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Etiology of Persistent Tubo-Ovarian Abscess in Nairobi, Kenya

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Etiology of Persistent Tubo-Ovarian Abscess in Nairobi, Kenya Infect Dis Obstet Gynecol 2003;11:45–51 Etiology of persistent tubo-ovarian abscess in Nairobi, Kenya Craig R. Cohen 1,2,3, Lisa Gravelle 5, Samwel Symekher 2, Peter Waiyaki 2, Walter E. Stamm 4 and Julia A. Kiehlbauch 1,2 1Department of Obstetrics and Gynecology, University of Washington, WA 2Center for Microbiology Research, Kenya Medical Research Institute 3Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya 4Department of Medicine, University of Washington, WA 5Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, OR Objective To study the microbial etiology of tubo-ovarian abscess (TOA). Methods Werecruited 11 women inNairobi, Kenyawho failed antibiotic therapyalone andrequired surgicaldrainage of apresumptiveTOA. Pusfrom the nineabscesses and two pyosalpingeswere collected and cultured for aerobic, facultative and anaerobic microorganisms. Results Elevenwomen suspectedof having aTOA were hospitalized andtreated for a median of 6days(range 3–14 days)prior to surgical drainage of the abscess.Nine (82%) specimenswere culturepositive. Aerobes were presentin all ninespecimens. Seven of the ninepositive cultures (78%) were polymicrobial andfive of the polymicrobial culturescontained both anaerobesand aerobes. Anaerobic Gram-negativebacilli ( Prevotella sp. , Porphyromonas sp. and Bacteroides sp.,Escherichia coli ) and Streptococcus sp. (S. viridans and S.agalactiae ) were the mostcommon microorganismsisolated. Neisseriagonorrhoeae and Chlamydia trachomatis werenot isolated by culture or detected by polymerase chain reaction. Conclusions InKenya, persistent TOAs areassociated with endogenousflora similar tothat normally found in the gastrointestinal tract. Key words: P ELVIC INFLAMMATORY DISEASE; SALPINGITIS; ANAEROBIC BACTERIA; AFRICA; ABSCESS; HIV INTRODUCTION antibioticsis initiated early after initial presenta- tionwith surgical drainagereserved forpatients Tubo-ovarianabscess (TOA), asignificant compli- 4 cationof pelvic inflammatory disease (PID), occurs whofail torespond .Success ofmedical therapy alonehas rangedbetween 67– 90%; but, approxi - in3– 16% of patients hospitalizedwith PID in the 5 UnitedStates 1,2 andin 22% of womenhospitalized mately 25% of TOAs require surgical drainage . 3 Initial studies byAltemeier foundanaerobic withsalpingitis inNairobi, Kenya . Effective 6 management ofaTOAhas evolved over thepast streptococciin 92% of TOAspecimens , and more 20years so thattreatment withbroad spectrum recentinvestigations detectedmixed aerobicand This study was supported by theNational Institutes of Health through the Sexually Transmitted Disease ClinicalTrials Unit (AI75329). Craig R.Cohen,MD, Departmentof Obstetrics and Gynecology, University of Washington, Box 356460, Seattle, WA 98195-6460, USA. Email: [email protected] ã 2003 The Parthenon Publishing Group 45 Etiology of persistent tubo-ovarian abscess in Nairobi, Kenya Cohenet al. anaerobicflora in nearly all cases ofTOA 4,7. The ofa pelvic mass after receiving at least 3days of recognitionthat pelvic abscesses are associated antibiotictherapy alone were recruited.After withanaerobic bacteria andare frequentlypoly- obtainingwritten informed consent for collection microbial led toimproved antibioticcoverage ofmicrobiologicalspecimens womenunderwent includingantibiotics like clindamycinand metro- laparotomydrainage by the hospital physician. nidazolethat have goodanaerobic activity 5. Laparotomy,rather than a less invasive drainage However, patients whofail antibiotictreatment proceduresuch as laparoscopyor ultrasound- aloneand require surgical drainagefor a persistent guideddrain placement was standardprocedure for TOArepresent very serious andpotentially life- persistent TOAat KenyattaNational Hospital. threateningcases formedical facilities worldwide, Priorto surgery ademographicand clinical andespecially inresource-poor settings suchas questionnairewas administered. Pusfrom the thosefound in sub-Saharan Africa. Furthermore, TOAwas removed duringsurgery andplaced insub-Saharan Africa where human immuno- inanaerobic transport media (AnaerobeSystems, deficiencyvirus (HIV)-1 infectionis common SanJose, CA). Before andafter surgery, patients theetiology of TOA has notbeen established. received empiric antibiotictreatment that Indata from studies conductedin Africa, includedintravenous (IV) penicillin 4million IU HIV infectionhas beenassociated with(a) alower every 6hoursand gentamicin 80mg every 8hours. prevalence ofgonococcaland chlamydial infection AnIVantibioticproviding activity against obligate andhigher odds of bacterial vaginosis (BV) in anaerobes was notavailable. Oral metronidazole womenwith histologically confirmed PID 8, (b) an 400mg every 8hourswas initiated whenavailable increased risk if aTOAamong women diagnosed inthe hospitalpharmacy. Patient management was withacute salpingitis 3,9 and(c) anincreased length directedby the physician in charge of the acute ofhospitalization for women diagnosed with gynecologyservice andwas notaffected by either aTOAand/ orpyosalpinx 3.As additional participation in the study. understandingof theetiology of persistent TOAs Studypersonnel were notinvolved inthe care couldlead tomore effective treatment guide- ordiagnosis ofsubjectsother than being present at lines suitable forresource-poor settings, we thelaparotomy procedure, and performing a short prospectively evaluated themicrobial floraof clinical/demographic questionnaire. pelvic abscesses inwomen hospitalized at the Followingtransport to the laboratory, speci- nationalreferral hospitalin Nairobi, Kenyawho mens were culturedfor both anaerobic and requiredsurgical drainageafter failing medical facultative organisms. Specimens were processed therapy alone. inan anaerobic chamber (Forma Scientific, Marietta, Ohio). Allmedia were preparedlocally fromcommercially available products.Each METHODS sample was inoculatedonto Brucella medium en- Thisstudy protocol was approvedby the richedwith vitamin KandHemin (Oxoid, InstitutionalReview Boardfor Human Subjectsat Ogdensburg,NY); Columbiaagar containing theUniversity ofWashington,and by theEthical colistin andnalidixic acid(CNA) (BBL, Review Committee at KenyattaNational Lockeysville, MD); andLaked Kanamycin Hospital, Nairobi, Kenya.Procedures followed Vancomycinagar foranaerobes (Oxoid, were inaccordance with the ethical standards Ogdensburg,NY); andChocolate agar enrich forhuman experimentation established bythe withisovitalex (BBL, Lockeysville, MD); CNA Declaration of Helsinki of 1975, revised in 1983. agar andtrypticase soyagar containing5% sheep Between Februaryand June 1999, women bloodfor aerobes (BBL, Lockeysville, MD). admittedto Kenyatta National Hospital witha Growthof eachorganism typewas recordedin a presumptive diagnosis ofTOAbased upon pelvic semi-quantitative fashion.In addition, each sample examination and/ortrans-abdominal ultrasound was inoculatedinto cooked meat medium findingsand who had either persistent low (BBL, Cockeysville, MD). Aerobiccultures were abdominalpain, fever and/orlimited regression incubatedfor 48 hours at 35 °C in 5% CO2, and 46 INFECTIOUSDISEASES IN OBSTETRICS AND GYNECOLOGY Etiology of persistent tubo-ovarian abscess in Nairobi, Kenya Cohenet al. anaerobiccultures incubated for 5 days at 35 °C in asingle sexual partnerduring the 3 months ananaerobic chamber before they were discarded priorto admission, while onerefused to answer as negative. Brothswere incubatedanaerobically questionsabout sexual practice. History ofsuffer- for5 days andexamined byvisual inspection. inga similar disease was recalled bytwo (18%) Brothswith visible growthwere Gram-stained and participants. subculturedto appropriate media. Eachorganism Allwomen reported acute low abdominal was identifiedusing simple biochemicaltests. Each painas their chiefcomplaint and the reason for isolate growingon anaerobic media was tested seeking hospitaladmission. Inaddition,five (45%) todetermine if it was afacultative orobligate hada temperature ³ 38°C,one(9%) abdominal anaerobe. Neisseria (QuadFerm, Biomerieux swelling, seven (64%) abnormalvaginal discharge, Vitek, St. Louis, MOorWee Tabs,Key Scientific, six (55%) dysuriaand one (9%) lowback pain. RoundRock, TX), Enterobacteriaceae (API 20E, Womenhad pain for a median of7 days (range Biomerieux Vitek, St. Louis, MO), and Haemo- 1–30 days) priorto hospital admission. Most philus were identifiedto the species level, and women(73%) hadsought some formof outpatient staphylococci,streptococci and Gram-positive medical attentionbefore seeking hospital rodswere identifiedto genus or group level as admission, andhad been prescribed different appropriate.For anaerobes, isolates of Peptostrepto- combinationsof oralantibiotics. Medical services coccus, Bacteroides , Fusobacterium , Prevotella, Porphy- rangedfrom being sold antibiotics at alocalstore tromonas and Bilophila/Sutterella were identified ordispensary toa visit toa primary healthcare tothe species level (Wee Tab,Key Scientific, facility. Followinghospitalization, intravenous RoundRock, TX). Gram-positive rodsand antibioticswere administered fora median of Mobiluncussp. were identifiedto the genus or 6days (range 3–14 days) priorto surgical drainage species level as appropriate.A polymerase chain and the collection of pus for culture (Table 1). reaction(PCR) assay (RocheDiagnostic System Overall, microorganisms were recovered from Inc., Somerville, NJ) was usedto test for nine(82%) of11 pelvic abscesses (seven ofnine N.gonorrhoeae and C. trachomatis ina subset
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