Breast Abscess in Lactation

A.B. is a 29‐year‐old gravida 1 para 1001 who experienced recurrent lactational breast abscess requiring surgical treatment. Her obstetric, medical, surgical, family, and social histories are unremarkable. She takes no medications and does not use alcohol, tobacco, or drugs. She gave birth at 41 weeks'gestation to a female infant, weighing 8 pounds 5 ounces. Her intrapartum course and immediate postpartum course were within normal limits. Breastfeeding was initiated within 40 minutes of birth and was successful. Her infant nursed on demand approximately every 2 to 4 hours while in the hospital. A.B. was discharged home with her baby at 28 hours postpartum. On day 3 postpartum, A.B.'s left nipple became cracked and bleeding. This was self‐treated with lanolin ointment and correction of latch‐on technique. Ten days postpartum, A.B. was diagnosed with mastitis and treated with dicloxacillin for 10 days. After 8 days of antibiotic treatment, she reported continued breast pain with a firm area of exquisite pain and redness in the upper outer quadrant of her left breast. The midwife ordered a breast ultrasound which revealed a 4‐cm abscess in the left breast. A.B. was referred to a therapeutic radiologist who performed an ultrasound‐guided needle aspiration of the abscess and obtained 15 mL of fluid. The fluid culture was positive for Staphylococcus aureus. She was treated postprocedure with doxycycline, and the breast pain, firmness and redness resolved within 36 hours. The rationale for treatment with doxycycline is unknown and subject to inquiry because S aureus is not sensitive to doxycycline. 1 Two weeks after the procedure, the abscess returned, and she was again treated with ultrasound‐guided needle aspiration and a regimen of amoxicillin with clavulanate. The abscess partially resolved, but worsened 6 days later. At that time, A.B. was referred to a breast surgeon who surgically incised and drained this 6‐cm abscess under general anesthesia. She was discharged home the same day with an indwelling Penrose drain. Two days later, the drain was removed and the wound was healing normally. A.B. continued breastfeeding exclusively throughout all of these events and was completely healed by 3 weeks after the incision and drainage. At 5 months postpartum, she had not experienced further breast infections and was continuing to breastfeed her baby.     

Pyogenic liver abscess caused by Burkholderia pseudomallei in Taiwan.

Pyogenic liver abscess in Taiwan is a well-known disease entity, commonly associated with a single pathogen, Klebsiella pneumoniae. Melioidosis is an endemic disease in Taiwan that can manifest as multiple abscesses in sites including the liver. We report three cases of liver abscesses caused by Burkholderia pseudomallei. The first patient was a 54-year-old diabetic woman, who presented with liver abscess and a left subphrenic abscess resulting from a ruptured splenic abscess, co-infected with K. pneumoniae and B. pseudomallei. The second patient, a 58-year-old diabetic man, developed bacteremic pneumonia over the left lower lung due to B. pseudomallei with acute respiratory distress syndrome, and relapsed 5 months later with bacteremic abscesses of the liver, spleen, prostate and osteomyelitis, due to lack of compliance with prescribed antibiotic therapy. The third patient was a 61-year-old diabetic man with a history of travel to Thailand, who presented with jaundice and fever of unknown origin. Liver and splenic abscesses due to B. pseudomallei were diagnosed. A high clinical alertness to patients' travel history, underlying diseases, and the presence of concomitant splenic abscess is essential to early detection of the great mimicker, melioidosis. The treatment of choice is intravenous ceftazidime for at least 14 days or more. An adequate duration of maintenance oral therapy, with amoxicillin-clavulanate or trimethoprim-sulfamethoxazole for 12-20 weeks, is necessary to prevent relapse. Liver abscess in Taiwan is most commonly due to K. pneumoniae, but clinicians should keep in mind that this may be a presenting feature of melioidosis.     

Absceso pélvico y tubo-ovárico en mujer portadora de DIU hace 16 años

We present a case of acute abdomen caused by rupture of a tubo-ovarian abscess in a 38-year-old woman who had been using an intrauterine device for 16 years. The diagnosis was made during surgery, since the intervention was performed for suspected acute appendicitis. The intervention revealed a right tubo-ovarian abscess with pelvic abscess. Culture of pelvic pus was positive for Streptococcus constellatus. The patient was treated by surgery and combined antibiotic therapy. Diagnosis was confirmed by histopathological examination.     

Management of a pregnant woman with Streptococcus group B

The relative rarity (1 to 5 cases for 1,000 births) of neonatal infections secondary to B Streptococcus, the epidemiological characteristics of this germ, especially the unstable vaginal carriage, make it difficult to select a therapeutic approach. Systematic screening of B Streptococcus and the treatment of all carriers or only of high-risk patients, present several practical problems, are complex to implement but the cost/benefit ratio seems however acceptable. Prophylactic intrapartum antibiotic treatment of known carriers of B Streptococcus does not seem debatable any longer, at least the treatment of those presenting other risk factors: premature delivery, premature rupture of the membranes, fever occurring during delivery. Today, the best prophylaxis of neonatal infections seems to be the intrapartum antibiotic treatment (ampicillin) resulting in a spectacular decrease of the frequency of neonatal contamination.     

Group B Streptococcus and pregnancy: a review

In the 1960s, early onset neonatal sepsis caused by group B Streptococcus (GBS) had an attack rate of 2 per 1000 live births and a 50% fatality rate. Early treatment and then antibiotic prophylaxis were shown to reduce morbidity and mortality rates; however, GBS remains a leading cause of perinatal infection. This article will review our investigations and related studies, including our studies in monkeys, that have contributed to current diagnosis, treatment, and prevention of disease caused by GBS. Although it has not been possible to eradicate GBS colonization, intravenous antibiotic prophylaxis given during parturition has been effective in the prevention of vertical transmission in animals and humans. Recently, diagnostic tests with polymerase chain reaction have offered promise for rapid accurate detection. This could lead to a major shift in the timing of diagnosis from the office setting to delivery suite. The potential for immunization remains a challenge.     

Case Study of Intrapartum Antibiotic Prophylaxis and Subsequent Postpartum Beta-Lactam Anaphylaxis

Universal screening for maternal group B Streptococcus (GBS) in the prenatal period has led to administration of intrapartum antibiotic prophylaxis (IAP). Although IAP decreased the rate of early neonatal GBS disease, exposure of childbearing women to penicillin and other beta-lactam antibiotics has increased. Beta-lactam-induced anaphylaxis in the breastfeeding woman during the postpartum period illustrates risk factors for beta-lactam allergy and anaphylaxis. Treatment and nursing implications for this adverse reaction are suggested.     

Mother with post-partum group B Streptococcus meningitis and cerebellar abscess

We report the case of a 25-year-old Malay woman, admitted for preterm delivery at 35 weeks' gestation. Vaginal swab did not isolate any organism. She delivered a baby girl who developed respiratory distress syndrome, requiring ventilation. Although chest radiograph showed hyaline membrane disease with pneumonia, septic workout was negative. The mother was discharged on the next day. Seven days postpartum, the mother presented with fever and fits and was diagnosed to have meningo-encephalitis. Lumbar puncture isolated group B Streptococcus (GBS) and MRI revealed a superior cerebellar abscess. She was treated and survived the episode. This case illustrates the uncommon situation where GBS infection was confirmed via maternal septic workout rather than neonatal, although both presented with severe disease.     

Upper genital tract isolates at delivery as predictors of post-cesarean infections among women receiving antibiotic prophylaxis

The introduction of antibiotic prophylaxis for cesarean delivery has decreased the risk of postpartum endometritis and wound infection, but factors that contribute to prophylaxis failure are not understood. To determine factors that might contribute to postpartum infections following antibiotic prophylaxis, we cultured amniotic fluid, decidua, and chorioamniotic membrane specimens for anaerobic and facultative bacteria and for genital mycoplasmas at cesarean delivery. Women were assessed daily for the development of infections, and if endometritis developed, a protected endometrial culture was obtained. Postpartum endometritis developed in 16 and wound infection in four of 102 women. Infection rates were similar for women receiving cefotetan (N = 50) or cefoxitin (N = 52) for prophylaxis. The isolation of group B streptococcus (P less than .001) or Enterococcus faecalis (P = .03) from the upper genital tract at delivery was significantly associated with postpartum endometritis. Antibiotic-resistant organisms (other than enterococci) were recovered uncommonly at delivery or with postpartum infections. Group B streptococcus was susceptible to the prophylactic agents used, suggesting that virulence factors other than antibiotic resistance are important for the development of postpartum endometritis. Group B streptococcus, E faecalis, and bacteria associated with bacterial vaginosis were recovered from the endometrium at the time of postpartum endometritis.     

Absceso epidural y de psoas bilateral tras anestesia epidural obstétrica: una complicación poco frecuente

Epidural abscess is a rare but serious complication of epidural anesthesia. We present the case of a healthy parturient who developed spinal epidural and psoas muscle abscesses following spinal analgesia for uneventful labor and delivery. Diagnosis requires a high index of suspicion and magnetic resonance imaging. Early surgical decompression and prolonged antibiotic therapy are the mainstays of epidural abscess treatment, while percutaneous drainage under imaging guidance with antibiotic coverage is an effective front-line treatment of psoas muscle abscess. Epidural abscess can be a catastrophic consequence of epidural anesthesia. Early diagnosis is essential to prevent permanent neurological damage.     

盆腔脓肿腹腔镜手术治疗进展

盆腔脓肿是育龄妇女最常见的急腹症之一,传统的抗生素保守治疗往往使病情迁延难愈,部分患者保守治疗失败仍需手术治疗。盆腔脓肿不仅引起慢性盆腔疼痛,还影响女性生殖和内分泌功能,病情严重者甚至危及生命。腹腔镜是诊断盆腔脓肿的金标准。与开腹手术相比,腹腔镜手术安全有效,早期手术患者从手术时间、术中出血量、术后体温恢复、肠道功能恢复等均提示病程明显缩短、症状缓解,且远期输卵管复通率高,更有机会保留子宫、附件,改善女性的生殖内分泌功能,减少盆腔炎复发,提高生活质量。临床上应筛选预期单纯抗感染治疗无效的患者以及年轻有生育要求的女性及早施行腹腔镜手术,个体化制定手术术式。由于盆腔脓肿手术相对复杂,建议由熟练掌握腹腔镜技术的妇科医师来完成手术。     

Immunostimulation as a part of urologic infection therapy in pregnancy

Twenty-six pregnant women (group I) with uroinfection were treated with Urostim and antibiotic. The effect of treatment was compared to that of 20 pregnant women (group II) treated with antibiotic only. In group I recurrence of infections was found out in 15.3%, while in group II in 55%. We would like to offer it as part of the treatment of uroinfections with pregnant women, because it will reduce the usage of antibiotics and the recurrence of the uroinfections in postpartum period.     

Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess

Objective: Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess. Study Design: A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed. Results: Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess (p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients. Conclusions: Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess. (Am J Obstet Gynecol 1998;178:1272-8.)     

Severe infection following pudendal anesthesia

A case of severe infection following pudendal anesthesia is presented. The probable spread of the infection to the subgluteal space and the complications are discussed. Musculoskeletal symptoms arising in the hip area and the pelvis during the early postpartum period pose a challenging diagnostic problem. When these symptoms are accompanied by fever and pain, the possibility of a severe infection with possible abscess in the subgluteal or retropsoas space must be considered. The treatment consists of prompt surgical drainage and appropriate antibiotics.     

Clones of Lactobacillus casei and Torulopsis glabrata associated with recurrent abdominal wall abscess.

Infectious disease caused by Lactobacillus sp has not been previously reported in Taiwan. We present a case of recurrent abdominal wall abscess in a chronically ill 36-year-old woman, and review the literature on Lactobacillus infection. Five isolates of L. casei were recovered from blood and pus samples, and two isolates of Torulopsis glabrata were isolated from two blood specimens 3 months apart. Two clones of L. casei and T. glabrata were identified by means of antibiotyping with the E test and molecular methods. The abscess was surgically removed because of poor response to 7 months of antimicrobial therapy for the second infectious episode. Recurrent Lactobacillus infection can occur in chronically ill or immunosuppressed patients. Treatment of these infections may require a longer duration of antibiotic therapy, or surgical intervention.     

Pharmacokinetics of piperacillin in the postpartum patient

Six women were given 1 g of piperacillin on the 2nd postpartum day and serum concentrations of the drug were measured at 0.5, 1, 2, and 4 h after infusion. The same women returned for an identical test 6 months later and hence served as their own controls. A second group of 6 women were treated identically except that they received the first dose of piperacillin on the 3rd postpartum day. The serum levels of antibiotic were consistently lower during the puerperium than at 6 months. The levels obtained at 2 compared to 3 days post partum were similar, but were about one half the levels obtained at 6 months post partum. These results indicate that antibiotic therapy for postpartum endomyometritis may need to take account of the fact that the altered pharmacokinetics of pregnancy persists into the puerperium. If used in this setting, the dose of piperacillin may need to be increased by 50% over the normal adult dose.     

Pyomyoma: a case report

EDITORIAL COMMENT: We accepted this case for publication because, although rare, it is interesting and has been associated with a high fatality rate unlike pyometra where the pus is usually sterile on culture. One of the reviewers wondered whether it was wise to aspirate such a tumour but since this patient survived treatment uneventfully it may be that the preoperative knowledge of the abscess provided an advantage at least in suggesting the need for antibiotic therapy. The editor has seen a number of cases of submucous fibroids associated with infection, especially when they have prolapsed through the cervix into the vagina, but he has never seen a case of a pyomyoma as described here. N.B.     

Comparison of early-onset neonatal sepsis caused by Escherichia coli and group B Streptococcus

OBJECTIVE: The purpose of this study was to compare maternal characteristics and neonatal morbidity and mortality rates that are associated with early-onset neonatal sepsis that is caused by group B Streptococcus and Escherichia coli. STUDY DESIGN: This was a retrospective review of newborn infants with a positive blood culture (and/or cerebrospinal fluid) that was positive for either E coli or group B Streptococcus during the first week of life. Data were abstracted from maternal and neonatal medical records. RESULTS: Among 28,659 deliveries during the study period, 102 episodes of early-onset neonatal sepsis were identified, 61 of which were caused by group B Streptococcus and 41 of which were caused by E coli. E coli sepsis cases had a lower birth weight, a higher percentage with 5-minute Apgar score <7, and a longer stay in the hospital neonatal intensive care unit and required mechanical ventilation more frequently. Death after early-onset neonatal sepsis with E coli was also more frequent. CONCLUSION: Early-onset sepsis with E coli is associated with more morbidity and a higher mortality rate compared with early-onset group B Streptococcus.     

Puerperal breast abscess

The mechanism of breast infection is most likely one in which the infant acquires the pathogenic staphylococcus either in the hospital or home environment and transmits it to the breast upon suckling. Under favorable conditions of milk stasis, retrograde invasion of the duct occurs and an inflammatory process is initiated which may progress to abscess formation. Since the average duration of symptoms was 7.7 days before the patients sought medical care, personalized postpartum instruction to nursing mothers seems essential. This would permit earlier awareness of breast abnormality and allow for prompt antibiotic therapy in order to circumvent abscess formation. Infants who exhibit signs of upper respiratory infection should be removed from the breast, isolated (manual emptying of breasts instituted temporarily), and receive proper antibiotic care. In such cases the two conditions apparently necessary for promoting breast infection are present: (a) inability of sick infants to feed well with resultant ineffectual emptying of breasts, thereby promoting stasis and stagnation, and (b) the presence of a pathogenic organism in the upper respiratory tract of the infant.Infants of mothers who display breast infection should be placed in the isolation nursery and given antibiotic treatment. In smaller hospitals, when mastitis appears on the maternity floor, it would be feasible to administer antibiotics prophylactically to all infants in an attempt to prevent cross infection. At Cook County Hospital this practice would be virtually impossible. All normal postpartum patients leave the institution within 48 to 72 hours of delivery, long before signs and symptoms of infection are manifested. Also, the distribution of drugs to infants numbering in excess of 1,200 per month is in itself a prohibitive procedure. The ultimate but drastic measure for prevention of breast infection would be to eliminate all breast feeding during periods of increased breast infection. Breast feeding could be resumed when the infection has been curtailed.This protracted series of augmented numbers of breast infections would indicate that more than an “outbreak” has occurred. It is more plausible that a new norm or standard of bacterial virulence has been established, which is refractory to the more commonly used antibiotics, particularly penicillin.     

Hepatic abscess caused by Aspergillus fumigatus infection following splenectomy and immunosuppressive therapy.

Hepatic abscess caused by Aspergillus fumigatus infection is rare. The incidence of fungal hepatic abscess has recently increased. We report a case of Aspergillus fumigatus infection in a 66-year-old man with aplastic anemia who presented with intermittent high fever. He had received splenectomy about 2 years before this admission followed by treatment with anti-human thymocyte globulin, corticosteroids, and cyclosporin. Abdominal sonography and computerized tomography scan of the liver revealed a hepatic abscess and empiric broad-spectrum antibiotics were administered, but fever persisted. Culture of abscess aspirate yielded Aspergillus fumigatus. Amphotericin B was administered, but the patient died of sepsis. With the increasing number of immunocompromised patients, various fungal infections, including Aspergillus fumigatus, are increasingly common, and this infection can be very serious with fatal outcome. Alertness to the possibility that fungal infection may be present when an immunocompromised patient with hepatic abscess presents in hospital is important to decreasing morbidity and mortality.     

Treatment of Bartholin's abscess. Marsupialization versus incision, curettage and suture under antibiotic cover. A randomized study with 6 months' follow-up.

Conventional marsupialization was compared with incision plus curettage and primary suture of the abscess cavity under antibiotic (Clindamycin) cover in a prospective, randomized study of 32 patients with Bartholin's abscess. The median time to healing was 5 days less after suture than after marsupialization alone. The difference was statistically significant. 29 patients were followed up for 6 months. Recurrence of abscesses tended not to be more frequent after suture, making suture an attractive, safe and convenient alternative treatment for Bartholin's abscess.