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 ~  Abstract
 ~  Material and Methods
 ~  Results
 ~  Discussion
 ~  References

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Year : 2003  |  Volume : 21  |  Issue : 3  |  Page : 189-192
 

Role of anaerobes in acute pelvic inflammatory disease


Department of Microbiology, Pt. BD Sharma Post Graduate Institute of Medical Sciences, Rohtak - 124 001, Haryana, India

Correspondence Address:
Department of Microbiology, Pt. BD Sharma Post Graduate Institute of Medical Sciences, Rohtak - 124 001, Haryana, India

 ~ Abstract 

Pouch of Douglas aspirates were collected from 50 women with history and examination suggestive of acute pelvic inflammatory disease (PID) and 20 healthy women admitted for tubal ligation served as control. A total of 57 microorganisms were isolated from 37 patients out of 50 in study group. Of 37 positive cultures 21(56.7%) were monomicrobial and 16(43.2%) were polymicrobial. Most common symptom in study group was lower abdominal pain (90%), vaginal discharge (70%) and irregular bleeding (40%) and 30% patients had history of intrauterine contraceptive device (IUCD) implantation. The predominant aerobic isolates were Escherichia coli, Coagulase Negative Staphylococcus (CONS), Staphylococcus aureus, Klebsiella pneumoniae while common anaerobes were Bacteroides fragilis, Prevotella melaninogenica, Fusobacterium nucleatum and Peptostreptococcus spp. Our study shows that cefotaxime, cefuroxime and gentamicin may be used for gram negative aerobic bacilli; cloxacillin, cephaloridine and erythromycin for aerobic gram positive cocci and amikacin and ceftazidime for Pseudomonas aeruginosa. Thus for optimum therapy of acute PID it is beneficial to keep in mind major conceptual changes and therapeutic realities that have influenced current understanding of acute PID and have affected the choice of therapy.

How to cite this article:
Saini S, Gupta N, Aparna, Batra G, Arora D R. Role of anaerobes in acute pelvic inflammatory disease. Indian J Med Microbiol 2003;21:189-92


How to cite this URL:
Saini S, Gupta N, Aparna, Batra G, Arora D R. Role of anaerobes in acute pelvic inflammatory disease. Indian J Med Microbiol [serial online] 2003 [cited 2014 Oct 26];21:189-92. Available from: http://www.ijmm.org/text.asp?2003/21/3/189/8014


Pelvic inflammatory disease (PID) is a major health problem in both developing and developed countries. Despite advances in defining its etiology, pathogenesis and availability of many powerful antimicrobial drugs, it consumes a significant portion of the medical resources of numerous countries. Often the infection rates are highest in areas where medical resources are most severely limited. PID is not a notifiable disease in most countries, so accurate statistics are not available. But, there is no question that thousands of young women have salpingitis every year and their sheer number makes it an important health problem.[1] It is the most common serious complication of sexually transmitted disease. Acute PID increases a woman's risk for recurrent PID, chronic pelvic pain, infertility and ectopic pregnancy.[2]
Our concept of etiology and pathophysiology of acute PID has changed considerably over the past few years and as might be expected, treatment regimens have changed in parallel. Although aerobic and anaerobic bacteria that constitute the normal vaginal flora are frequent secondary invaders following an initially sexually transmitted infection, these bacteria can also primarily cause PID.[3] In laboratories where strict anaerobic culture techniques are followed anaerobes are isolated even more frequently than aerobes and facultative anaerobes. This study was done to determine role of anaerobes in acute PID.

 ~ Material and Methods Top

The present study was done in microbiology and gynaecology & obstetrics departments of a tertiary care and teaching hospital.
Patients
Twenty healthy women admitted for tubal ligation served as control. Fifty women in reproductive age group, who presented with atleast four of the following criteria, were included in the study: history of recurrent lower abdominal pain, presence of lower abdominal tenderness, presence of cervical motion tenderness, presence of adnexal motion tenderness, oral temperature greater than 100.4F, and/or leucocytosis >10,500/cumm. The patients who had already received antibiotics were excluded. A detailed history was taken for cases and controls including menstrual and obstetric history, past history of IUCD insertion, acute PID, any surgery, MTP or dilatation and curettage. Detailed general physical examination was done followed by abdominal per speculum and per vaginal examination.
Samples
Pouch of Douglas (cul-de-sac) aspirates were collected with all aseptic precautions using 18 gauge medicut needle after exposing posterior fornix with speculum and cleaning the area with betadine. The samples were transferred and transported in thioglycollate broth (Hi-media, Mumbai).
Direct examination of the specimens was done followed by aerobic culture on blood agar (BA) and MacConkey agar and plates were incubated at 37C for 24 hours. Identification of the aerobes was done using standard methods.[4] Anaerobic culture was done in thioglycollate broth, brain heart infusion agar (BHIA), neomycin BHIA, Kanamycin - vancomycin BA,  Brucella More Details blood agar and Bacteroides bile esculin agar using appropriate biological (Pseudomonas aeruginosa) and chemical (alkaline methylene blue glucose solution) indicators. Plates were incubated at 37C and examined after 48-72 hours. Suspected colonies were subcultured on BA and chocolate agar and incubated anaerobically. Metronidazole disc was put in anaerobic culture whereas an additional blood agar plate was incubated in air. Those organisms which failed to grow aerobically and were sensitive to metronidazole were considered as anaerobes. For preliminary grouping of anaerobes, kanamycin (1 mg), colistin (10 g), vancomycin (5 mg) discs were placed on first quadrant of purity blood agar plates. Other discs which aided in identification were sodium polyanethol sulphonate (SPS) discs (placed near colistin discs), nitrate disc (placed on 2nd quadrant) and bile esculin disc. Results were recorded after 48 to 72 hours of incubation. Pure culture isolates were identified by standard methods.[5]
Antibiotic sensitivity for aerobes and anaerobes was done using various antibiotics by stokes disc diffusion method. Controls used were Staphylococcus aureus   NCTC 6571 for gram positive bacteria and  Escherichia More Details coli NCTC 10418 for gram negative bacteria.

 ~ Results Top

In the present study, 20% of study group of patients had undergone one abortion and 8% had undergone two abortions. 30% of the study group also had IUCD implanted. The most common symptom in study group was lower abdominal pain (90%), vaginal discharge (70%), irregular bleeding (40%). These patients also showed marked abdominal tenderness and palpable abdominal mass on examination. None of these features were seen in control group who were healthy and admitted for tubal ligation.
Ampi - Amipicillin, Genta - Gentamicin, Nor - Norfloxacin, Cefo - Cefotaxime, Cfu - Cefuroxime, Amika - Amikacin, Cipro - Ciprofloxacin, Cftz - Ceftazidime, Peni - Penicillin, Tetra - Tetracycline, Erythro - Erythromycin, Cloxa - Cloxacillin, Cotrimox - Cotrimoxazole, Cepha - Cephaloridine, Metro - Metronidazole, Clinda - Clindamycin, Cefox - Cefoxitin, Chloram - Chloramphenicol.
In the study group, organisms were isolated in 37 patients. The monomicrobial isolates constituted 56.7% whereas polymicrobial constituted 43.2% of the isolates. A total of 57 organisms were isolated from the study group out of which aerobic bacteria constituted 73.6% and anaerobic bacteria constituted 26.3% of the isolates. The predominant aerobic isolates were E. coli, Coagulase Negative Staphylococcus (CONS), Staphylococcus aureus, Klebsiella pneumoniae while common anaerobes were Bacteroides fragilis, Prevotella melaninogenica, Fusobacterium nucleatum and Peptostreptococcus spp. [Table - 1]. [Table - 1] shows the antibiotic susceptibility patterns of the anaerobic and aerobic isolates.

 ~ Discussion Top

PID is a common disease occurring in young women, more so in the sexually active age group. The bacteriology of acute PID is polymicrobial in nature and the presence of anaerobes in PID is often associated with a more severe clinical presentation, poor response to therapy, increased risk for chronic pelvic pain, ectopic pregnancy and infertility.
In the present study pouch of Douglas (cul-de-sac) aspirate was collected as the organisms isolated from this site correlate better with that of  Fallopian tube More Details. Amongst the study group, there were 56.7% monomicrobial and 43.2% polymicrobial cultures. These findings are comparable to other studies. Ayyagari et al [6] reported mixed infections by aerobes and anaerobes in 21.8% of cases where as Chaudhary and Talwar[7] reported the isolation rate to be 42% of cases. Among the aerobes, the predominant isolates in our study were E. coli (33.2%), CONS (30.9%), Staphylococcus aureus (14.2%) and Klebsiella pneumoniae (9.5%). But the clinical relevance of CONS has to be assessed for individual patient as in our study only in a single case CONS were found in pure growth. CONS were usually encountered in combination with other aerobes and anaerobes which are more likely pathogens in acute PID. The sensitivity pattern of CONS is presented in the [Table - 1]. Our study shows that cefotaxime (50 to 83.3%), cefuroxime (50 to 100%) and gentamicin (50 to 83.3%) may be used for gram negative aerobic bacilli; cloxacillin (66.6 to 100%), cephaloridine (76.9 to 100%) and erythromycin (66.6% to 69.2%) for aerobic gram positive cocci and amikacin (100%) and Ceftazidime (100%) for P. aeruginosa.
Anaerobes were isolated from the study group of patients of acute PID only and the isolation rate was 26.3%. Studies done by Chaudhary et al [8] and Chow et al [9] to find out the incidence of various anaerobes from cul-de-sac aspirates showed the isolation rate to be 10% and 33% respectively. In our study, gram negative bacilli were found to be the more common anaerobic isolates. The isolation rate of Bacteroides fragilis,  Prevotella melaninogenica  ca and Fusobacterium nucleatum   was 13.3% each whereas 6.6% gram negative rods belonged to other Bacteroides spp. Eshenbach et al [10] found B. fragilis as the most frequent anaerobe from patients of acute PID. B. fragilis was observed to be commonest isolate in other studies on female genital tract infections. Chaudhary and Talwar[7] found gram negative bacilli to be the predominant isolates (33.8%) followed by gram positive cocci at 28.5%. In contrast, gram positive cocci were predominant isolates in studies by Ayyagiri et al [6] (50.2%) and by Gupta (54%).[11]
Susceptibility of anaerobes to penicillin was 28.5% in gram negative bacilli whereas gram positive bacilli and gram positive cocci showed 50% and 66.6 % susceptibility. Out of gram negative bacilli, B. fragilis and P. melaninogenica showed resistance but F. nucleatum was susceptible. Bach and Thadepalli[12] also showed resistance of B. fragilis to penicillin and same results were shown by Narayan et al.[13]
In our study, all isolates were sensitive to metronidazole as reported by other workers.[6],[13] However few strains were found to be resistant by Narayanan et al.[14] Clindamycin had 100% susceptibility against both gram negative and gram positive bacilli but only 83.3% against gram positive cocci which correlates with a study of Narayan et al.[14] Chloramphenicol was also found to be a good drug for anaerobic isolates as reported previously by Ferrera et al.[15]
As PID is polymicrobial, bacterial synergism, involvement of multiple organisms and antibiotic resistance make the selection of an optimal antibiotic regimen difficult.[16] Thus we recommend the use of newer third generation cephalosporins e.g. ceftriaxone, ceftizoxime and cefotaxime which give excellent coverage for Gonococcus and members of Enterobacteriaceae. It is still important to include doxycycline and tetracycline to cover Chlamydia trachomatis. For patients with advanced disease or a tuboovarian abscess clindamycin plus gentamicin has been the regimen of choice. These provide excellent coverage of anaerobes and aerobic gram negative rods. Thus anaerobes play an important role in acute PID and their therapy should be sought to prevent further complications. 

 ~ References Top

1.Sweet RL. Pelvic inflammatory disease. Sexually transmitted disease 1986;13(3):192-198.  Back to cited text no. 1    
2.Washington AE, Sweet RL, Shafer Ma. Pelvic inflammatory disease and its sequelae in adolescents. J Adolescent Health Care 1985;6(4):298-310.  Back to cited text no. 2    
3.Eschenbach DA. New concepts of obstetric and gynecologic infection. Arch Intern Med 1982;142(11):2039-2044.  Back to cited text no. 3    
4.Miles RS, Amyes SGB. Laboratory control of antimicrobial therapy. In: Collee JG, Fraser AG, Marmion BP, Simmons A, Eds. Mackie and McCartney's Practical Medical Microbiology. 14th ed. (Churchill Livingstone, New York) 1996: 151-178.  Back to cited text no. 4    
5.Baron EJ, Peterson LR, Finegold SM. Processing clinical specimens for anaerobic bacteria: isolation and identification procedures. In: Shanahan JF, Ed. Bailey and Scott's Diagnostic Microbiology. IXth ed. (Von Hoffman Press Inc., USA) 1994:474-550.  Back to cited text no. 5    
6.Ayyagari A, Chakrabarti A, Singh K, Sapru S, Aggarwal KC. Bacteriology of diverse infections of female genital tract with particular reference to anaerobic bacteria. Ind J Med Microbiol 1987;5:189-195.  Back to cited text no. 6    
7.Chaudhry R, Talwar V. Role of mixed bacterial flora of female genital tract infections with special reference to obligate anaerobes. Proceedings of the Ist Asian Congress on Anaerobic Bacteria in Health and Diseases, Mehta A, Kochar N, editors, 1987:184-189.  Back to cited text no. 7    
8.Chaudhry R, Thakur R, Talwar V, Aggarwal N. Anaerobic and aerobic microflora of pouch of Douglas aspirate v/s high vaginal swab in cases of pelvic inflammatory disease. Ind J Med Microbiol 1996;39(2):115-120.  Back to cited text no. 8    
9.Chow AW, Makasian KL, Marshall JR, Guze LB. The bacteriology of acute pelvic inflammatory disease. Am J Obstet Gynecol 1975;122:876-879.  Back to cited text no. 9    
10.Eschenbach DA, Buchanan TM, Pollock HM. Polymicrobial etiology of acute pelvic inflammatory disease. N Engl J Med 1975;293:166-171.  Back to cited text no. 10    
11.Gupta V. Anaerobic bacteria human infections - a review. Indian Practitioner 1978;31:271-289.  Back to cited text no. 11    
12.Bach VJ, Thadepalli H. Susceptibility of anaerobic bacteria in vitro to 23 antimicrobial agents. Antimicrobial Agents Chemother 1980;26:344-353.  Back to cited text no. 12    
13.Gale BH, Quida MA, Barbara QE. Susceptibilities of anaerobic gram negative bacilli to thirteen antimicrobials and b-lactamase inhibitor combinations. J Antimicrob Chemother 1991;28:855-867.  Back to cited text no. 13    
14.Narayan K, Bhatkhande R, Shah SC. Antimicrobial susceptibility of clinical isolates of non-clostridial anaerobic bacteria. First Asian Congress on Anaerobic Bacteria in Health and Disease, 1987;106-112.  Back to cited text no. 14    
15.Ferreira MC, Dornigues RM, de Uzeda M. Influence of metronidazole, chloramphenicol, clindamycin and penicillin G on growth and neuraminidase activity of bacteroides fragilis. J Antimicrob Chemother 1989;24:157-164.  Back to cited text no. 15    
16.Melvin DG. Optimum therapy for acute pelvic inflammatory disease. Drugs 1990;39(4):511-522.  Back to cited text no. 16    
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2004 - Indian Journal of Medical Microbiology
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