434
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
20 minute office visit. The academic history should include observations regarding school behavior as well as academic progress and achievement. School records, including samples of school work and test results should be available to the diagnostic team. A first-hand look at the school environment should be undertaken. Psychological evaluation should include behavioral observations in a variety of settings, measures of complex visual-motor-perceptual functioning, an assessment of personality characteristics, and indices of learning styles. Information derived from testing should be presented with much less emphasis on scores (than is the usual common practice) and much more emphasis on individual strengths and weaknesses, with descriptive and prescriptive recommendations for teaching. The language evaluation should include a detailed assessment of speech and language behavior, articulation, voice quality, and both the expressive and receptive aspects of language. Educational evaluation is best conducted by an educational diagnostician. The evaluation should include a complete analysis of academic abilities, and levels and methods of skills aquisition. From the array of information needed to appropriately and adequately assess "learning problems" in children, it requires only a little humility to acknowledge that no one professional discipline is omnipotent. Such realization enhances the possibility of more accurate, humane, and unbiased diagnoses in the future. The aim of the diagnosis is away from medically oriented, etiological diagnostic categorization and toward a description of the strengths and weaknesses of the individual that are understandable to the parent, useable by the teacher and commensurate with the function of the school.
SEPTEMBER, 1976
A child who has not had benefit of both a medical evaluation and behavioral assessment as detailed herein, has not had an adequate diagnostic evaluation of his learning problems. Psychopharmacological intervention should be used only where indicated, and only after a complete diagnostic assessment; not for the convenience of the parents or school. If a multidisciplinary team is not available to you in your community, perhaps you can serve as a catalyst in bringing professionals together for this purpose. If you, as pediatricians, do not accept the responsibility of acting as coordinator of services for the child, he/she will continue to be shuttled from specialist to specialist with many things being done to him but without anything ever being donefor him. Discriminatory labelling and educational mismanagement of black, poor, and other minority group children have reached epidemic proportion. One immediate way that you can help to curtail this epidemic is to stop indiscriminantly referring children for intelligence testing with the belief that you know the child's capabilities and potentialities when you get back that magical IQ score. This is not to say that I am calling for a moratorium on testing-although it may well come to that if the situation does not improve significantly. What I am asking is your enlightened and prudent use of this kind of information and your push and support for researching alternative, unbiased, culture fair measuring methods. Pediatricians must get involved as advocates for these children's rights and realize that if we do not actively work for correction of discriminatory labelling and educational mismanagement, then we are a part of the national problem and should be openly recognized as such.
.
SELECTION OF ANTIBIOTICS IN PELVIC INFECTIONS* CHARLES C. VINCENT, M.D., Department of Obstetrics & Gynecology, Wayne State University, Detroit, Michigan
Gynecologic infections usually occur in young, otherwise healthy women. As might be expected, a rather prompt favorable response to therapy is usually attained within the initial 24-48 hour period of treatment. Several factors influence this response, including the nutritional and general medical status of the patient, i.e. freedom from other disease entities as diabetes, or other chronic physiologic or metabolic disease, the ini*Read at the 80th Annual Convention of the National Medical Association, Miami Beach, Florida, August, 1975.
tial antimicrobial drug selection and supportive management. The nutritional status of American women has improved during the past 10 years. At Detroit General Hospital, formerly receiving hospital, it is now the exception, rather than the rule, to see women admitted with nutritional anemia or other gross evidence of poor nutrition. This was not so as recently as 10 years ago. Various city, state and federal programs have been oriented to the problem of poor nutrition of women in the child-bearing age (as the Women's, Infant and
Vol. 68, No. 5
Selection of Antibiotics in Pelvic Infections
Children Program, Project Hope, etc.) Associated medical problems as diabetes, anemia, chronic renal, pulmonary or liver diseases are still seen, but usually in a less severe state. With better armamentarium, both diagnostic and therapeutic, these are better managed. The control of pelvic infection is thus reduced to three major factors: 1) the initial selection of antibiotics; 2) identification of the offending microorganisms and their susceptibility thru current testing methods to more commonly used antimicrobial agents; and 3) use of surgical procedures when indicated. Most gynecologic infections respond quite promptly to antimicrobial agents initially selected. This has been substantiated by many studies. Various investigators have reported, and it has been our experience also, that a few microorganisms are responsible for most gynecologic infections. The proven susceptibility of these microorganisms to a few antimicrobial agents has been substantiated. The more commonly encountered microbes responsible for gynecologic infections are: I. Aerobes 1. Neisseria gonorrhea 2. Enterobacteriaceae 3. Escherichia coli 4. Klebsiella aerogenes 5. Aerobacter aerogenes 6. Serratia marcescens 7. Proteus 8. Pseudomonas aeruginosa II. Anaerobes 1. Clostridium 2. Bacteriodes fragilis 3. Anaerobic streptococcus With this knowledge, one can formulate a plan of action at the time of admission to the hospital. To avoid the effects of penicillinase producing staphylococci, the semisynthetic penicillins are preferred frequently. One must not forget, however, that penicillin G is the most effective agent against proteus maribalis. If the infection were post-operative or hospital acquired, we would assume, until culture reports are received, that a penicillinase producing organism is very likely. One should not use penicillin G, but proceed immediately with a semisynthetic penicillin, which ampicillin is most popular in our area. The coliform organisms are also very susceptible to ampicillin and a synergistic response has been noted when used in combination with gentamycin. This combination of antimicrobial agents is our initial choice prior to culture and sensitivity (disc or tube dilution with the latter preferred, but more expensive and timeconsuming) reporting. Bacteroides are being reported with increasing fre-
435
quency as an offending organism in gynecologic infections. This has probably been a frequent pathogenic microbe, however, with better culture methods its identification is more common. The sensitivity of bacteroides to tetracyclines has been proven, but resistant strains are emerging. Recently, clindamycin (cleocin) a semisynthetic lincomycin, has proven more effective and adds a third drug to our armamentarium. It should be remembered that bacteroides may require four to seven days incubation prior to isolation. The hospital microbiology department should be specifically notified that this organism is suspect in any gynecologic infection so that cultures are not reported as "no growth" prior to five days incubation. The method of administration and fate of the various antimicrobials must be considered. The cellular response to drugs, or what they do and why, how they act and when, should form the basis for selection of any agent. While the oral route is the most common method of administering antimicrobials, in the hospitalized or more severely infected women, we can more accurately control blood levels of these agents by the intravenous or intramuscular routes. The intra-peritoneal application of antimicrobials has not been used at our institution for the past 10 years. While there are many antimicrobial agents, their actions are quite similar and usually involve either: 1)interaction with receptors on the cellular membrane, or 2) interfere with metabolism of cells by altering their metabolic patterns. Some of the more common antimicrobial agents used by our service are indicated in the following discussion. Penicillin G was our most potent agent and gave good coverage in treating the more common offending organisms. While not the agent of choice for gram negative organisms in a massive dose regimen, it may be effective. The penicillinase producing organisms, which includes most hospital acquired infections, are not susceptible to penicillin G. Fortunately, the semisynthetic penicillins (ampicillin, methicillin, oxacillin) are not reduced in efficiency by penicillinase. Ampicillin, being the best of the broad spectrum antibiotics, is preferable and may be administered orally or parenterally. Using ampicillin, 2 grams intravenously piggyback every six hours, a rapid and sustained blood level may be obtained. It is excreted in the urine and, therefore, very effective in urinary tract infections. Cephalosporin C compounds (keflin, kefsol, loridin, keflex, etc.) have a spectrum of coverage similar to penicillin and may be administered orally and parenterally. It is very closely related to penicillin and 5% of persons allergic to penicillin will also show cross sensitivity to cephalosporin C derivaties. In patients who have a history of penicillin allergy and if cephalosporin C is indicated, we proceed with its administration and closely monitor the patient's clinical state. The cepha-
436
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
losporins are excreted by the kidney and is known to be nephrotoxic. Cephalosporins are not effective against pseudomonas organisms. Gentamycin, a broad spectrum aminoglycoside, is very effective against pseudomonas. It is also frequently effective against organisms with proven insensitivity to other aminoglycosides (kanamycin). It is nephrotoxic and, therefore, its use requires frequent laboratory evaluation of the bun and creatinine at least every three days. Gentamycin therapy should not exceed 10 days. Clinical changes, such as oliguria or anuria must also be closely observed. Frequently, with the use of gentamycin, a rise of SGOT, SGPT and bilirubin may be observed. Erthromycin and lincomycin are used as penicillin substitutes in patients with a history of penicillin allergy. Clindamycin, a chlorinated lincomycin analogue, has been proven very effective against bacteroides fragilis. This agent is also active against all other aerobes except Neisseria gonorrhea. Recently, fatal toxic diarrhea related to clindamycin, has been reported. Patients on this antimicrobial agent must be observed closely, and the agent immediately discontinued if diarrhea occurs. A newer antimicrobial aminoglyoside, tobramycin (nebcin) is being evaluated by our service. It has been reported less nephrotoxic than gentamycin, yet has a similar spectrum coverage. If current studies prove cor-, rect, it might replace gentamycin as our planned antimicrobial agent for gram negative organisms. Initial selection of antibiotics for the severely infected gynecologic patient may include 1) ampicillin which has excellent broad spectrum coverage particularly against gram positive cocci and enterococci, and 2) gentamycin which covers almost all gram negative bacilli. With the addition of clindamycin, the anaerobe Bacteroids fragilis is adequately controlled. One might debate the combined usage of clindamycin and ampicillin for the only organism not adequately controlled by clindamycin alone, Neiserrhea gonorrhea. Since Neiserrhea is recovered in 60% of patients on our service with acute pelvic inflammatory disease, these agents should be used in combination. An exception is made when Neiserrhea gonorrhea, or bacteroides are particularly suspect. Currently our schedule is: 1) Ampicillin
2 grams
PBIV
q6h
2) Clindamycin 3) Gentamycin
(5 mg/Kg/day/IM)
600 mg. 60-80 mg.
SEPTEMBER, 1976 PBIV q6h IM orIV q 8 h
IV
Other recommended schedules are for 1) the moderately ill patient with the use of one antibiotic, ampicillin, or one of its substitutes cephalosporin, tetracycline, or lincomycin; and 2) the more severely infected individual, with the use of penicillin G and gentamycin in combination. For the patient with a history of penicillin allergy, we substitute keflin in the same dosage and method of administration as ampicillin. Erthrocyn or lincomycin may also be used. If a favorable response is not elicited within 48-72 hours, the patient must be re-evaluated for complications such as pelvic peritonitis, abscess formation, pelvic thrombophlebitis with or without embolism, and antibiotic fever. Possible drug dependence developed by microorganisms to several antibiotics is currently being evaluated. We recently had a hospital acquired infection due to Serratia marcescens, which is very susceptible to gentamycin. Its origin was found on the burn unit. The patient with a developing pelvic abscess, (cul de sac or adnexa) will often demonstrate the common, persisting signs of afternoon or evening spiking temperatures, chills and fever. The appropriate surgical procedures should be performed immediately, as indicated. D&C for infected abortion; colpotomy for drainage of a pelvic abscess; and laparotomy may be life-saving. These procedures may greatly decrease morbidity and length of hospital confinement. While there are no pathonomonic signs or symptoms of pelvic thrombophlebitis, a rapid pulse rate, out of proportion to the temperature, should make the clinician suspicious. Appropriate anticoagulant therapy should be instituted and consideration for surgical intervention (vena cava and/or ovarian vein ligation) entertained. If a favorable response is noted, no change of antimicrobial agents is made even if sensitivity studies indicate inappropriate coverage. With the knowledge of usual causative microbial organisms, their response to selected antimicrobial agents and the use of surgical procedures when indicated, the woman with a pelvic infection can be managed in a sound and secure method.
(Lombardo and Shields, from page 403) LITERATURE CITED
1. M. E. MULLER, M. ALLGOWER, and M. WILLEWEGGER: Manual of Internal Fixation. Springer-Verlag. New York, 1970. P. 40. 2. Personal Communication: Professor DR. M. E.
MULLER, Universitat Bern, Bern, Switzerland. November 14, 1974. 3. Personal Communication: M. ALLGOWER, M. D., F.A.C.S., Kantonsspital Basel, Basel, Switzerland. October2, 1974.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
20 minute office visit. The academic history should include observations regarding school behavior as well as academic progress and achievement. School records, including samples of school work and test results should be available to the diagnostic team. A first-hand look at the school environment should be undertaken. Psychological evaluation should include behavioral observations in a variety of settings, measures of complex visual-motor-perceptual functioning, an assessment of personality characteristics, and indices of learning styles. Information derived from testing should be presented with much less emphasis on scores (than is the usual common practice) and much more emphasis on individual strengths and weaknesses, with descriptive and prescriptive recommendations for teaching. The language evaluation should include a detailed assessment of speech and language behavior, articulation, voice quality, and both the expressive and receptive aspects of language. Educational evaluation is best conducted by an educational diagnostician. The evaluation should include a complete analysis of academic abilities, and levels and methods of skills aquisition. From the array of information needed to appropriately and adequately assess "learning problems" in children, it requires only a little humility to acknowledge that no one professional discipline is omnipotent. Such realization enhances the possibility of more accurate, humane, and unbiased diagnoses in the future. The aim of the diagnosis is away from medically oriented, etiological diagnostic categorization and toward a description of the strengths and weaknesses of the individual that are understandable to the parent, useable by the teacher and commensurate with the function of the school.
SEPTEMBER, 1976
A child who has not had benefit of both a medical evaluation and behavioral assessment as detailed herein, has not had an adequate diagnostic evaluation of his learning problems. Psychopharmacological intervention should be used only where indicated, and only after a complete diagnostic assessment; not for the convenience of the parents or school. If a multidisciplinary team is not available to you in your community, perhaps you can serve as a catalyst in bringing professionals together for this purpose. If you, as pediatricians, do not accept the responsibility of acting as coordinator of services for the child, he/she will continue to be shuttled from specialist to specialist with many things being done to him but without anything ever being donefor him. Discriminatory labelling and educational mismanagement of black, poor, and other minority group children have reached epidemic proportion. One immediate way that you can help to curtail this epidemic is to stop indiscriminantly referring children for intelligence testing with the belief that you know the child's capabilities and potentialities when you get back that magical IQ score. This is not to say that I am calling for a moratorium on testing-although it may well come to that if the situation does not improve significantly. What I am asking is your enlightened and prudent use of this kind of information and your push and support for researching alternative, unbiased, culture fair measuring methods. Pediatricians must get involved as advocates for these children's rights and realize that if we do not actively work for correction of discriminatory labelling and educational mismanagement, then we are a part of the national problem and should be openly recognized as such.
.
SELECTION OF ANTIBIOTICS IN PELVIC INFECTIONS* CHARLES C. VINCENT, M.D., Department of Obstetrics & Gynecology, Wayne State University, Detroit, Michigan
Gynecologic infections usually occur in young, otherwise healthy women. As might be expected, a rather prompt favorable response to therapy is usually attained within the initial 24-48 hour period of treatment. Several factors influence this response, including the nutritional and general medical status of the patient, i.e. freedom from other disease entities as diabetes, or other chronic physiologic or metabolic disease, the ini*Read at the 80th Annual Convention of the National Medical Association, Miami Beach, Florida, August, 1975.
tial antimicrobial drug selection and supportive management. The nutritional status of American women has improved during the past 10 years. At Detroit General Hospital, formerly receiving hospital, it is now the exception, rather than the rule, to see women admitted with nutritional anemia or other gross evidence of poor nutrition. This was not so as recently as 10 years ago. Various city, state and federal programs have been oriented to the problem of poor nutrition of women in the child-bearing age (as the Women's, Infant and
Vol. 68, No. 5
Selection of Antibiotics in Pelvic Infections
Children Program, Project Hope, etc.) Associated medical problems as diabetes, anemia, chronic renal, pulmonary or liver diseases are still seen, but usually in a less severe state. With better armamentarium, both diagnostic and therapeutic, these are better managed. The control of pelvic infection is thus reduced to three major factors: 1) the initial selection of antibiotics; 2) identification of the offending microorganisms and their susceptibility thru current testing methods to more commonly used antimicrobial agents; and 3) use of surgical procedures when indicated. Most gynecologic infections respond quite promptly to antimicrobial agents initially selected. This has been substantiated by many studies. Various investigators have reported, and it has been our experience also, that a few microorganisms are responsible for most gynecologic infections. The proven susceptibility of these microorganisms to a few antimicrobial agents has been substantiated. The more commonly encountered microbes responsible for gynecologic infections are: I. Aerobes 1. Neisseria gonorrhea 2. Enterobacteriaceae 3. Escherichia coli 4. Klebsiella aerogenes 5. Aerobacter aerogenes 6. Serratia marcescens 7. Proteus 8. Pseudomonas aeruginosa II. Anaerobes 1. Clostridium 2. Bacteriodes fragilis 3. Anaerobic streptococcus With this knowledge, one can formulate a plan of action at the time of admission to the hospital. To avoid the effects of penicillinase producing staphylococci, the semisynthetic penicillins are preferred frequently. One must not forget, however, that penicillin G is the most effective agent against proteus maribalis. If the infection were post-operative or hospital acquired, we would assume, until culture reports are received, that a penicillinase producing organism is very likely. One should not use penicillin G, but proceed immediately with a semisynthetic penicillin, which ampicillin is most popular in our area. The coliform organisms are also very susceptible to ampicillin and a synergistic response has been noted when used in combination with gentamycin. This combination of antimicrobial agents is our initial choice prior to culture and sensitivity (disc or tube dilution with the latter preferred, but more expensive and timeconsuming) reporting. Bacteroides are being reported with increasing fre-
435
quency as an offending organism in gynecologic infections. This has probably been a frequent pathogenic microbe, however, with better culture methods its identification is more common. The sensitivity of bacteroides to tetracyclines has been proven, but resistant strains are emerging. Recently, clindamycin (cleocin) a semisynthetic lincomycin, has proven more effective and adds a third drug to our armamentarium. It should be remembered that bacteroides may require four to seven days incubation prior to isolation. The hospital microbiology department should be specifically notified that this organism is suspect in any gynecologic infection so that cultures are not reported as "no growth" prior to five days incubation. The method of administration and fate of the various antimicrobials must be considered. The cellular response to drugs, or what they do and why, how they act and when, should form the basis for selection of any agent. While the oral route is the most common method of administering antimicrobials, in the hospitalized or more severely infected women, we can more accurately control blood levels of these agents by the intravenous or intramuscular routes. The intra-peritoneal application of antimicrobials has not been used at our institution for the past 10 years. While there are many antimicrobial agents, their actions are quite similar and usually involve either: 1)interaction with receptors on the cellular membrane, or 2) interfere with metabolism of cells by altering their metabolic patterns. Some of the more common antimicrobial agents used by our service are indicated in the following discussion. Penicillin G was our most potent agent and gave good coverage in treating the more common offending organisms. While not the agent of choice for gram negative organisms in a massive dose regimen, it may be effective. The penicillinase producing organisms, which includes most hospital acquired infections, are not susceptible to penicillin G. Fortunately, the semisynthetic penicillins (ampicillin, methicillin, oxacillin) are not reduced in efficiency by penicillinase. Ampicillin, being the best of the broad spectrum antibiotics, is preferable and may be administered orally or parenterally. Using ampicillin, 2 grams intravenously piggyback every six hours, a rapid and sustained blood level may be obtained. It is excreted in the urine and, therefore, very effective in urinary tract infections. Cephalosporin C compounds (keflin, kefsol, loridin, keflex, etc.) have a spectrum of coverage similar to penicillin and may be administered orally and parenterally. It is very closely related to penicillin and 5% of persons allergic to penicillin will also show cross sensitivity to cephalosporin C derivaties. In patients who have a history of penicillin allergy and if cephalosporin C is indicated, we proceed with its administration and closely monitor the patient's clinical state. The cepha-
436
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
losporins are excreted by the kidney and is known to be nephrotoxic. Cephalosporins are not effective against pseudomonas organisms. Gentamycin, a broad spectrum aminoglycoside, is very effective against pseudomonas. It is also frequently effective against organisms with proven insensitivity to other aminoglycosides (kanamycin). It is nephrotoxic and, therefore, its use requires frequent laboratory evaluation of the bun and creatinine at least every three days. Gentamycin therapy should not exceed 10 days. Clinical changes, such as oliguria or anuria must also be closely observed. Frequently, with the use of gentamycin, a rise of SGOT, SGPT and bilirubin may be observed. Erthromycin and lincomycin are used as penicillin substitutes in patients with a history of penicillin allergy. Clindamycin, a chlorinated lincomycin analogue, has been proven very effective against bacteroides fragilis. This agent is also active against all other aerobes except Neisseria gonorrhea. Recently, fatal toxic diarrhea related to clindamycin, has been reported. Patients on this antimicrobial agent must be observed closely, and the agent immediately discontinued if diarrhea occurs. A newer antimicrobial aminoglyoside, tobramycin (nebcin) is being evaluated by our service. It has been reported less nephrotoxic than gentamycin, yet has a similar spectrum coverage. If current studies prove cor-, rect, it might replace gentamycin as our planned antimicrobial agent for gram negative organisms. Initial selection of antibiotics for the severely infected gynecologic patient may include 1) ampicillin which has excellent broad spectrum coverage particularly against gram positive cocci and enterococci, and 2) gentamycin which covers almost all gram negative bacilli. With the addition of clindamycin, the anaerobe Bacteroids fragilis is adequately controlled. One might debate the combined usage of clindamycin and ampicillin for the only organism not adequately controlled by clindamycin alone, Neiserrhea gonorrhea. Since Neiserrhea is recovered in 60% of patients on our service with acute pelvic inflammatory disease, these agents should be used in combination. An exception is made when Neiserrhea gonorrhea, or bacteroides are particularly suspect. Currently our schedule is: 1) Ampicillin
2 grams
PBIV
q6h
2) Clindamycin 3) Gentamycin
(5 mg/Kg/day/IM)
600 mg. 60-80 mg.
SEPTEMBER, 1976 PBIV q6h IM orIV q 8 h
IV
Other recommended schedules are for 1) the moderately ill patient with the use of one antibiotic, ampicillin, or one of its substitutes cephalosporin, tetracycline, or lincomycin; and 2) the more severely infected individual, with the use of penicillin G and gentamycin in combination. For the patient with a history of penicillin allergy, we substitute keflin in the same dosage and method of administration as ampicillin. Erthrocyn or lincomycin may also be used. If a favorable response is not elicited within 48-72 hours, the patient must be re-evaluated for complications such as pelvic peritonitis, abscess formation, pelvic thrombophlebitis with or without embolism, and antibiotic fever. Possible drug dependence developed by microorganisms to several antibiotics is currently being evaluated. We recently had a hospital acquired infection due to Serratia marcescens, which is very susceptible to gentamycin. Its origin was found on the burn unit. The patient with a developing pelvic abscess, (cul de sac or adnexa) will often demonstrate the common, persisting signs of afternoon or evening spiking temperatures, chills and fever. The appropriate surgical procedures should be performed immediately, as indicated. D&C for infected abortion; colpotomy for drainage of a pelvic abscess; and laparotomy may be life-saving. These procedures may greatly decrease morbidity and length of hospital confinement. While there are no pathonomonic signs or symptoms of pelvic thrombophlebitis, a rapid pulse rate, out of proportion to the temperature, should make the clinician suspicious. Appropriate anticoagulant therapy should be instituted and consideration for surgical intervention (vena cava and/or ovarian vein ligation) entertained. If a favorable response is noted, no change of antimicrobial agents is made even if sensitivity studies indicate inappropriate coverage. With the knowledge of usual causative microbial organisms, their response to selected antimicrobial agents and the use of surgical procedures when indicated, the woman with a pelvic infection can be managed in a sound and secure method.
(Lombardo and Shields, from page 403) LITERATURE CITED
1. M. E. MULLER, M. ALLGOWER, and M. WILLEWEGGER: Manual of Internal Fixation. Springer-Verlag. New York, 1970. P. 40. 2. Personal Communication: Professor DR. M. E.
MULLER, Universitat Bern, Bern, Switzerland. November 14, 1974. 3. Personal Communication: M. ALLGOWER, M. D., F.A.C.S., Kantonsspital Basel, Basel, Switzerland. October2, 1974.
