In clinical practice, to treat infectious diseases, doctors should focus on pathogens, biomarkers and medication-related problems, such as drug selection, administration, usage, and dosage of drugs. Only when all the ingredients above are taken into consideration can satisfactory therapeutic effects be achieved. In addition to referring to doctors’ clinical experience, clinical pharmacists, as the main clinical consultants of severe infectious patients in China, should summarize their experience to provide better medical and pharmaceutical services. To our knowledge, this is the first observational study to analyse common gynaecological pathogens, integrate targeted medication plans and screen the most valuable infectious indicators. Compared to previous studies, this retrospective study could offer insights from clinical pharmacists for doctors in the field of gynaecology and obstetrics when encountering patients with severe infections.
Previous studies have shown that the urinary tract is the main site of postoperative infection in patients who undergo gynecological surgery, followed by the respiratory system and incision . SSI is the most common infection complication after gynecological surgery and mainly includes wound surface cellulitis, deep abscess, and pelvic or vaginal stump infection [16,17,18]. The results of this study showed that SSI was the most common infection, followed by urinary tract infection, fever of unknown origin, pelvic inflammatory disease and pulmonary infection. The site with the highest infection rate is not consistent with the literature; however, the types of diseases are similar, which may be attributed to the fact that consultation cases are mainly difficult cases identified by physicians, resulting in a low correlation with the actual incidence of infection. Mothes et al.  found that gynecological infections were mainly caused by Group B Streptococcus, Escherichia coli, Klebsiella, Enterobacterales, Proteus and other Enterobacterales bacteria, which was consistent with the results shown in this study. In this study, we found that the most recommended treatment plans included imipenem/cilastatin, piperacillin/tazobactam, and meropenem alone or in combination with other antibiotics. Clinical pharmacists selected the most proper medications mainly based on their antibacterial spectrum and toxicity for specific patients in some cases. Notably, according to the results in Table 3, the WBCs in the urine of patients diagnosed with urinary tract infection did not decrease significantly after 3 days of treatment, but the treatment effect was obvious after 7 days of treatment (P < 0.01), suggesting the importance of sufficient medication duration and measurement frequency.
CRP and WBC count are commonly used as biomarkers in clinics. They have become focal points of research endeavours for the identification and assessment of inflammation prognosis [11, 12]. WBC count is a viable biochemical marker of the severity of infection in patients. CRP values can increase more than 100 times over, which are more noteworthy than baseline values and show a functioning state of infection. Their sensitivity and specificity were different in different bacterial infections.
The PCT level marks the degree of inflammatory response activity and helps to clarify the colonization or invasion of a detected bacterial pathogen, which may contribute to choosing an empiric therapy [7, 20]. Previous studies have shown that PCT could distinguish Gram-negative from Gram-positive bacteria at a significantly higher level [21, 22]. However, some contradictory voices support that PCT levels are easily affected by a series of factors, including infection sites, anti-infective drugs and specific pathogens. Gram-negative bacteria are not the decisive factor [23,24,25]. In this study, we investigated the importance of PCT in clinical pharmacists’ treatment plans for gynecological infections. The results demonstrated that the effect of PCT level was not obvious after 7 days of antibiotic treatment, which was not consistent with the outcomes of WBC count or CRP (Table 3). This means that PCT did not show any value in assessing the prognosis of patients with gynecological infection. This may be attributed to the relatively small sample size of the study, which to a large extent depends on physicians’ clinical experience, lower accuracy of the test results and low capacity for rapid PCT assays, as was pointed out in many studies [25,26,27]. Moreover, our results showed that Gram-negative bacteria were the most common strains in consultations of obstetrics and gynecological infections. However, in terms of the infection sites, SSI ranked first (35.09%), resulting in the proportion of Gram-positive bacteria-induced infections being higher than that reported in the literature. This may also exert a negative impact on PCT levels in this study .
Rashwan et al.  revealed that PCT > CRP > WBC count in terms of sensitivity for bacterial infections and PCT > CRP > WBC in terms of specificity for common pathogenic bacteria. Li et al.  pointed out that the positivity rate and value of CRP in acute and chronic pelvic inflammation were significantly higher than those in other cases, whereas it was low in nongonococcal urethritis and cervicitis, and the differential diagnosis was difficult. Hasan et al.  investigated the clinical value of the measurement of CRP and WBC count in the differential diagnosis of gynecological infections, with highly accurate results for the combined detection of CRP and WBC count, which can be used as a routine diagnosis and treatment method to assist clinical screening and early guidance; this is consistent with our results. Our results showed that the combination of WBC count and CRP used for 7-day prognosis was superior to the use of a single biomarker and other combination regimens.
In this study, the outcomes in Fig. 5 show that both WBC count and CRP decreased on the 3rd and 7th days after anti-infective treatment, which was consistent with the results presented in Table 3 and demonstrates that the prognosis after anti-infective treatment is good. In Fig. 6, ROC curves were utilized to investigate the diagnostic efficiency of these biomarkers, including WBC count, CRP and PCT. Various examinations determined that the CRP test sensitivity ranged from 70% to 93%, specificity ranged from 41% to 98%, PPV ranged from 6% to 83%, and NPV ranged from 97% to 99% [28, 29]. Although the results appear to present normal sensitivity and specificity, as detailed by Çetinkaya et al., the increase in CRP levels is delayed during the first 24–48 h of disease, which negatively affects its specificity. In addition, the increase in the CRP level in noninfective cases severely affects its specificity. Therefore, based on our findings, we propose that to acquire a more accurate inflammation prognosis, CRP combined with WBC count could be utilized as an inflammation indicator. Studies have added that the advantages of WBC count over CRP are that its typical level increases mostly in bacterial infection, and its normal level is rapidly re-established after antibiotic treatment .
Since health administration authorities in China attached greater importance to the rational use of antibacterial drugs, which has been included in hospital management and performance evaluation indicators, clinical pharmacists have given more attention to the improvement in anti-infective consultations. In this study, the effectiveness rate of consultations (calculated by the number of patients whose biomarkers and symptoms returned to normal 7 days after treatment) was 94.34%. Clinical pharmacists are indispensable members of the treatment team. They can help physicians use antibiotics more safely and effectively, which could lead to better patient outcomes. Clinical pharmacists specializing in gynecological and obstetric systems should continuously improve their capabilities of dealing with problems such as individualized adjustment of medication plans based on blood drug concentrations and PK/PD characteristics. With more consultation requests and accumulated experience, clinical pharmacists could better serve patients and physicians troubled by infections.