease (PID) compared with the diagnosis of PID made by laparoscopy, endometrial biopsy, transvaginal ultrasound, and cervical and endometrial cultures.
STUDY DESIGN: A diagnostic performance test study was carried out by cross-sectional analysis in 61 women. A group presenting PID (n = 31) was compared with a group (n = 30) presenting another cause for non-specific lower abdominal pain (NSLAP). Diagnosis provided by an evaluated method was compared with a standard diagnosis (by surgical findings, histopathology, and microbiology). The pathologist was unaware of the visual findings and presumptive diagnoses given by other methods.
RESULTS: All clinical and laboratory PID criteria showed low discrimination capacity. Adnexal tenderness showed the greatest sensitivity. Clinical diagnosis had 87% sensitivity, while laparoscopy had 81% sensitivity and 100% specificity; transvaginal ultrasound had 30% sensitivity and 67% specificity; and endometrial culture had 83% sensitivity and 26% specificity.
CONCLUSIONS: Clinical criteria represent the best diagnostic method for discriminating PID. Laparoscopy showed the best specificity and is thus useful in those cases having an atypical clinical course for discarding abdominal pain when caused by another factor. The other diagnostic methods might have limited use.

PMID 12648310  Infect Dis Obstet Gynecol. 2002;10(4):171-80. doi: 10.1・・・
著者: S D Reed, D V Landers, R L Sweet
雑誌名: Am J Obstet Gynecol. 1991 Jun;164(6 Pt 1):1556-61; discussion 1561-2.
Abstract/Text One hundred nineteen patients with tuboovarian abscess were evaluated for response to antibiotics. Results were stratified into three groups by antimicrobial regimen. Group 1 consisted of 37 patients treated with a single-agent broad-spectrum intravenous antibiotic and oral doxycycline. Initial clinical response (defined as decreased pain, diminished white blood cell count, or defervescence) in group 1 was 31/37 (84%). Group 2 consisted of 64 patients treated with clindamycin in combination with an aminoglycoside with or without a penicillin. There was an initial clinical response in 45 of 64 (70%). Group 3 consisted of 18 patients from group 1 who were changed to a clindamycin-containing regimen after 2 to 3 days of initial treatment with a single-agent broad-spectrum antibiotic. The decision to switch antibiotics was not based on treatment failure but occurred when delayed ultrasonography confirmed the diagnosis of tuboovarian abscess. The switch reflected physician preference for clindamycin-containing regimens in the treatment of tuboovarian abscesses. The response rate in this subset of patients was 14 of 18 (78%). Overall initial clinical response rate was 90 of 119 (75%). There were no statistically significant demographic or clinical differences among the three groups. There was no statistical difference in the rate of early and late antibiotic failure rates among the groups. Our study demonstrates that extended-spectrum antibiotic coverage, including single-agent broad-spectrum antibiotics such as cefoxitin, in conjunction with doxycycline has efficacy that is equivalent to that of clindamycin-containing regimens. An overall medical treatment success rate of 75% suggests that conservative treatment of tuboovarian abscesses is warranted.

PMID 2048603  Am J Obstet Gynecol. 1991 Jun;164(6 Pt 1):1556-61; disc・・・
著者: Simon Nadel, Brahm Goldstein, Mark D Williams, Heidi Dalton, Mark Peters, William L Macias, Shamel A Abd-Allah, Howard Levy, Robinette Angle, Dazhe Wang, David P Sundin, Brett Giroir, REsearching severe Sepsis and Organ dysfunction in children: a gLobal perspective (RESOLVE) study group
雑誌名: Lancet. 2007 Mar 10;369(9564):836-43. doi: 10.1016/S0140-6736(07)60411-5.
Abstract/Text BACKGROUND: Drotrecogin alfa (activated) (DrotAA) is used for the treatment of adults with severe sepsis who have a high risk of dying. A phase 1b open-label study has indicated that the pharmacokinetics and pharmacodynamics of DrotAA are similar in children and adults. We initiated the RESOLVE (REsearching severe Sepsis and Organ dysfunction in children: a gLobal perspectiVE) trial to investigate the efficacy and safety of the drug in children.
METHODS: Children aged between 38 weeks' corrected gestational age and 17 years with sepsis-induced cardiovascular and respiratory failure were randomly assigned to receive placebo or DrotAA (24 microg/kg/h) for 96 h. We used a prospectively defined, novel primary endpoint of Composite Time to Complete Organ Failure Resolution (CTCOFR) score. Secondary endpoints were 28-day mortality, major amputations, and safety. Analysis was by intention-to-treat. This trial is registered with clinicaltrials.gov, number NCT00049764.
FINDINGS: 477 patients were enrolled; 237 received placebo, and 240 DrotAA. Our results showed no significant difference between groups in CTCOFR score (p=0.72) or in 28-day mortality (placebo 17.5%; DrotAA, 17.2%; p=0.93). Although there was no difference in overall serious bleeding events during the 28-day study period (placebo 6.8%; DrotAA 6.7%; p=0.97), there were numerically more instances of CNS bleeding in the DrotAA group (11 [4.6%], vs 5 [2.1%] in placebo, p=0.13), particularly in children younger than 60 days. For CTCOFR score days 1-14, correlation coefficient was -0.016 (95% CI -0.106 to 0.74); relative risk for 28-day mortality was 1.06 (95% CI 0.66 to 1.46) for DrotAA compared with placebo.
INTERPRETATION: Although we did not record any efficacy of DrotAA in children with severe sepsis, serious bleeding events were similar between groups and the overall safety profile acceptable, except in children younger than 60 days. However, we gained important insights into clinical and laboratory characteristics of childhood severe sepsis, and have identified issues that need to be addressed in future trials in critically ill children.

PMID 17350452  Lancet. 2007 Mar 10;369(9564):836-43. doi: 10.1016/S014・・・
著者: Henry E Wang, Nathan I Shapiro, Derek C Angus, Donald M Yealy
雑誌名: Crit Care Med. 2007 Aug;35(8):1928-36. doi: 10.1097/01.CCM.0000277043.85378.C1.
Abstract/Text OBJECTIVE: The emergency department (ED) often serves as the first site for the recognition and treatment of patients with suspected severe sepsis. However, few evaluations of the national epidemiology and distribution of severe sepsis in the ED exist. We sought to determine national estimates of the number, timing, ED length of stay, and case distribution of patients presenting to the ED with suspected severe sepsis.
DESIGN: Analysis of 2001-2004 ED data from the National Hospital Ambulatory Medical Care Survey.
SETTING: National multistage probability sample of United States ED data.
PATIENTS: Adult (age, >or=18 yrs) patients with suspected severe sepsis, defined as the concurrent presence of an infec-tion (ED International Classification of Diseases, 9th Revision; ICD-9) diagnosis of infection, or a triage temperature <96.8 degrees F or >or=100.4 degrees F) and organ dysfunction (ED ICD-9) diagnosis of organ dysfunction, intubation, or a triage systolic blood pressure INTERVENTIONS: None.
MEASUREMENTS: Estimated number of ED patients presenting with suspected severe sepsis, and their times of arrival, ED lengths of stay, and clinical characteristics.
MAIN RESULTS: Of 331.5 million adult ED visits, approximately 2.3 million (571,000 annually, 0.69%; 95% confidence interval [CI], 0.61-0.77%) were for suspected severe sepsis. Mean ED length of stay for suspected severe sepsis was 4.7 hrs (95% CI, 4.3-5.1 hrs), with 20.4% spending >6 hrs in the ED. Of suspected severe sepsis patients, 20.6% presented to a low-volume ED (CONCLUSIONS: Suspected severe sepsis patients account for more than 500,000 ED visits annually, with individual patients spending an average of almost 5 hrs in the ED. These national data offer key systemwide information for designing and implementing strategies for severe sepsis treatment.

PMID 17581480  Crit Care Med. 2007 Aug;35(8):1928-36. doi: 10.1097/01.・・・
著者: James A Russell, Keith R Walley, Joel Singer, Anthony C Gordon, Paul C Hébert, D James Cooper, Cheryl L Holmes, Sangeeta Mehta, John T Granton, Michelle M Storms, Deborah J Cook, Jeffrey J Presneill, Dieter Ayers, VASST Investigators
雑誌名: N Engl J Med. 2008 Feb 28;358(9):877-87. doi: 10.1056/NEJMoa067373.
Abstract/Text BACKGROUND: Vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock, but its effect on mortality is unknown. We hypothesized that low-dose vasopressin as compared with norepinephrine would decrease mortality among patients with septic shock who were being treated with conventional (catecholamine) vasopressors.
METHODS: In this multicenter, randomized, double-blind trial, we assigned patients who had septic shock and were receiving a minimum of 5 microg of norepinephrine per minute to receive either low-dose vasopressin (0.01 to 0.03 U per minute) or norepinephrine (5 to 15 microg per minute) in addition to open-label vasopressors. All vasopressor infusions were titrated and tapered according to protocols to maintain a target blood pressure. The primary end point was the mortality rate 28 days after the start of infusions.
RESULTS: A total of 778 patients underwent randomization, were infused with the study drug (396 patients received vasopressin, and 382 norepinephrine), and were included in the analysis. There was no significant difference between the vasopressin and norepinephrine groups in the 28-day mortality rate (35.4% and 39.3%, respectively; P=0.26) or in 90-day mortality (43.9% and 49.6%, respectively; P=0.11). There were no significant differences in the overall rates of serious adverse events (10.3% and 10.5%, respectively; P=1.00). In the prospectively defined stratum of less severe septic shock, the mortality rate was lower in the vasopressin group than in the norepinephrine group at 28 days (26.5% vs. 35.7%, P=0.05); in the stratum of more severe septic shock, there was no significant difference in 28-day mortality (44.0% and 42.5%, respectively; P=0.76). A test for heterogeneity between these two study strata was not significant (P=0.10).
CONCLUSIONS: Low-dose vasopressin did not reduce mortality rates as compared with norepinephrine among patients with septic shock who were treated with catecholamine vasopressors. (Current Controlled Trials number, ISRCTN94845869 [controlled-trials.com].).

Copyright 2008 Massachusetts Medical Society.
PMID 18305265  N Engl J Med. 2008 Feb 28;358(9):877-87. doi: 10.1056/N・・・
著者: Charles L Sprung, Djillali Annane, Didier Keh, Rui Moreno, Mervyn Singer, Klaus Freivogel, Yoram G Weiss, Julie Benbenishty, Armin Kalenka, Helmuth Forst, Pierre-Francois Laterre, Konrad Reinhart, Brian H Cuthbertson, Didier Payen, Josef Briegel, CORTICUS Study Group
雑誌名: N Engl J Med. 2008 Jan 10;358(2):111-24. doi: 10.1056/NEJMoa071366.
Abstract/Text BACKGROUND: Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin.
METHODS: In this multicenter, randomized, double-blind, placebo-controlled trial, we assigned 251 patients to receive 50 mg of intravenous hydrocortisone and 248 patients to receive placebo every 6 hours for 5 days; the dose was then tapered during a 6-day period. At 28 days, the primary outcome was death among patients who did not have a response to a corticotropin test.
RESULTS: Of the 499 patients in the study, 233 (46.7%) did not have a response to corticotropin (125 in the hydrocortisone group and 108 in the placebo group). At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% in the hydrocortisone group and 36.1% in the placebo group, P=0.69) or between those who had a response to corticotropin (28.8% in the hydrocortisone group and 28.7% in the placebo group, P=1.00). At 28 days, 86 of 251 patients in the hydrocortisone group (34.3%) and 78 of 248 patients in the placebo group (31.5%) had died (P=0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. However, there were more episodes of superinfection, including new sepsis and septic shock.
CONCLUSIONS: Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed. (ClinicalTrials.gov number, NCT00147004.)

2008 Massachusetts Medical Society
PMID 18184957  N Engl J Med. 2008 Jan 10;358(2):111-24. doi: 10.1056/N・・・
著者: L Weström
雑誌名: Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):880-92.
Abstract/Text Pelvic inflammatory disease is used herein synonymously with acute salpingitis. In modern industrialized countries, the annual incidence of PID in women 15 to 39 years of age seems to be 10 to 13 per 1,000 women, with a peak incidence of about 20 per 1,000 women in the age group 20 to 24 years. Since 1960 an increase in incidence by a factor of 1.6 to 1.9 has been observed in the age group 20 to 29 years. The incidence of PID is correlated strongly with the prevalence of sexually transmitted diseases, although a fraction of the infections might be of endogenous origin. Use of intrauterine contraceptive devices and operations for legal abortions contribute to the increase in incidence. The prevalence of women in the post-PID state has increased by a factor of about 1.5 since 1960. Women in the post-PID state have a tenfold increased risk for ectopic pregnancy and 25% of the increase in ectopic pregnancy can be accounted for by the increase in post-PID women. Infertility after PID ranges between 5.8% and 60% depending on severity of infection, number of infections, and age of the women. The fraction of women rendered infertile because of PID has increased by a factor of about 1.6 since 1960.

PMID 7008604  Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):880-92.
著者: L S Elting, G P Bodey, B H Keefe
雑誌名: Clin Infect Dis. 1992 Jun;14(6):1201-7.
Abstract/Text Between 1972 and 1989, the incidence of viridans streptococcal bacteremia at the University of Texas M. D. Anderson Cancer Center in Houston increased from one case per 10,000 admissions to 47 cases per 10,000 admissions (P less than .0001). A shock syndrome characterized by hypotension, rash, palmar desquamation, adult respiratory distress syndrome, and occasionally death developed in 26% of cases of streptococcal septicemia but in only 4% of cases of septicemia involving other gram-positive bacteria (P = .0005). The risk of streptococcal infection increased with the prophylactic administration of trimethoprim-sulfamethoxazole or a fluoroquinolone (P less than .0001) and with profound neutropenia (P less than .0001). Treatment of chemotherapy-induced gastritis with antacids or with histamine type 2 (H2) antagonists was associated with a sevenfold increase in risk (P less than .001), while sucralfate therapy did not increase risk (P = .65). Streptococcal infection may result from gastric overgrowth of organisms resistant to trimethoprim-sulfamethoxazole in an antacid- or H2 antagonist-induced alkaline environment, with the gastrointestinal tract ulceration caused by antineoplastic therapy providing a convenient portal of entry. In patients receiving chemotherapy, replacement of antacids or H2 antagonists by an acid-sparing regimen should be considered to preserve the natural acidic barrier to infection.

PMID 1623076  Clin Infect Dis. 1992 Jun;14(6):1201-7.
著者: Frank M Brunkhorst, Michael Oppert, Gernot Marx, Frank Bloos, Katrin Ludewig, Christian Putensen, Axel Nierhaus, Ulrich Jaschinski, Andreas Meier-Hellmann, Andreas Weyland, Matthias Gründling, Onnen Moerer, Reimer Riessen, Armin Seibel, Maximilian Ragaller, Markus W Büchler, Stefan John, Friedhelm Bach, Claudia Spies, Lorenz Reill, Harald Fritz, Michael Kiehntopf, Evelyn Kuhnt, Holger Bogatsch, Christoph Engel, Markus Loeffler, Marin H Kollef, Konrad Reinhart, Tobias Welte, German Study Group Competence Network Sepsis (SepNet)
雑誌名: JAMA. 2012 Jun 13;307(22):2390-9. doi: 10.1001/jama.2012.5833.
Abstract/Text CONTEXT: Early appropriate antimicrobial therapy leads to lower mortality rates associated with severe sepsis. The role of empirical combination therapy comprising at least 2 antibiotics of different mechanisms remains controversial.
OBJECTIVE: To compare the effect of moxifloxacin and meropenem with the effect of meropenem alone on sepsis-related organ dysfunction.
DESIGN, SETTING, AND PATIENTS: A randomized, open-label, parallel-group trial of 600 patients who fulfilled criteria for severe sepsis or septic shock (n = 298 for monotherapy and n = 302 for combination therapy). The trial was performed at 44 intensive care units in Germany from October 16, 2007, to March 23, 2010. The number of evaluable patients was 273 in the monotherapy group and 278 in the combination therapy group.
INTERVENTIONS: Intravenous meropenem (1 g every 8 hours) and moxifloxacin (400 mg every 24 hours) or meropenem alone. The intervention was recommended for 7 days and up to a maximum of 14 days after randomization or until discharge from the intensive care unit or death, whichever occurred first.
MAIN OUTCOME MEASURE: Degree of organ failure (mean of daily total Sequential Organ Failure Assessment [SOFA] scores over 14 days; score range: 0-24 points with higher scores indicating worse organ failure); secondary outcome: 28-day and 90-day all-cause mortality. Survivors were followed up for 90 days.
RESULTS: Among 551 evaluable patients, there was no statistically significant difference in mean SOFA score between the meropenem and moxifloxacin group (8.3 points; 95% CI, 7.8-8.8 points) and the meropenem alone group (7.9 points; 95% CI, 7.5-8.4 points) (P = .36). The rates for 28-day and 90-day mortality also were not statistically significantly different. By day 28, there were 66 deaths (23.9%; 95% CI, 19.0%-29.4%) in the combination therapy group compared with 59 deaths (21.9%; 95% CI, 17.1%-27.4%) in the monotherapy group (P = .58). By day 90, there were 96 deaths (35.3%; 95% CI, 29.6%-41.3%) in the combination therapy group compared with 84 deaths (32.1%; 95% CI, 26.5%-38.1%) in the monotherapy group (P = .43).
CONCLUSION: Among adult patients with severe sepsis, treatment with combined meropenem and moxifloxacin compared with meropenem alone did not result in less organ failure.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00534287.

PMID 22692171  JAMA. 2012 Jun 13;307(22):2390-9. doi: 10.1001/jama.201・・・
著者: Tetsuro Matsumoto, Tetsuro Muratani, Koichi Takahashi, Yukiko Ando, Yumiko Sato, Masako Kurashima, Daisuke Yokoo, Toshihiro Ikuyama, Hiroshi Shimokawa, Shigeaki Yanai
雑誌名: J Infect Chemother. 2006 Apr;12(2):97-9. doi: 10.1007/s10156-006-0431-5.
Abstract/Text Cefodizime (CDZM) has strong antimicrobial activity to Neisseria gonorrhoeae in vitro. However, multidrug-resistant N. gonorrhoea emerged and has been increasing in Japan. To know the effectiveness of CDZM on gonococcal urethritis and uterine cervicitis even in the era of multidrug-resistant N. gonorrhoeae, a clinical trial of single-dose therapy of CDZM for gonococcal urethritis and uterine cervicitis was conducted. N. gonorrhoeae was eradicated from 100% of patients with gonococcal urethritis and uterine cervicitis by a single dose of CDZM. In conclusion, CDZM is one of most suitable drugs for the treatment of gonococcal genital infection in the era of multidrug-resistant N. gonorrhoeae.

PMID 16648949  J Infect Chemother. 2006 Apr;12(2):97-9. doi: 10.1007/s・・・
著者: D E Soper, N J Brockwell, H P Dalton
雑誌名: Am J Obstet Gynecol. 1992 Sep;167(3):653-60.
Abstract/Text OBJECTIVES: We attempted to define the microbiologic characteristics of acute salpingitis in women presenting to an urban emergency department with pelvic inflammatory disease and to determine the effectiveness of ofloxacin in treating this disease.
STUDY DESIGN: Women with pelvic inflammatory disease underwent laparoscopy to confirm the diagnosis and to culture the fallopian tubes and cul-de-sac. All patients (n = 36) were treated with parenteral ofloxacin and discharged on a regimen of oral ofloxacin to complete a 10- to 14-day course.
RESULTS: Neisseria gonorrhoeae was isolated from at least one site in 25 patients (69.4%) including the fallopian tube or cul-de-sac in 12 of them. Chlamydia trachomatis was isolated from the endocervix and/or endometrium in 6 patients (16.7%); concomitant Neisseria gonorrhoeae was present in 4 patients (66.6%). A polymicrobial infection was identified in only one patient. All patients responded to antibiotic therapy with ofloxacin.
CONCLUSIONS: Acute salpingitis in our urban emergency department population is related primarily to upper genital tract infection with Neisseria gonorrhoeae. Ofloxacin is effective therapy for this disease.

PMID 1530018  Am J Obstet Gynecol. 1992 Sep;167(3):653-60.
著者: W R Crombleholme, J Schachter, M Ohm-Smith, J Luft, R Whidden, R L Sweet
雑誌名: Am J Med. 1989 Nov 30;87(5A):142S-147S.
Abstract/Text A prospective, randomized, controlled, non-blind clinical trial was conducted to compare the efficacy of monotherapy with ciprofloxacin with that of a combination of clindamycin plus gentamicin in the treatment of patients with acute pelvic inflammatory disease. Pretreatment and post-treatment cervical culture specimens were obtained for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis, and Ureaplasma urealyticum. Pretreatment and post-treatment endometrial culture specimens were obtained for those organisms plus facultative and anaerobic bacteria. Minimal inhibitory concentrations were determined on all isolates by agar dilution. Clinical resolution of infection was seen in 31 of 33 (94 percent) ciprofloxacin-treated patients compared with 34 of 35 (97 percent) clindamycin/gentamicin-treated patients. N. gonorrhoeae was eradicated in all cases and C. trachomatis in 12 of 13 cases (92 percent). Ciprofloxacin appeared less effective than clindamycin/gentamicin in eradicating bacterial-vaginosis-associated organisms from post-treatment culture specimens obtained from the endometrium. Comparable clinical response was seen with both regimens. The significance of persistent bacterial-vaginosis-associated organisms following ciprofloxacin therapy is unclear. However, since one goal of treatment of pelvic inflammatory disease should be to eliminate organisms from the upper genital tract, ciprofloxacin may not provide optimal single-agent therapy for pelvic inflammatory disease.

PMID 2589358  Am J Med. 1989 Nov 30;87(5A):142S-147S.
著者: M G Martens, S Gordon, D R Yarborough, S Faro, D Binder, A Berkeley
雑誌名: South Med J. 1993 Jun;86(6):604-10.
Abstract/Text A multicenter randomized comparative trial was done to assess the safety and efficacy of oral ofloxacin (400 mg twice daily for 10 days) versus cefoxitin (2 g intramuscularly) followed by doxycycline (100 mg twice daily orally for 10 days) for the outpatient treatment of uncomplicated pelvic inflammatory disease (PID). Neisseria gonorrhoeae (GC) grew on pretreatment endocervical cultures from 43 of 268 women (16%), and in 30 of 247 women (12%) cultures were positive for Chlamydia trachomatis (Ct). Ninety-five percent (122/128) of the women treated with the ofloxacin regimen and 93% (112/121) of those treated with the cefoxitin/doxycycline regimen had cure or improvement on examination at a minimum of one follow-up visit. All GC species were eradicated by both ofloxacin and cefoxitin. Among women who returned for follow-up, the eradication of C trachomatis was 88% (15/17) for the cefoxitin/doxycycline group and 100% (18/18) for ofloxacin. Side effects were more prevalent in the cefoxitin/doxycycline group (15%) than in the ofloxacin group (7%), nausea/vomiting being the most frequent adverse effect. In this study, it appears that ofloxacin and cefoxitin/doxycycline have similar clinical effectiveness for the outpatient treatment of uncomplicated pelvic inflammatory disease.

PMID 8506477  South Med J. 1993 Jun;86(6):604-10.
著者: Roberta B Ness, David E Soper, Robert L Holley, Jeffrey Peipert, Hugh Randall, Richard L Sweet, Steven J Sondheimer, Susan L Hendrix, Antonio Amortegui, Giuliana Trucco, Thomas Songer, Judith R Lave, Sharon L Hillier, Debra C Bass, Sheryl F Kelsey
雑誌名: Am J Obstet Gynecol. 2002 May;186(5):929-37.
Abstract/Text OBJECTIVE: Pelvic inflammatory disease (PID) is a common and morbid intraperitoneal infection. Although most women with pelvic inflammatory disease are treated as outpatients, the effectiveness of this strategy remains unproven.
STUDY DESIGN: We enrolled 831 women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease into a multicenter randomized clinical trial of inpatient treatment initiated by intravenous cefoxitin and doxycycline versus outpatient treatment that consisted of a single intramuscular injection of cefoxitin and oral doxycycline. Long-term outcomes were pregnancy rate, time to pregnancy, recurrence of pelvic inflammatory disease, chronic pelvic pain, and ectopic pregnancy.
RESULTS: Short-term clinical and microbiologic improvement were similar between women randomized to the inpatient and outpatient groups. After a mean follow-up period of 35 months, pregnancy rates were nearly equal (42.0% for outpatients and 41.7% for inpatients). There were also no statistically significant differences between outpatient and inpatient groups in the outcome of time to pregnancy or in the proportion of women with pelvic inflammatory disease recurrence, chronic pelvic pain, or ectopic pregnancy.
CONCLUSION: Among women with mild-to-moderate pelvic inflammatory disease, there was no difference in reproductive outcomes between women randomized to inpatient treatment and those randomized to outpatient treatment.

PMID 12015517  Am J Obstet Gynecol. 2002 May;186(5):929-37.
著者: Lisa Hauk
雑誌名: Am Fam Physician. 2016 Jan 15;93(2):144-54.
Abstract/Text
PMID 26926414  Am Fam Physician. 2016 Jan 15;93(2):144-54.
著者: P Judlin, Q Liao, Z Liu, P Reimnitz, B Hampel, P Arvis
雑誌名: BJOG. 2010 Nov;117(12):1475-84. doi: 10.1111/j.1471-0528.2010.02687.x. Epub 2010 Aug 18.
Abstract/Text OBJECTIVE: To evaluate the efficacy and safety of moxifloxacin versus levofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease (uPID) in Asia.
DESIGN: Prospective, randomised, double-blind, double-dummy, parallel-group study.
SETTING: Multicentre, multinational study in the inpatient and/or outpatient setting.
POPULATION: Women (aged ≥18 years) with uPID (defined as PID with no pelvic or tubo-ovarian abscess on pelvic ultrasonography and at laparoscopic examination) and not requiring intravenous treatment.
METHODS: Women received a 14-day course of either oral moxifloxacin, 400 mg once daily, or oral levofloxacin, 500 mg once daily, plus oral metronidazole, 500 mg twice daily. Additionally, a single dose of ceftriaxone, 250 mg intramuscularly, was administered to women who had a positive screening test for Neisseria gonorrhoeae.
MAIN OUTCOME MEASURES: The primary measure of efficacy was clinical response at test-of-cure (TOC) (7-14 days after the last dose of study drug) in the per-protocol population. Non-inferiority of moxifloxacin to the comparator regimen was demonstrated if lower limit of 95% CI was >-15%. Other measures were clinical response during therapy and at 4-week follow up, microbiological response at TOC, and safety.
RESULTS: A total of 460 women were randomised to the study. For the primary measure of efficacy (clinical cure at TOC), moxifloxacin was noninferior to levofloxacin plus metronidazole (moxifloxacin: 152/194, 78.4%; comparator 155/190, 81.6%; 95% CI -10.7 to +4.9). The most commonly isolated pathogens at baseline included Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Staphylococcus aureus, Peptostreptococcus spp., Proteus mirabilis, Streptococcus agalactiae and Klebsiella pneumoniae. Bacteriological success rates were high and comparable between treatment arms (microbiologically valid populations, moxifloxacin 27/30, 90.0%; comparator 22/26, 84.6%; 95% CI -12.7 to +20.3). Both treatments were well tolerated.
CONCLUSIONS: Moxifloxacin monotherapy, 400 mg once daily for 14 days, is an effective and well-tolerated oral treatment for women with uPID.

© 2010 The Authors Journal compilation © RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology.
PMID 20716255  BJOG. 2010 Nov;117(12):1475-84. doi: 10.1111/j.1471-052・・・
著者: C D Bevan, G L Ridgway, C D Rothermel
雑誌名: J Int Med Res. 2003 Jan-Feb;31(1):45-54.
Abstract/Text The objective of the study was to compare the efficacy of azithromycin, alone or with metronidazole, versus two standard multidrug regimens for the treatment of acute pelvic inflammatory disease (PID). Patients with PID were treated with once-daily intravenous (i.v.) azithromycin 500 mg for 1 day or 2 days followed by once-daily azithromycin 250 mg orally for a total of 7 days, alone or with three-times-daily metronidazole 400 mg or 500 mg i.v. then orally for a total of 12-14 days. The comparators were either metronidazole + doxycycline + cefoxitin + probenecid or doxycycline + amoxycillin/clavulanate given at standard recommended doses for up to 21 days. In total, 309 patients were treated for PID. The diagnosis was confirmed laparoscopically in 74.8% of patients. Rates of clinical success for azithromycin, alone (97.1%) or with metronidazole (98.1%), were comparable to those for the comparator regimens (94.6%). Eradication rates for Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma hominis and anaerobes were also comparable for each of the treatment groups. Both azithromycin regimens were well tolerated. In conclusion, azithromycin, alone or with metronidazole, provides a shorter, simpler treatment option for the successful management of acute PID.

PMID 12635534  J Int Med Res. 2003 Jan-Feb;31(1):45-54.
著者: Knut Gjelland, Erling Ekerhovd, Seth Granberg
雑誌名: Am J Obstet Gynecol. 2005 Oct;193(4):1323-30. doi: 10.1016/j.ajog.2005.06.019.
Abstract/Text OBJECTIVE: Our purpose was to evaluate the effectiveness and safety of transvaginal ultrasound-guided aspiration together with antibiotic therapy for treatment of tubo-ovarian abscess.
STUDY DESIGN: A review of women treated with transvaginal ultrasound-guided aspiration for tubo-ovarian abscess at Haukeland University Hospital, Bergen, Norway, between June 1986 and July 2003 was performed. Immediate clinical response and longer-term follow-up results were assessed.
RESULTS: A total of 449 transvaginal aspirations were performed on 302 women. A total of 282 women (93.4%) were successfully treated for transvaginal aspiration of purulent fluid, together with antibiotic therapy. In the other 20 women (6.6%), surgery was performed. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain. No procedure-related complications were diagnosed.
CONCLUSION: Transvaginal ultrasound-guided aspiration combined with antibiotics is an effective and safe treatment regimen for tubo-ovarian abscess. The high success rate indicates that it should be a first-line procedure.

PMID 16202721  Am J Obstet Gynecol. 2005 Oct;193(4):1323-30. doi: 10.1・・・
著者: Mukesh G Harisinghani, Debra A Gervais, Michael M Maher, Che Hee Cho, Peter F Hahn, Jose Varghese, Peter R Mueller
雑誌名: Radiology. 2003 Sep;228(3):701-5. doi: 10.1148/radiol.2283020924. Epub 2003 Jul 24.
Abstract/Text PURPOSE: To assess the effectiveness of a computed tomographic (CT) image-guided transgluteal approach for percutaneous drainage of deep pelvic abscesses as an alternative to surgical drainage.
MATERIALS AND METHODS: The medical records of 140 patients who underwent percutaneous CT-guided transgluteal drainage of 154 deep pelvic abscesses were reviewed to determine the origins, location, and size of the abscesses; volume of initial aspirate; organisms identified in fluid culture; duration of catheter drainage; incidence of catheter-related pain and procedure-related complications; and short- and long-term outcomes. The resultant data were analyzed with a Fisher exact test for difference in the incidence of postprocedural catheter-site pain between transpiriformis and infrapiriformis approaches.
RESULTS: The origins of the pelvic abscesses included postoperative fluid collection (n = 115), perforating appendicitis (n = 6), diverticulitis (n = 16), tubo-ovarian inflammation (n = 5), Crohn disease (n = 10), and internal bowel fistula due to irradiation (n = 2). The abscesses were 4-12 cm in diameter. The volume of the aspirate was 5-310 mL. Laboratory cultures of the aspirate grew mixed flora, but the organism most frequently isolated was Escherichia coli. Catheters were removed after a mean of 8 days. In 134 (96%) of 140 patients, there was complete resolution of the abscess following transgluteal drainage, without subsequent surgery. In six of 140 (4%) patients, incomplete resolution necessitated subsequent surgery for postoperative fluid collection (n = 3), diverticulitis (n = 2), or perforating appendicitis (n = 1). Complications of transgluteal drainage were rare and included hemorrhage in three (2%) of the 140 patients. There was no procedure-related mortality. A transpiriformis approach was significantly more likely to be associated with postprocedural pain (P <.001) than was an infrapiriformis approach.
CONCLUSION: Percutaneous CT-guided transgluteal drainage is a safe and effective alternative to surgery for deep pelvic abscesses. Major complications are rare.

PMID 12881584  Radiology. 2003 Sep;228(3):701-5. doi: 10.1148/radiol.2・・・
著者: S G McNeeley, S L Hendrix, M M Mazzoni, D C Kmak, S B Ransom
雑誌名: Am J Obstet Gynecol. 1998 Jun;178(6):1272-8.
Abstract/Text OBJECTIVE: Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess.
STUDY DESIGN: A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed.
RESULTS: Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess (p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients.
CONCLUSIONS: Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess.

PMID 9662312  Am J Obstet Gynecol. 1998 Jun;178(6):1272-8.
著者: A S Berkeley, K S Freedman, J C Hirsch, W J Ledger
雑誌名: Surg Gynecol Obstet. 1986 Mar;162(3):204-8.
Abstract/Text Thirty-four patients with pelvic inflammatory disease, postoperative, postabortal and postpartum infections were randomized to intravenous therapy with either 500 milligrams of imipenem and cilastatin sodium every six hours or 2 grams of moxalactam every eight hours for a minimum of four days. One patient in the moxalactam group was nonevaluable because of protocol noncompliance; three more patients had no bacteriologic pathogen isolated (two in the moxalactam group and one patient in the imipenem/cilastatin group). The two groups were similar with respect to age, diagnosis, etiologic agents and duration of therapy. Of the 17 evaluable patients in the imipenem/cilastatin group, all were complete clinical cures. Three patients in the imipenem/cilastatin group had persistence of at least one bacteriologic pathogen despite clinical cure and apparent laboratory evidence of susceptibility. Of the 13 evaluable patients in the moxalactam group, eight were complete clinical cures. Two more patients in that group were clinically improved enough to be discharged on oral antibiotics. There were three clinical failures in the moxalactam group, all of whom had group D streptococcus resistant to moxalactam. An additional three patients in the moxalactam group had other resistant organisms isolated despite clinical cure. Both drugs were well tolerated and no serious complications or side effects occurred in either group. Despite small numbers, our data suggest that imipenem and cilastatin is a more appropriate agent for initial treatment of obstetric and gynecologic infections than moxalactam.

PMID 3513346  Surg Gynecol Obstet. 1986 Mar;162(3):204-8.
著者: Catherine L Haggerty, Roberta B Ness, Antonio Amortegui, Susan L Hendrix, Sharon L Hillier, Robert L Holley, Jeffrey Peipert, Hugh Randall, Steven J Sondheimer, David E Soper, Richard L Sweet, Guiliana Trucco
雑誌名: Am J Obstet Gynecol. 2003 Jan;188(1):141-8.
Abstract/Text OBJECTIVE: We investigated the association between endometritis and reproductive morbidity.
STUDY DESIGN: Participants were 614 women in the PID Evaluation and Clinical Health (PEACH) Study with pelvic pain, pelvic organ tenderness, and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. We compared women with endometritis (>or=5 neutrophils or >or=2 plasma cells), Neisseria gonorrhoeae or Chlamydia trachomatis upper genital tract infection (UGTI) or both to women without endometritis/UGTI for outcomes of pregnancy, infertility, recurrent pelvic inflammatory disease (PID), and chronic pelvic pain (CPP), adjusting for age, race, education, PID history, and baseline infertility.
RESULTS: Endometritis/UGTI was not associated with reduced pregnancy (odds ratio [OR] 0.8, 95% CI 0.6-1.2) or elevated infertility (OR 1.0, 95% CI 0.6-1.6), recurrent PID (OR 0.6, 95% CI 0.4-0.9), or CPP (OR 0.6, 95% CI 0.4-0.9). PEACH participants with and without endometritis/UGTI had higher age- and race-specific pregnancy rates than 1997 national rates.
CONCLUSION: Among women with clinically suspected mild-to-moderate PID treated with standard antibiotics, endometritis/UGTI was not associated with reproductive morbidity.

PMID 12548208  Am J Obstet Gynecol. 2003 Jan;188(1):141-8.
著者: P K Heinonen, K Teisala, R Punnonen, A Miettinen, M Lehtinen, J Paavonen
雑誌名: Obstet Gynecol. 1985 Sep;66(3):384-90.
Abstract/Text The microbiologic correlates of upper genital tract infection were studied among 36 women with suspected upper genital tract infection and 11 control women undergoing tubal ligation. Laparoscopic evidence of confirmed salpingitis was seen in 25 (69%) of the 36 women. Pathologic evidence of endometritis was present in 26 women (72%), and 22 (85%) of them had salpingitis as well. Thus, four women had endometritis but no salpingitis, three women had salpingitis but no endometritis, and seven women had neither. Among the 25 women with salpingitis, one or more organisms were isolated from the fallopian tubes of nine women (36%) and from the cul-de-sac of six women (24%), versus none and one (9%), respectively, among the 11 cases without salpingitis, and one (9%) and none among the 11 control women. Among the 26 cases with endometritis, one or more organisms were isolated from the endometrium of 19 women (73%) versus 12 (67%) among the 18 women without endometritis. Chlamydia trachomatis was isolated from the uterine cavity of nine women and from the fallopian tubes of three women with upper genital tract infection. The corresponding figures for Neisseria gonorrhoeae were three and two. Other nongonococcal nonchlamydial organisms were commonly isolated from the fallopian tubes and/or culde-sac of women with salpingitis. Bacteria frequently were isolated from the endometrium of both study cases and control subjects, but the latter were more likely to have nonpathogens of low virulence.

PMID 3160987  Obstet Gynecol. 1985 Sep;66(3):384-90.
著者: J Paavonen, K Teisala, P K Heinonen, R Aine, S Laine, M Lehtinen, A Miettinen, R Punnonen, P Grönroos
雑誌名: Br J Obstet Gynaecol. 1987 May;94(5):454-60.
Abstract/Text Upper genital tract infection was investigated in 45 women admitted to hospital for suspected acute pelvic inflammatory disease (PID). Salpingitis was diagnosed by laparoscopy in 30 (67%) women. Histopathological evidence of endometritis was found significantly more often in the 30 women with salpingitis (87%) than in the other 15 women without salpingitis (33%). C. trachomatis or N. gonorrhoeae, or both, were isolated from the upper genital tract in 14 of the 31 women who had both salpingitis and endometritis or endometritis only but in none of the four women who had salpingitis alone and in none of the 10 women who had no evidence of PID. Bacterial vaginosis was associated with histopathological evidence of upper tract infection. Non-chlamydial non-gonococcal organisms were frequently isolated from the upper genital tract. No organisms were isolated from the upper genital tract from 9 of 35 women with laparoscopic or histopathological evidence of PID compared with 7 of 10 women without evidence of PID. C. trachomatis or N. gonorrhoeae in the endometrium was associated with lymphoid follicles comprising transformed lymphocytes, and correlated with the density of plasma cells on biopsy. The microbiological results support the recommendations of broad spectrum antimicrobial therapy for PID.

PMID 3580330  Br J Obstet Gynaecol. 1987 May;94(5):454-60.
著者: D E Soper, N J Brockwell, H P Dalton, D Johnson
雑誌名: Am J Obstet Gynecol. 1994 Apr;170(4):1008-14; discussion 1014-7.
Abstract/Text OBJECTIVES: The specific aims of this study were (1) to describe the microbiologic characteristics of patients with acute salpingitis and (2) to determine the incidence of bacterial vaginosis in patients with acute salpingitis and whether bacterial vaginosis microorganisms were common upper-genital-tract isolates in these patients.
STUDY DESIGN: Women with pelvic inflammatory disease underwent laparoscopy to confirm the diagnosis of acute salpingitis and for culture of the fallopian tubes and cul-de-sac. Endometrial and minute fimbrial biopsies were performed, and specimens were evaluated for evidence of inflammation. Bacterial vaginosis was diagnosed by vaginal Gram stain.
RESULTS: Eighty-four patients had visually confirmed acute salpingitis. Neisseria gonorrhoeae or Chlamydia trachomatis was isolated from 65 (77.4%) patients. Vaginal microorganisms were isolated from the endometrium in 16 (31.4%) of 51 cases and from the cul-de-sac in 12 (14.3%) of 84 cases. Bacterial vaginosis was present in 61.8% of patients with acute salpingitis, and 100% of anaerobes isolated from the upper genital tract of patients with acute salpingitis were bacterial vaginosis microorganisms. These anaerobes were isolated from the upper genital tract in the absence of a concurrent gonococcal, chlamydial, or Haemophilus influenzae infection in only two cases.
CONCLUSIONS: The initiation of acute salpingitis is predominantly due to the ascending spread of sexually transmitted microorganisms. Bacterial vaginosis is a common concurrent disorder of women with acute salpingitis, and bacterial vaginosis microorganisms are commonly isolated from the upper genital tracts of patients with pelvic inflammatory disease.

PMID 8166184  Am J Obstet Gynecol. 1994 Apr;170(4):1008-14; discussio・・・
著者: R L Sweet, D L Draper, J Schachter, J James, W K Hadley, G F Brooks
雑誌名: Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):985-9.
Abstract/Text Acute salpingitis is a polymicrobial disease. Neisseria gonorrhoeae and anaerobic gram-positive cocci were the predominant microorganisms isolated from the fallopian tubes of salpingitis patients. Gonococci were isolated from the fallopian tubes in eight of 35 (23%) patients; anaerobic bacteria were recovered from 10 of 35 (28.5%). Although Chlamydia trachomatis was not recovered from the fallopian tube exudate, there was abundant serologic evidence of chlamydial infection in the salpingitis patients. Twenty-three percent of patients with paired sera had a fourfold rise in IgM and IgG titer, which was consistent with systemic chlamydial infection. Comparison of cultures obtained via laparoscopy and culdocentesis suggested that culdocentesis is not an accurate reflection of the microbial milieu in the fallopian tube.

PMID 6451179  Am J Obstet Gynecol. 1980 Dec 1;138(7 Pt 2):985-9.
著者: E S Lennard, E P Dellinger, M J Wertz, B H Minshew
雑誌名: Ann Surg. 1982 Jan;195(1):19-24.
Abstract/Text Outcomes of 65 patients after operation who had exhibited a clinical response to treatment for intra-abdominal sepsis were compared based on the presence or absence of leukocytosis and fever at the conclusion of antibiotic therapy. Fifty-one patients were afebrile when antibiotics were stopped. Intra-abdominal infection developed in 7 of 21 (33%) who had a persistent leukocytosis, but no intra-abdominal infections developed after operation in 30 patients who had normal WBC counts at the end of antibiotic treatment (p less than 0.005). Nosocomial infections developed in 6 (12%) of the 51 patients, and there was no difference in the incidence between patients with or without leukocytosis. Eleven of 14 (79%) patients who were still febrile when antibiotics were discontinued developed infections after operation. Nosocomial infections occurred in three (21%) and intra-abdominal infections in eight (57%). Of the 15 patients who developed intra-abdominal infection after operation, only four responded to appropriate antibiotic treatment without requiring further surgery. The other patients required surgical management for definitive control within two months of the initial operation. In conclusion, patients at risk of developing infection after operation after exhibiting a clinical response to treatment of intra-abdominal sepsis are those who are afebrile with a persistent leukocytosis or who are still febrile when antibiotics are stopped.

PMID 7055379  Ann Surg. 1982 Jan;195(1):19-24.
著者: Jeanine Henry-Suchet
雑誌名: J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):235-7.
Abstract/Text
PMID 12101313  J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):235-7.
著者: H C Wiesenfeld, R L Sweet
雑誌名: Clin Obstet Gynecol. 1993 Jun;36(2):433-44.
Abstract/Text The last 20 years have witnessed remarkable improvements in the treatment of tuboovarian abscesses. Gone are the days of significant mortality associated with ruptured and unruptured TOAs. Broad-spectrum antibiotics have enabled patients to be treated solely with medical therapy, avoiding the need for surgery. Operative intervention is still necessary in 25% of cases of unruptured TOAs, but the combination of conservative surgical procedures, such as unilateral salpingo-oophorectomy, and broad-spectrum antimicrobial agent therapy have reduced the need for total abdominal hysterectomy with bilateral salpingo-oophorectomy greatly. Although fertility after TOAs is compromised significantly, new advances in reproductive technology, including in vitro fertilization and donor egg transplantation, represent reproductive options for these women. Percutaneous drainage and laparoscopic treatment of TOAs are becoming popular treatment options, but prospective studies urgently are needed to assess their efficacy.

PMID 8513637  Clin Obstet Gynecol. 1993 Jun;36(2):433-44.
著者: Sheng-Mou Hsiao, Fon-Jou Hsieh, Yih-Ron Lien
雑誌名: Taiwan J Obstet Gynecol. 2006 Sep;45(3):234-8. doi: 10.1016/S1028-4559(09)60231-X.
Abstract/Text OBJECTIVE: To compare the clinical features of tuboovarian abscess (TOA) in pre- and postmenopausal women.
MATERIALS AND METHODS: Between January 1992 and December 2000, all patients with surgically documented TOA at National Taiwan University Hospital were enrolled into this retrospective study. Salient information with respect to the history, current illnesses, risk factors, physical findings, laboratory data, surgeries and postoperative complications was obtained from medical records.
RESULTS: Of 74 patients with TOA, nine were postmenopausal women. Compared with the premenopausal group, postmenopausal patients were significantly more likely to have contributing medical disorders (p < 0.001) and concomitant pelvic malignant tumors (p = 0.037).
CONCLUSION: Thorough investigation for concomitant pelvic malignant tumors and meticulous medical care should be provided for postmenopausal women with TOA.

PMID 17175470  Taiwan J Obstet Gynecol. 2006 Sep;45(3):234-8. doi: 10.・・・

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