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OBJECTIVE: Our objective was to describe the risk of hospital admission for virologically confirmed dengue (VCD) and the risk of clinically severe hospitalized VCD occurring up to 4 years after the first dose (years 1 to 4) in three randomized clinical trials comparing tetravalent dengue vaccine with placebo. METHODS: The relative risks (RR) for hospitalized VCD from first dose to year 4 were estimated by year and age-group in individual and combined studies. RESULTS: Overall, from Year 1 to Year 4, 233 and 228 participants had at least one episode of hospitalized VCD in the vaccinated (n = 22 603) and placebo (n = 11 301) groups, respectively (RR = 0.511, 95% CI 0.42-0.62). Among these, 48 and 47 cases, respectively, were classified as clinically severe. In children aged ≥9 years, 88 and 136 participants had at least one episode of hospitalized VCD in the vaccinated (n = 17 629) and placebo (n = 8821) groups, respectively (RR = 0.324; 95% CI 0.24-0.43). In vaccinated participants aged <9 years, particularly in those aged 2-5 years, there were more hospitalized VCD cases compared with the control participants in Year 3 but not in Year 4. The overall RR in those aged <9 years for Year 1 to Year 4 was 0.786 (95% CI 0.60-1.03), with a higher protective effect in the 6-8 year olds than in the 2-5 year olds. CONCLUSIONS: The overall benefit-risk remained positive in those aged ≥9 years up to year 4, although the protective effect was lower in years 3 and 4 than in years 1 and 2.

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AIMS: To assess the different phenotypes and mechanisms of fluoroquinolone (FQ) resistance in clinical and environmental isolates of Escherichia coli. METHODS AND RESULTS: We compared FQ-resistant E. coli isolates, measuring minimal inhibitory concentrations (MIC) of ciprofloxacin, along with susceptibility to other antibiotics. We also searched for the presence of efflux pumps, using efflux inhibitors, and for plasmid-borne FQ-resistance by PCR. We found that, aside from the higher FQ-resistance prevalence among clinical strains, environmental ones resist much lower concentrations of ciprofloxacin. Efflux pumps mediate fluoroquinolone resistance as frequently among environmental isolates than in clinical strains. Plasmid-borne qnrA genes were not detected in any resistant strain. CONCLUSIONS: Environmental FQ-resistant strains may have a nonclinical origin and/or a selective pressure different from the clinical use of FQs. SIGNIFICANCE AND IMPACT OF THE STUDY: The identification of the source of low-level FQ-resistant strains (ciprofloxacin MIC c. 8 microg ml(-1)) in the environment could be important to curb the rapid emergence and spread of FQ-resistance in clinical settings, as these strains can easily become fully resistant to FQ concentrations achievable in fluids and tissues during therapy.

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BACKGROUND: As the incidence of tuberculosis (TB) has increased worldwide, it is expected that pregnant women will acquire this infection more frequently. Mycobacterium tuberculosis infection during pregnancy may represent a risk for maternal and neonatal complications. METHODS: We studied the perinatal events of 35 consecutive pregnancies complicated by TB from March 1990 to June 1998; 105 apparently healthy pregnant women were included as controls, matched in age, gestational age upon arrival at the Institute, and socioeconomic status. Frequency and type of neonatal complications were recorded. Relative risk (RR) with 95% confidence interval (CI) was calculated. To control potentially confounding variables, a stratified analysis was performed. RESULTS: Seventeen (48.5%) tuberculous mothers had a pulmonary infection and 18 (51.5%), an extrapulmonar localization of the TB. The neonatal morbidity rate in children born to women with TB was 23% against 3.8% of the children of the control cohort (p <0.05). Average weight of newborn infants of tuberculous mothers was 2,859 +/- 78.5 g, while average weight at birth of control neonates was 3,099 +/- 484 g (p = 0.03). Newborns of women with TB had a higher risk of prematurity (RR 2.1; 95% CI 1-4.3), perinatal death (RR 3.1; 95% CI 1.6-6), and weight at birth less than 2,500 g (RR 2.2; 95% CI 1.1-4.9). Pulmonary localization of the TB and late start of the treatment in the mothers increase the risk of perinatal death and neonatal morbidity. CONCLUSIONS: Children born to women with TB have an increased risk of morbidity and mortality in the neonatal period.

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BACKGROUND: High concentrations of interleukin-6 (IL-6) have been demonstrated in amniotic fluid (AF) from women with intra-amniotic infection. Recent studies have reported that IL-6 levels in AF were related to an increase in neonatal morbidity; moreover, higher IL-6 plasma levels have been observed in neonates with sepsis. METHODS: A cohort study was carried out at the National Institute of Perinatology in Mexico City. Inclusion criteria were the following: 1) preterm singleton pregnancy; 2) intact membranes at time of enrollment, and 3) written informed consent. Women with other complications of pregnancy were excluded. Newborn sepsis during the first 72 h was defined as early-onset sepsis. Amniotic fluid was obtained at the moment of delivery. Amniotic fluid IL-6 (AF IL-6) was determined by enzyme-linked immunoassays. RESULTS: Ninety-three women met the criteria for enrollment in the study and 31 (33%) of their newborns had early-onset neonatal sepsis. The mean AF IL-6 in mothers of septic newborns was 5779 +/- 2804 pg/ml compared to 729 +/- 382 pg/ml in mothers with non-infected neonates (p < 0.001). AF IL-6 concentrations higher than 1250 pg/ml were significantly associated with early-onset sepsis (OR 33.3; 95% CI 9.4-117.3) (p < 0.001). Gestational age under 32 weeks was also associated with neonatal sepsis (OR 2.56; 95% CI 1.2-9) (p = 0.002). Women whose infants developed neonatal sepsis had a higher frequency of clinical chorioamnionitis (p = 0.02). CONCLUSIONS: IL-6 determination in AF may be a useful indicator to identify neonates with higher risk of in utero bacterial infection.

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OBJECTIVE: To describe the experience of management of pregnant women complicated with rubella and to evaluate the perinatal outcome. MATERIAL AND METHODS: A total of 67 pregnant women with positive IgM test for rubella were studied in the period from January 1st, 1990 to October 31st, 1997. Sixty-six of these women were followed until the end of gestation, in 4 patients an elective abortion was performed and 1 patient had a molar pregnancy. The effects of rubella on gestation and on the product were evaluated in sixty-one of the patients. Anti-rubella IgM was determined at birth and positive infants were subjected to evaluation by echocardiogram, brainstem auditory evoked potentials (BAEP) and ophthalmological study. RESULTS: Mean age of the patients was 24.7 +/- 5.5 years; 28 patients were primigravidae. Pregnancies were normal showing no complications due to the rubella episode. In 35 cases (52.2%), the viral infection occurred during the first trimester of pregnancy, in 23 cases (34.5%) during the second and in 9 (13.3%) during the third. Seventy-one percent of infants born to mothers infected during the first trimester of pregnancy were also infected, and 51.6% developed congenital rubella syndrome. The most frequent manifestations of CRS were: prematurity, low birth weight and alterations of the BAEP. CONCLUSIONS: In Mexico, rubella is still a cause of fetal damage, which shows the need for preventive strategies, such as universal vaccination, to avoid rubella infection during pregnancy.

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The objective of this article is to evaluate the impact of tuberculosis (TB) on perinatal outcome in a cohort of 25 pregnant women with TB treated at the National Institute of Perinatology (Mexico, City) from March 1990 to September 1995. They were compared with a cohort of normal pregnant women; both cohorts were matched by age, gestational age, and socioeconomic status. For purposes of analysis, patients with TB were further stratified into two groups: one included 9 women who started treatment either before or at the beginning of pregnancy, and the other constituted 16 women who started treatment in either the second or third trimester of gestation. Thirteen women (52%) had pulmonary TB, 7 (28%) had renal infection, and the rest of patients had diverse extrapulmonary localization of the infection. Obstetrical morbidity and neonatal mortality were significantly higher in pregnant women with TB who started treatment late in pregnancy. Perinatal morbidity was similar in pregnant women receiving antituberculous drugs early during pregnancy to that in uninfected women. We conclude that TB represents a risk factor for pregnancy. Early treatment of the disease during gestation reverts its negative impact on perinatal outcome.

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Near 70 per cent of Mexican women infected by the Human Immunodeficiency virus (HIV) are between 15 and 44 years old, in this women sexual transmission are the most frequent route of infection. The objective of this article was to describe the obstetric course and perinatal repercussion of the HIV-Positive pregnant women with medical care at the Instituto Nacional de Perinatología, Mexico city between January 1994 to December 1996. Nineteen women were studied, sexual transmission was the route of infection in 16 of them. One had diagnostic criteria for AIDS, the others 18 had HIV asymptomatic infection. At delivery 18 a term products were born. The mean of the newborn weight was 3159 g. At moment of this report 4 children (22%) have been diagnosed as HIV infected, all of them dead during their first year of life.

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Varicella-Zoster (V-Z) virus infection during pregnancy is uncommon. Nevertheless, it has importance due to the risk of vertical transmission of the infection and also because of a higher morbidity rate among pregnant women. The cases of varicella infection that occur in the first and second trimesters of pregnancy are occasionally associated to the development of congenital varicella syndrome. We studied 22 women whose pregnancy was complicated with varicella during the first 20 weeks of gestation. The average age of these patients was 20 +/- 3.6 years with a range of 16 to 20 years. None of the patients presented complications due to the V-Z virus infection. Two pregnancies finalized in preterm labor. None of the newborns had congenital anormalies; one presented microcephaly, and another low birth weight. There was no significant difference between the infants of women with varicella and those of the controls in birth weight, size, and head circumference. We concluded that varicella infection during the first 20 weeks of gestation was not associated with serious maternal morbidity, and has low repercussion in the pregnancy outcome and the fetus.

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OBJECTIVE: To determine the seroprevalence of hepatitis A, B, C and D virus infection among pregnant women attending a perinatal care hospital. MATERIAL AND METHODS: A prospective study was carried out to determine the seroprevalence of hepatitis A virus IgG antibodies (anti-HAV), hepatitis B virus markers (anti-HBcAg and HBsAg) and hepatitis C virus antibodies (anti-HCV) in pregnant women. In HBsAg positive cases. HBeAg and hepatitis D virus antibodies (anti-HDV) were investigated. All analyses were performed with the ELISA technique. RESULTS: Of the 1500 pregnant women studied. 93.3% were positive for anti-HAV IgG. The HBsAg seroprevalence was 0.26% and anti-HCV seroprevalence was 0.53%. There were no patients with HBeAg or anti-HDV. CONCLUSIONS: A higher seroprevalence of HBsAg was found in this study than in other studies of pregnant Mexican women. We propose that HBsAg screening become a routine prenatal test.

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OBJECTIVE: To discuss the clinical presentation and consequences of genital tuberculosis (GTB), a known cause of infertility. Although it appears to be a rare entity, usually secondary to a primary site of infection by Mycobacterium tuberculosis, its true incidence is not known owing, in part, to inadequate diagnostic procedures, particularly in less developed areas of the world. PATIENTS AND METHODS: We present our experience with 25 cases of genital TB. Of these woman, 21 were seen for infertility; 3 were postmenopausal with uterine hemorrhage, and 1 was admitted with an acute abdomen. All women were treated medically and/or surgically. RESULTS: Only five women were found to be suitable for artificial insemination. Two of the women became pregnant but aborted. CONCLUSIONS: The incidence of genital TB may be higher than one might imagine, based on the lack of reports in the literature, and may account for a significant amount of female infertility.

PIP: During 1988-93, in Mexico City, the National Institute of Perinatology diagnosed 25 cases of female genital tuberculosis. Their age ranged from 21 to 42 years. The diagnostic procedures used to detect these cases included laparoscopy, PPD skin test reaction, hysterosalpingography (HSG), culture of tissue and fluid samples, and histopathological examination of tissue biopsies. 16% had a history of tuberculosis. 39.1% had a history of contact with a relative with tuberculosis. Three women were postmenopausal and suffered from uterine bleeding; they underwent a hysterectomy. 17 of 21 women who went on to infertility studies had suffered infertility for 2-14 years. HSG revealed abnormalities in 95.2%, especially bilateral tubal occlusion (57.1%) and deformity of the uterine cavity (54.5%). Mycobacterium tuberculosis was isolated in 4 women, all of whom had fluid in the pelvic cavity. 14 of the 16 patients who underwent the PPD skin test had an induration larger than 10 mm in diameter. 68% of the 19 patients who underwent endometrial biopsy had granulomas consistent with tuberculosis. All the women received antibiotics to treat female genital tuberculosis. Five of the 17 patients referred for infertility evaluation underwent in vitro fertilization and embryo transfer. Two of these women became pregnant but later suffered a spontaneous abortion. The other 3 women never conceived. These findings indicate that the incidence of female genital tuberculosis may be higher than expected and may be responsible for a substantial amount of female infertility. Pregnancy occurs when female genital tuberculosis is detected at an early stage and when no irreversible anatomical pathology is evident. Thus, it is important to determine the existence of tuberculosis early in cases of infertility and to begin therapy immediately.

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Traditionally obstetric infections have been treated with combination antimicrobial agents that provide coverage against aerobic and anaerobic bacteria commonly found in these infections. New antibiotics may be a monotherapy alternative for this type of infections. The objective of the study was to compare the efficacy of the agent piperacillin/tazobactam against ampicillin plus gentamicin in the treatment of postcesarean endometritis. By randomized way 14 patients were enrolled in the piperacillin/tazobactam group and 42 in the ampicillin-gentamicin group. A favorable clinical response occurred in 78.6% of piperacillin/tazobactam patients and 88.1% of ampicillin and gentamicin patients (p = NS). There was no statistically significant difference in the times to recovery and days of hospitalization between the two groups. The combination piperacillin/tazobactam did not show advantage towards the standard treatment, so combination antimicrobial agent continue been the optimal approach to the management of obstetric infection.

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Perinatal vertical transmission has increased in all the world; it is considered that at the present time there are about one million of children with HIV. Variation goes from 12 to 40%, at different countries. During the last years antiretroviral drugs as AZT, ddI and others have been used to diminish the virus passage via transplacentary. Eighteen placentaes from HIV seropositive women, three corresponded to first trimester, and 15 to the third trimester of gestation; in four cases they were treated with AZT in weeks fourteen (two patients), 26 and 35 of gestation; and one patient received AZT and ddI at week 28. Control group was with ten normal placentaes. Ultraestructural analysis and immuno-peroxidase and immuno-oro with antibody anti gp 41, were done. Ultraestructurally there were different localizations of HIV virus, at sincitiotrophoblast, decidual cells and umbilical vessels (six cases). In 13 cases there was hyperplasia and hypertrophy of macrophages containing a great amount of lysosomes. In one case, where a girl was seropositive many viriones HIV, were identified in macrophages. With immuno-oro viral proteins were seen in cytoplasm an plasmatic membrane, in endothelium of fetal capillars and trophoblast. With immunoperoxidase, four cases were positive. Placentaes with antiretroviral treatment since week 14, trophoblast was more dense by philaments increment. Placentaes with treatment during the third trimester, showed normal morphology with slight increase of philaments. In the cases treated with AZT and ddI, there were not macrophages hyperplasia and hypertrophy, nor viral particles. It is concluded that in seropositive mothers without treatment, the virus may be present in any part of chorionic villi, and in patients with treatment, virus is not identified, but a viral proteins synthesis.

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The cesarean section is associated with a high incidence of puerperal infections. The antibiotic prophylaxis in obstetric surgery may reduce infectious complications, nevertheless antibiotic prophylaxis only has proved to be effective in women with risk factors for the occurrence of infection. We made a comparative study of the prophylactic efficacy of the ceftriaxone a single dose versus cefazolin three doses, in women with risk factor for infection. There were enrolled 100 patients, 50 in each group. Six percent of the ceftriaxone group patients developed puerperal infections while 12% of the cefazolin group women developed this complication. The statistic analysis don't show difference between the groups. We consider the single dose prophylactic schema is better because its application is easier, administration is safety and reduces the risk of adverse reactions.

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The sensitivity, specificity, positive and negative predictive values and positive and negative false percentage of three monoclonal immunofluorescence reagents for direct diagnosis of Chlamydia trachomatis infections were evaluated, 150 cervical specimens and 50 samples of peritoneal liquid of patients with pelvic inflammatory disease, were studied. The results showed that the reagents against the main protein of external membrane of Chlamydia introduced high sensitivity but minor specificity than the reagent of immunofluorescence direct against then chlamydial lipopolysaccharide.

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Nosocomial infections (NI) are still a major cause of morbidity among gynecology & obstetrics patients (GOP). At the Instituto Nacional de Perinatología (INPer), during 1989, there was an overall NI rate of 2.37 per 100 GOP discharged, while specific NI rates for the subgroups of puerperal and gynecologic surgery patients were 2.11 and 6.3 respectively. Endometritis and infected surgical wounds were the most frequent type of NI, having a multimicrobial etiology. There was a significant increase in hospital days of stay for those patients who developed NI. It is clearly necessary to improve the surveillance of NI as well as the collaboration among different wards dealing with GOP, in order to find more effective and efficient ways to prevent the development of NI.

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Rabies infection in humans is still a major public health problem. A review of the literature shows 25 cases of pregnant human exposure to rabies virus. We report two patients with rabies exposure during the second and third trimester of pregnancy, that received immunization respectively with Vero cell vaccine and Fuenzalida vaccine. There were no repercutions in the products or in the mothers attributed to the prophylaxis, which appear safe when given during pregnancy. Because of the high likelihood of fatal disease following a rabid animal bite, this cases report supports the recommendation that pregnancy is not a contraindication to post-rabies exposure immunoprophylaxis.

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