Table Of ContentInfectious Diseases of the Female Genital Tract, 4th edition: by Richard L., Md.
Sweet, Ronald S., MD Gibbs By Lippincott Williams & Wilkins Publishers (January 15,
2002)
By OkDoKeY
Infectious Diseases of the Female Genital Tract
CONTENTS
Editors
Acknowledgment
Dedication
Preface
INTRODUCTION
1 Clinical Microbiology of the Female Genital Tract
2 Use of the Microbiology Laboratory in Infectious Diseases
SPECIAL ORGANISMS
3 roup B Streptococci
4 Genital Mycoplasmas
5 Chlamydial Infections
6 Herpes Simplex Virus Infection
7 Sexually Transmitted Diseases
8 Mixed Anaerobic-Aerobic Pelvic Infection and Pelvic Abscess
9 Hepatitis Infection
10 HIV-AIDS
GYNECOLOGIC AND OBSTETRIC INFECTIONS
11 Toxic Shock Syndrome
12 Infectious Vulvovaginitis
13 Postabortion Infection, Bacteremia, and Septic Shock
14 Pelvic Inflammatory Disease
15 Urinary Tract Infection
16 Perinatal Infections
17 Premature Rupture of the Membranes
18 Intraamniotic Infection
19 Subclinical Infection as a Cause of Premature Labor
20 Postpartum Infection
21 Wound and Episiotomy Infection
22 Parasitic Disease in Pregnancy
ANTIBIOTICS/ANTIVIRALS
23 Antimicrobial Agents
24 Antibiotic Prophylaxis in Obstetrics and Gynecology
IMMUNIZATION
25 Immunization
EDITORS
RICHARD L. SWEET, M.D.
The Milton Lawrence McCall Professor and Chair
Department of Obstetrics, Gynecology, and Reproductive Sciences
University of Pittsburgh School of Medicine
Magee-Women's Hospital
Pittsburgh, Pennsylvania
RONALD S. GIBBS, M.D.
Professor and Chair
Department of Obstetrics and Gynecology
University of Colorado Health Sciences Center
Denver, Colorado
ACKNOWLEDGMENT
We acknowledge the administrative and editorial assistance of Phyllis Catrell, Jane
Cook, and Susan Kostilnik in the preparation of this edition.
DEDICATION
This book is dedicated to our wives, Rhea and Jane, for their continued love, support
and understanding. To our children, Jennifer, Suzanne, Andrew, Eric, and Stuart and
our grandchildren Hanna, Dylan, Benjamin and Emily and future grandchildren who
provide us with the ongoing spark and impetus for our continued commitment to this
work.
PREFACE
During the writing of this fourth edition of Infectious Diseases of the Female Genital
Tract, infections seem to have played an ever-expanding role, not only in the practice of
obstetrics and gynecology but in the practice of medicine in general. Regularly the news
media produced stories about new infections and antibiotic resistance. These, indeed,
continue to be challenging and exciting times in the world of infectious diseases.
For this fourth edition, we have maintained the goal of providing physicians with
up-to-date knowledge that—in a highly readable form—deals with infectious diseases in
the female. We have substantially revised and updated every chapter and have added
several eye-appealing features. We are especially pleased that accompanying this
fourth edition will be an atlas to add to the usefulness of this text.
We have been gratified by the place this text has earned in the offices and libraries of
many obstetricians and gynecologists, and we thank the readers for their support.
1 CLINICAL MICROBIOLOGY OF THE FEMALE GENITAL TRACT
Infectious Diseases of the Female Genital Tract
1
CLINICAL MICROBIOLOGY OF THE FEMALE GENITAL
TRACT
Virulence
Aerobic Organisms
Gram-Positive Cocci
Gram-Positive Bacilli
Gram-Negative Bacilli
Gram-Negative Cocci
Anaerobic Isolates
Gram-Positive Anaerobes
Gram-Negative Anaerobes
Yeasts and Actinomyces
Trichomonads
Mycoplasmas
Chlamydia Trachomatis
Viruses
Changes in Vaginal Microflora
Age
Sexual Activity
Contraception
Pregnancy and Delivery
Surgery
Homeostasis
Chapter References
The microbiology of the female genital tract is indeed complex. In healthy women, the
vagina contains 109 bacterial colony-forming units per gram of secretions. Isolates
commonly found in the lower genital tract include a variety of aerobic and anaerobic
bacteria, yeast, viruses, and parasites (Table 1.1). Influences upon these microbes
include phase of the menstrual cycle, sexual activity, contraceptive use, childbirth,
surgery, and antibiotic therapy. The upper genital tract usually is sterile, but bacteria
from the lower genital tract may ascend into the uterine cavity, fallopian tubes, or pelvic
peritoneum because of menstruation, instrumentation, foreign bodies, surgery, or other
predisposing factors.
TABLE 1.1. OVERALL CLASSIFICATION OF MICROORGANISMS FOUND IN THE
FEMALE GENITAL TRACT
This chapter presents a working knowledge of genital tract microbes for the clinician.
More detailed descriptions of selected microbes are provided in other chapters.
VIRULENCE
Distinguishing “virulent” or “pathogenic” isolates from “nonvirulent” or “nonpathogenic”
ones often is difficult because the behavior of a given isolate is so dependent upon the
numbers of isolates present, host factors, and local conditions (presence of necrosis
and foreign body). For example, although group B streptococcus is a leading cause of
maternal and neonatal septicemia, most women with genital colonization by group B
streptococci (GBS) suffer no consequences. On the other hand, Staphylococcus
epidermidis is generally considered a low-virulence organism and is commonly
considered part of the normal skin and vaginal flora, but it also may cause disease when
conditions allow. For example, S. epidermidis has been recognized as a cause of
infective endocarditis of neurologic shunts.
Despite such widely ranging behavior patterns, it still is practical to distinguish “high”-
from “low”-virulence genital isolates. For practicality, the bacteria are divided into
aerobes and anaerobes. Each of these groups is subdivided further into Gram-positive
and Gram-negative organisms.
AEROBIC ORGANISMS
Gram-Positive Cocci
The organisms in this group include the aerobic streptococci and staphylococci (Table
1.2).
TABLE 1.2. ANTIBIOTIC THERAPY FOR AEROBIC AND FACULTATIVE BACTERIA
FOUND IN FEMALE GENITAL INFECTIONS
Streptococci
Many varieties of streptococci have been found in the pelvis, and they have been
classified by two independent schemes. In one scheme, the streptococci are
distinguished by their hemolytic properties on blood agar plates. Aerobic streptococci
showing partial (or green) hemolysis are termed alpha (a) streptococci, those showing
complete (or clear) hemolysis are termed beta (b) streptococci, and those showing no
hemolysis are termed gamma (g) streptococci. In the other scheme, the Lancefield
system, many streptococci can be classified according to surface antigens, designated
by the letters A through O. In humans, streptococci of groups A, B, and D are common
pathogens. Group A and B streptococci nearly always produce b hemolysis. Group D
streptococci usually are nonhemolytic (g streptococci), but on occasion they may be
either a or b hemolytic as well.
Group A Streptococci (Streptococcus pyogenes)
Streptococcus pyogenes causes pharyngeal, cutaneous, puerperal, and postoperative
infections and necrotizing fasciitis. Sequelae of group A streptococcal infections may
include rheumatic fever and acute glomerulonephritis. It is not generally considered to
be a member of the normal vaginal flora, as it is isolated in less than 1% of
asymptomatic women. Pelvic infection caused by group A streptococci may produce a
characteristic clinical picture, with a high, early initial fever, chills, prostration, and
diffuse tenderness. Historically, the group A b-hemolytic streptococcus was the
organism responsible for fatal puerperal sepsis. On Gram stains, one sees
Gram-positive cocci in chains. The microorganism remains exquisitely sensitive to
penicillin, and erythromycin or a cephalosporin usually can be substituted for treatment
of the penicillin-allergic patient. Clindamycin is an alternative agent, as is vancomycin.
Group A streptococcal pelvic infections occur in both sporadic and epidemic forms.
Epidemics usually are exogenous in origin, commonly resulting from nasopharyngeal
