Journal of the American Venereal Disease Association最新文献

The frequency of oropharyngeal infections with Neisseria gonorrhoeae in pregnant women was studied in two prenatal clinics in Bandkok, Thailand. A third group of women visiting a dental clinic on a routine basis was included for comparison purposes. Group I, from an American dependent clinic, had an oropharyngeal infection rate of 15% while only 0.7% had cervical infections. None had infections in more than one site. In Group III, from a Thai clinic, no patients had oropharyngeal infections while 11.9% had infections from either the cervix or rectum or both. One and eight-tenths percent of the patients attending the dental clinic had oropharyngeal infections. Oropharyngeal gonorrhea was found in a prenatal population of American military dependents at a high rate. We propose that all women visiting a prenatal clinic routinely have their oropharynx cultured for N gonorrhoeae.

Penicillin has remained the choice drug for the treatment of gonorrhea. Its cure rate has been relative, and because cure rates are not as good as one would wish, an additional increase in dosage has been advised. Despite an improved cure rate with increased dosages, we are rapidly approaching a dose requirement beyond that which can be administered practically on an outpatient basis. Therefore other antimicrobial agents have been evaluated for the treatment of gonorrhea. Ampicillin 2 gm (IM) with 1 gm probenecid was evaluated in 1969 with a 99% plus cure rate. It also has been found that 3.5 gm of ampicillin orally (7 capsules of 500 mg) and probenecid (2 tablets of 500 mg) is an effective treatment for gonorrhea. We undertook the present study to evaluate the efficacy of a new single oral combination treatment, Polycillin-PRB.

Data collected from experimental rabbit syphilis and from in vitro studies with nonpathogenic treponemes can be extended only with great caution to human syphilis. The following tentative conclusions may be drawn: penicillin acts on Treponema pallidum by interfering with cell wall synthesis. Concentrations of penicillin greater than 0.1 mug/ml do not have increased treponemicidal effect. Regimens producing penicillinemia for at least 8 days are considerably more efficient than treatment yielding high peak serum levels of brief duration. Treponemal residence in antibiotic-protected sites increases the need for long duration therapy. Other antibiotics are less effective than penicillin, and patterns of antibiotic interaction against treponemes do not match those seen with other bacteria.

Penicillin has some ameliorative effect in every stage of neurosyphilis. Meningovascular disease responds most dramatically. Once anatomic damage has occurred, penicillin is not effective in restoring lost function. In addition, blindness secondary to primary optic atrophy or 8th nerve deafness responds poorly to any type of treatment. Penicillin schedules employing more than 5 million units appear more effective than lower dose regimens. Reports of alternative antibiotic regimens are too fragmentary to allow recommendations to be made.

Epidemiologic treatment refers to antibiotics administered when a diagnosis is considered likely on clinical, laboratory, or epidemiologic grounds, but before the results of confirmatory laboratory tests are known. This treatment is justified on the grounds that the potenial benefits of treating the patient outweigh the potential harm of not treating. This potential harm may affect the individual or the community. Individual sequelae are most significnat when congenital syphilis is allowed to develop due to delays in treating the pregnant woman or newborn child. Community sequelae occur when an infected patient disseminates disease during the interval between initial presentation and final diagnosis. Unless qualified by time limitation and the behavioral and disease characteristics of a given population, exposure to syphilis is a poor criterion for epidemiologic treatment. The risk of infection of certain groups (defined by epidemiologic, clinical, or serologic criteria) should be determined empirically so that epidemiologic treatment is only provided to groups in which this risk has been estimated.

Two hundred physicians, public health nurses, medics, and physician's assistants, comprising 92% of health care providers treating gonorrhea in Alaska, were interviewed to determine the number of cases seen during a 12-month period and to determine the adequacy of treatment given. Significantly more cases were reported on the survey than were reported to the State Department of Health. However, an attempt to validate the survey results through a chart review suggested that surveys relying on memory provide overestimates of cases and that gonorrhea may not be as underreported as previously thought. A wide variety of antibiotics were used to treat gonorrhea. Physicians in private practice accounted for the majority of inadequately treated cases. The actual number of cases receiving ineffective therapy was estimated as 2%.

Today, there is an apparent increase in oral genital activity among heterosexual groups not only in the United States but also globally. As a result, gonococcal pharyngitis was rediscovered, and primary syphilis of the oral cavity has been recognized with increasing frequency. In addition, physicians are seeing a wide variety of traumatic lesions of the genitals from "hickeys" of the labia to dental imprints and ulcerations of the glans penis. Our patient exhibits an interesting phenomenon recognized readily elsewhere on the skin but infrequently diagnosed on the glans penis.

Reactions related to treatment of syphilis may be due to treponemal infection, therapy, or to the interaction of these. In this review I discuss the Jarisch-Herxheimer (J-H) reaction and the therapeutic paradox. Antibiotic side effects are not unique among patients treated for syphilis; therefore, readers are referred elsewhere for reviews of major antibiotic side effects. J-H reactions are acute, transient episodes with manifestations occurring both systemically and at local sites of treponemal concentration. These reactions are related to the rapid destruction of treponemes by various therapeutic agents. In this review, I suggest that J-H reactions may be significant only in syphilitic paresis, pregnancy complicated by syphilis, and when local inflammation can cause serious functional compromise, as with second or eighth cranial nerve involvement. Many workers use prednisone in conjunction with penicillin in some or all of these situations. However, the efficacy of corticosteroids has not been evaluated for such problems in clinical trials. Therefore, the use of prednisone can be supported only in very selected situations and for short duration (ie, 2 days). Therapeutic paradox, which is clinical worsening despite cure of infection, is said to result from scar formation after rapid treponemal destruction by therapeutic agents. The therapeutic paradox does not appear of great significance. Futhermore, no methods to prevent such reactions are generally advocated.