At follow-up 21 to 126 days after treatment), persistent or recurrent infection was found in 13% of standard referral patients and 10% of expedited treatment patients (relative risk, 0.76; 95% confidence interval, 0.59–0.98).
Expedited treatment decreased the rate of persistent or recurrent gonorrhea more than that of persistent or recurrent chlamydia.
Patients in the expedited group were more likely to report that all of their partners were treated, and less likely to report having had sex with an untreated partner.
Advantages of the direct approach
The challenge for the ObGyn is how to arrange treatment for the female patient’s sex partner(s). This study indicates that a proactive approach is likely to be more effective than simply asking the patient to encourage her partner to seek medical attention. Direct provision of a separate prescription for the partner(s) resulted in a 24% decrease in the frequency of persistent or recurrent infection.
Failure to treat the patient’s sex partner is the principal cause of persistent or recurrent infection, which may lead to pelvic inflammatory disease, Fitz-Hugh-Curtis syndrome, and infertility. Gonorrhea may disseminate and manifest primarily by arthritis and dermatitis. If a pregnant woman is colonized with gonorrhea or chlamydia at the time of delivery, her infant may acquire gonococcal or chlamydial conjunctivitis or chlamydial pneumonia.
6 caveats
Although the results of this investigation are impressive and of great practical importance, these caveats should be noted.
- The oral drug used to treat gonorrhea in this study, cefixime (400 mg), is not presently available, and although another oral drug such as ciprofloxacin (500 mg) would be highly effective, it should not be used in pregnant or lactating women, or women younger than 17 years.1
- Although ceftriaxone, 125 mg intramuscularly, also is a superb drug for treatment of uncomplicated gonorrhea, the logistical problems of arranging for the partner to receive an intramuscular injection are daunting.
- Some women in the expedited treatment group were reluctant to provide medication to their partner(s), and study personnel were forced to intervene. Keep in mind that individual private practitioners and even well-organized clinics may not have sufficient support personnel to trace and treat all contacts.
- There is the important issue of a provider writing a prescription for an individual who is not actually his or her patient and who has not been interviewed and examined. Certainly, many state laws and insurance company regulations may discourage or even prohibit such a practice.
- Lack of a detailed assessment of the partner(s) means there is no opportunity to evaluate them for other conditions such as syphilis and HIV infection.
- Finally, taking a proactive approach in treating the sex partner(s) of patients who have gonorrhea or chlamydia (and, by extension, trichomoniasis) requires documentation of complete rationale in the patient’s medical record.
In addition, detailed written instructions must be provided for the partner(s) and must include a specific caution about possible reactions to the antibiotic.
Single-dose plus intrapartum therapy effective for chorioamnionitis
Edwards RK, Duff P. Single additional dose postpartum therapy for women with chorioamnionitis. Obstet Gynecol. 2003;102:957–961.
Short-course therapy is simpler to administer and reduces costs compared with more extended treatment.
Intrapartum therapy plus 1 additional dose of combination antibiotics after delivery produced a very high rate of cure (95.4%)—equivalent to that achieved when a more extended course of treatment was used.
In this randomized study of 292 otherwise healthy women with chorioamnionitis, 151 women were treated intrapartum with intravenous (IV) ampicillin (2 g every 6 hours) plus gentamicin (1.5 mg/kg every 8 hours). They received 1 dose of each drug postpartum. In addition, if they had a cesarean delivery, they received 1 dose of IV clindamycin (900 mg) immediately after the infant’s umbilical cord was clamped.
Women in the control group received IV antibiotics (including clindamycin, if indicated) until they had been afebrile and asymptomatic for 24 hours.
In the study group, 4.6% of women had a treatment failure and required an additional course of antibiotics. In the control group, 3.5% of patients required additional antibiotics (P = .639, not significant). When patients were stratified by method of delivery, no significant difference was found in treatment outcome.
Pathogens and regimens
Chorioamnionitis occurs in approximately 1% to 5% of term patients and in as many as 25% of patients having a preterm delivery. The infection is caused by multiple aerobic and anaerobic organisms, notably group B streptococci, E coli, and anaerobes. The former 2 pathogens pose the greatest risk to the infant and are the predominant causes of neonatal pneumonia, bacteremia, and meningitis. These organisms also are major causes of maternal bacteremia.