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Endometritis- Treatment outcomes?

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  • Endometritis- Treatment outcomes?

    Hi COTH,

    This is my first post so please bear with me! however, given there are many experienced breeders on here I thought I would find out what success you have had with treating mares with endometritis.
    My mare's case is complicated!
    Last season she developed placentitis and was treated for just over 5 months. She made it through to 327 days and foal pulled through gave plasma etc. Placenta was a mess though with lots of brown pus-like goo (not meconium) and large areas of stunted villi. The non pregnant horn was ok but still some goo in there!
    Anyway, mare had a couple of bags of saline infused and then some gentamicin. Some concern that attending vet was not repro-savvy. I questioned her on her AB choice at the time and asked her if it would target strep and her reply was "why would it need to target strep?" My reply was that I was concerned that strep was the causative organism as us commonly the case with ascending placentitis! Mare received no further treatment as focus shifted to foal although I did ask if mare needed more therapy to which I was told "no, she should clear it herself"
    Ok fast forward...
    Prior to breeding I had a biopsy done. Result 2A but some indications of mild inflammation and possible mild bacterial infection. Lab recommended therapy. Vet reluctant to lavage etc so decide that will just give settle.

    Next cycle mare was cultured and clean, given settle and bred. Didn't take, but also an issue with insemination timing with FS which did not help!

    Mare bred 2 cycles later with different vet, everything "perfect" no fluid before, during or next day etc. but gets lavages 24 & 48 hrs post ovulation as standard. Next day has discharge which continues for 10 days. Mare then comes back in season the next day. Again, no treatment as vet 1 believes her immune system should get rid of infection.

    Skip that cycle hoping she will clean up and then breed on next cycle, no fluid on scans everything looks perfect.
    Mare bred, aggressive oxytocin protocol (6 hourly for 2 days) but then develops discharge for 2 days and comes back in right on schedule

    Next cycle has discharge again and so I insist on another biopsy.

    Took a biopsy during diestrous, she had a pus discharge for 4 days post biopsy procedure (no discharge after first biopsy). Evaluation of the exudate revealed lots of neutrophils and heavy strep growth. No other significant numbers of any other bacteria.

    Biopsy result still 2A but now chronic lymphocytic endometritis with appears to be evidence of a deeper infection/ inflammation.

    So my question... Should my mare "just get over it?", do give up or insist on treatment? Vet thinks that she is immuno-compromised and that is why she can't eliminate the infection herself. I realise there is the issue of post-breeding endometritis but I feel that this is a subclinical or acute infection that has become chronic due to lack of therapy.

    I am inclined to get her treated by a repro specialist as local does not seem keen. I also feel that perhaps this infection has lingered since the placentitis and that if treatment was initiated earlier the outcome may have been different?

    Have any of you guys had success in similar cases?

  • #2
    Perhaps I missed this, but has the mare had a recent culture/cytology, in conjunction with the biopsy? I would find a vet well-versed and enthusiastic about repro work and start at the beginning with a culture/cytology. No need for another biopsy, IMHO. If she indeed has an infection, and not just inflammation, then the causative agent needs to be identified (be it bacterial or fungal) and then a sensitivity needs to be done to find out what medication will work to kill it. That would be my starting point. And no, mares don't generally "get over" an infection like this on their own, and it doesn't neccessarily mean that she has an immune problem.

    Something else to keep in mind is that if the gentamicin was not/is not buffered when used in the uterus it can be very irritating in and of itself.
    Already excited about our 2016 foals! Expecting babies by Indoctro, Diamant de Semilly, Zirocco Blue and Calido!


    • #3
      What Hillside Ranch said.... By now you have spent enough time and money on vets that didn't get to the bottom of things and expected the mare to "fix" herself. If you let us know which geographic area you're in, we can probably come up with some excellent vet recommendations.
      Siegi Belz
      2007 KWPN-NA Breeder of the Year
      Dutch Warmbloods Made in the U. S. A.


      • #4
        A couple of articles that may help you.



        Good luck!
        Equine-Reproduction.com Now offering one on one customized training!
        Leg-Up Equestrian Assistance Program, Inc. A 501(c)(3) non-profit charity


        • Original Poster

          Thanks for your input so far.

          I have read the articles above not to mention over 30 peer reviewed articles! But most if them don't cover chronic endometritis.
          The oxytocin was given based partly on protocol outlined in the article mentioned. 6 hourly from 6 hours post AI. Mare was not scanned for fluid post breeding as in my case it would not have changed treatment- vet 1 very unlikely to go flushing or infusing AB.

          No cytology was done at first biopsy and culture because there was no need. The biopsy is gold standard for telling you there is inflammation and infection. First biopsy also showed evidence of supurrative (pus) discharge. The culture performed on the next cycle was negative, just low growth. But since the biopsy indicated there was a problem it is likely culture result was a false- negative.

          Since mare had no fluid vet decided not to swab as felt there would be little point and biopsy would tell us what is going on. Sure wont tell us the causative organism but will indicate if there is infection. Cyto was performed from the 2nd biopsy ie slide smeared over biopsy and did show neutrophils. So it's pretty clear we have an ongoing (chronic) infection causing ongoing inflammation.

          I think she is symptomatic of strep infection given discharge and history. Furthermore, given the discharge post biopsy I wonder if the trauma to the endometrium allowed the bacteria to proliferate?? Particularly as strep zoo is haemolytic?
          Of course a culture would help confirm.

          Re the treatment post foaling. I am not sure how much effect it had as the saline was not actively removed, just pumped in. Also I am aware of the gentamicin having an irritating effect and as far as I am aware it was just mixed with saline and I distinctly remember the mare being quite agitated after it was administered.
          Furthermore, from what I have read gent isn't actually effective against strep zoo so could have been a complete waste of time? Also one dose on a uterus full of saline is probably a waste of time too!

          Also just to add, I got the 2nd biopsy to check if there had been degenerative changes as i was concerned about all the infection/ inflammation causing fibrosis. Thankfully, it appears not to be the case or I guess she would be in categiry 2b or 3.
          Also, here the cost of biopsy is about the same as a culture or a cytology so by the time you do the lot it gets quite expensive! I have lost a lot of $$, time, and FS this year so need to ascertain if it is worth spending considerably more to try and fix the problem.

          My only reason to do a 3rd biopsy would be after she is treated to measure the success of the treatment. Given the inflammation is deeper now I don't think a cyto test will tell us if that has cleared?

          Oh and I am in Southern Hemisphere so trying to get this fixed before winter!


          • #6
            I don't see why you would want to/need to do a 3rd biopsy? You don't need a biopsy to tell you that you've cleared an infection, a negative culture/cytology will tell you that, for usually a lot less money.
            You really need to identify the causative agent (if there is indeed an infection). No one can tell what a mare is infected with just by guessing; that is why I recommended a culture/cytology with an identification and sensitivity. Yes, the biopsy is the gold standard for diagnosing the extent of inflammation and fibrosis and sometimes even identifying a bacterial or fungal infection, but unless you can identify WHAT the bacteria or fungus is and what medications it is sensitive to then your information isn't of much help.
            I'm not sure why you are guessing strep, other than it is a common bacteria. But it could be many, many other bacterias or even a fungus. I would NOT treat for strep without getting an actual identification and sensitivity done on a culture/cytology. Yes, this gets expensive, but if the causative agent had been identified initially and treated with an appropriate medication then you may have saved yourself a lot of time/money at this point. I stand by my reccomendation of getting a culture/cytology now, identifying whether there is a bacterial or fungal infection, and if so what it is sensitive to. The absolute worst thing you can do now is treat for strep, using antibiotics, and find out that you have a fungus in there, instead. The antibiotics used to treat bacterial infections will make a fungus go crazy, and then you have a real problem on your hands.
            Already excited about our 2016 foals! Expecting babies by Indoctro, Diamant de Semilly, Zirocco Blue and Calido!


            • Original Poster

              Thanks for your advice hillside!
              Its is a very frustrating position to be in. About 20k has been spent/ lost on this mare this season in terms of vet fees, diagnostics and FS. I do want the best for my horse but don't want to waste too much more either!

              My thinking of strep was based on the symptoms- strep is known to produce a discharge. Plus, the cytology showed what appeared to be bacterial cells.
              We took a sample of the pus/discharge from her genital tract and the gram stain showed gram positive cocci and stacks of them! Not to mention loads of neutrophils. The sample was cultured on both mac Conkeys (no growth) and blood agar to determine if the cocci were the dominant organism. No E. coli growth or any other significant contaminants. No fungal growth. Only quite heavy growth if strep.
              I realise strep it is part of the normal flora but, to produce a pus discharge that would be considered abnormal?

              I realise that there are other organisms that can cause chronic conditions eg E. coli pseudomonas etc but I would have expected a stronger growth if those if they had been the cause (as opposed to no growth)

              Vet is reluctant to do any ab therapy as feels that it just causes more problems is get rid of strep and end up with E. coli or a fungal infection. Clearly this is why you need to perform a culture and sensitivity.
              That said, because her symptoms are only present for a few days it is hard to obtain a sample at the right time- one vet, no clinic.
              She has never had any fluid on u/s and she has been scanned umpteen times at various stages of her cycle.
              The only time she wasn't scanned was after the lavage treatments... This is where I am concerned there may have been a problem with the fluid not getting back out in a timely manner as performed at 48h post ovulation not post breeding. Again, may not be an issue for most mares?

              Also have you seen the recent research on endometritis treatment by the Danish scientists? Interesting theory and quite plausible. I read this after I came up with my theory but did think it struck a similar chord!

              Of course I could be completely down the wrong track here!


              • #8
                I did see the recent Danish research, but I don't think that is what you are dealing with here. It sounds as if the mare has a bacterial infection, that seems pretty straight-forward, based upon the heavy growth on the culture plates, the cytology results and the identification of cocci. So if that is the case then the mare needs to be treated with intra-uterine antibiotics, and it is that simple. Uterine infections, especially one that has been going on this long, with these types of characteristics, rarely clear up on their own. I see you say that your vet is "reluctant" to treat with antibiotics, but what else are they proposing? Unless I'm missing something major here, this seems straight-forward: mare has a bacterial infection in the uterus, mare needs to be treated with antibiotics. That being said, I still don't see a definitive strep diagnosis. There are other cocci bacteria that can grow on the culture plates, so a bacterial identification needs to be made, as well as a sensitivity. Then treat the mare.
                Also, mares can be badly infected and never show fluid in the uterus on an ultrasound.

                For example, just a few weeks ago we had a young mare in for breeding (frozen semen). She did have a bacterial infection, based upon a cytology and then a culture with identification and sensitivity. It was, indeed, a strep infection and we determined an appropriate antibiotic. Mare was bred, then treated post breeding (three separate treatments). Mare was just confirmed in foal and all is well.
                Already excited about our 2016 foals! Expecting babies by Indoctro, Diamant de Semilly, Zirocco Blue and Calido!


                • Original Poster

                  Thanks again Hillside you have a lot of sound advice!

                  I agree mares can be infected without u/s signs, this was why I insisted to my vet to take a biopsy. Vet was of the opinion that because there was no fluid there was no infection and mare was basically infertile now. I told him I had read otherwise and wanted to know what state her uterus was in.

                  The cocci was identified as strep equi zoo so I think that assists one with their antibiotic choice. But again another culture probably would be of benefit to confirm.

                  Yes I agree that mare needs treating asap and i have been keen to have this performed but vet is very conservative and worried about risks. It seems that treatment is a standard procedure and at the moment I haven't got much to lose. Vet on other-hand thinks mare is in too hard basket and not worth treating- so basically proposing to retire the mare. Sure I would agree if score was 2b or 3 but hoping she is salvageable with a 2a score. It's not like we have treatment failure yet as there has been no treatment!

                  I wanted to find out if others had positive outcomes with similar symptoms and your recent case and the outcomes of the Danish study give me hope!

                  At least I can not feel like such a deluded horse breeder when I request for further treatment! She is a good mare, proven producer and worth trying to fix IMO!


                  • #10
                    Uterine infections are common, treating them with intra-uterine antibiotics is common and mares going on to have foals after treatment is common. If you know what the bacteria is, then find an appropriate antibiotic and go for it! This may be harsh, but if your vet won't treat (and this is the standard way of managing these cases, so it isn't like you're asking for some experimental treatment) then it might be time to find another veterinarian to treat your horse.

                    Best of luck to you and your mare!
                    Already excited about our 2016 foals! Expecting babies by Indoctro, Diamant de Semilly, Zirocco Blue and Calido!


                    • #11
                      I do not profess to be an equine expert in anyway...however, I just attended a veterinary CE on endometritis and here are some salient points I took away that may help you. If I convey any info that is incorrect maybe Hillside or Kathy can correct me

                      1) For cytology samples he prefers to use a "brush" type sampler (purchase from Har-vet). Says he gets MUCH better results.
                      2) If fungal is at all a consideration he prefers to do PCR testing on tissue
                      3) If a strep infection (he says 56% of bacterial are strep, 15% ecoli, 10% staph) he prefers to use ceftiofur 1gm for 1-3 days in a row. He will also use systemic antibiotics (excede)
                      4) there is some evidence that steroids (dex or pred) can be used at 12hrs to help with mares that have high inflammatory responses. This is controversial.
                      5) if there is a mucoid discharge in uterine lavage then he uses acetylcysteine to lavage.
                      6) for mares with a "flaccid" uterus they can be prone to these infections. He recommends flushing with a couple liters fluid, deflating the cuff, pass the catheter further down and then lower the bag to reclaim as much fluid as possible.

                      Not sure if any of this may help you, but there might be a few things to try.
                      Read about my time at the Hannoveraner Verband Breeders Courses:


                      • #12
                        A few years ago I had a mare with endometritis. The vet (Theriogenologist) suspected that there was a biofilm that was preventing her from clearing the infection. His treatment included the use of EDTA. I just googled EDTA and found an article about its use in mares with uterine infections. You might find it interesting.