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doi: 10.1111/j.1751-0813.2009.00469.x
ndometritis in dairy cattle reduces reproductive performance.1,2 It is generally caused by bacterial infection post
partum and is dened as uterine inammation that is conned
to the endometrium.3 The denitive diagnosis of endometritis relies
on histological examination of the endometrium, or cytological
examination of uterine uid,1,2,4,5 but these techniques are of little
practical economic benet to dairy producers, because they are time
*Correspondence author.
a
University of Melbourne Rural Veterinary Unit, Mara, Victoria, Australia;
drunciman@maravet.com.au
b
University of Melbourne, Werribee, VIC, Australia
c
Mara Veterinary Centre, Mara, VIC, Australia
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demonstrate the eect on reproductive performance of treating cows
with a purulent or mucopurulent discharge with intrauterine cephapirin when treatment is administered 7 to 28 days after calving.
Materials and methods
In the spring of 2004, six seasonal calving dairy herds that milked 2163
cows were enrolled in the clinical trial. From these herds, cows were
selected if they had one or more of the following conditions that may
predispose to the development of endometritis or indicate the presence of endometritis: retained fetal membranes (24 h after calving),
dystocia, twin or other multiple birth, stillbirth (or calf death within
24 h) or a vulval discharge observed 7 days or more after calving. Each
cows age, calving date and calving induction status was recorded.
The selected cows were examined at fortnightly visits to each herd,
commencing approximately 21 days after the calving start date for
each herd such that cows would be examined between 7 and 21 days
after calving. Cows that had calved up to 28 days were admitted to the
nal analysis because a previously reported study indicated that cows
examined and treated with intrauterine cephapirin within 28 days of
calving had improved reproductive performance compared with
untreated cows.14 The distribution of the calving to examination
intervals is shown in Figure 2.
On the day of examination cows were moved into a race in groups of
6 to 22 cows and body condition score (BCS) was determined using
370
All variables that were associated with an outcome of interest (P < 0.2)
were included in a full model and a reverse stepwise model building
process using a likelihood-ratio test statistic was used to arrive at a
nal model, with threshold P-values for inclusion being <0.05 and
>0.10 for exclusion. For analysis of reproductive indices, Metricheck
or VV score or status (depending on model analysed), treatment, and
herd were forced to remain in each model to calculate the nal odds
ratio (OR) and 95% condence interval of the eect of treatment and
method of examination on reproductive performance. Interactions
involving endometritis/treatment status and CMSD were assessed
within the full dataset and in subsets (VV positive or Metricheck
positive) of treated and control cows. No interaction terms were signicant (P > 0.5). Goodness of t was examined using the Hosmer
Lemeshow test, and the ability of each model to discriminate between
those cows that experienced the outcome of interest versus those who
did not was estimated by calculating the receiver operating characteristic value for each model. The relative risk and 95% CI were calculated
using a modied Poisson regression with the variables from the nal
model.22,23 The log-binomial model was not used because convergence
could not be achieved.23
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were also tested for non-zero slope against log of time using a generalised linear regression. Model terms were also tested for interaction
with time.19,25,27 Harrells C index of concordance was calculated
and has values between 0 and 1, with 0.5 indicating no predictive
discrimination.28
The mating start date to conception interval was dened as the date a
cow conceived minus the mating start date plus one, such that a cow
conceiving on mating start date had a mating start date to conception
interval of 1. The nal day of the mating period was used for all cows
that survived until the nal pregnancy testing but were not pregnant.
Cows were categorised as 2, 3, 4 to 8 and >8 years old. BCS was
categorised as <4.5, 4.5, 5.0 and >5.0, as well as categories 4.5 and
> 4.5. CMSDI (in weeks) was tested in the statistical models as a linear
term. Breeds were categorised as FF (Friesian), FJ (Friesian and Jersey
Cross) or JJ (Jersey).
The software packages SPSS version 5.0 (SPSS Inc., Chicago, IL, USA),
and Stata version 9.2 (StataCorp, College Station, TX, USA) were used
for analyses. Statistical signicance was set as P < 0.05.
Results
We examined 423 cows in 6 herds (range 26151; mean 67.3, SD 50.3).
Of these, 19 cows were excluded (2 with severe uterine or vaginal
pathology, 3 with ambiguous identication, 6 with data irregularities,
6 had calved more than 28 days at time of examination, and 2 had
previous intrauterine treatment), leaving 404 cows eligible for inclusion in the study. Of the 404 cows, 202 were examined with VV as the
rst procedure and 202 were examined rst with Metricheck.
The mean age ( SD) for included cows was 5.0 2.5 years (range
212), BCS was 5.0 0.6 (range 3.06.5) and calving to examination
interval was 14.2 4.6 days (range 727; Figure 2).
The range of at risk conditions by age group are presented in Table 1.
Comparison of VV and Metricheck for diagnosis of vaginal pus
Tables 2 and 3 show that the method that was performed rst had little
bearing on the outcome of the comparison between the two diagnostic procedures. The measure of agreement between the two methods
was moderate (unweighted kappa) or almost perfect (quadratic
weighted kappa) with regard to measuring individual scores, and substantial when assessing the status (pus or no pus) of the discharge. Of
the 404 cows examined, only 109 (27.0%) had a negative score for both
methods (Table 3); 124 (30.7%) cows were Metricheck negative, and
143 (35.4%) were VV negative, therefore performing both methods
increased the sensitivity for detecting pus.
Factors associated with positive VV or Metricheck status
A model for the predictors of a positive status (Table 4) shows that the
longer cows had calved, the lower the risk of a positive Metricheck or
VV status. Primiparous cows were signicantly more likely to have a
positive Metricheck and VV status. Cows with a BCS 4.5 were more
likely to have positive VV status than cows with a BCS > 4.5 (OR 1.68,
P = 0.04).
Analysis of reproductive performance and eect of treatment
Of the 391 cows with reproductive data, 42 were administered CIDR
and intramuscular oestradiol (Cidrol) as part of the treatment for
non-visible oestrous. They were removed from analysis of reproductive performance because CIDR/oestradiol treatment reduces time to
conception in non-cycling cows.29 Analysis including CIDR cows was
performed to ascertain whether intrauterine cephapirin treatment had
any bearing on cows requiring CIDR treatment. In a regression model
including herd (P = 0.19) and CMSDI (P = 0.001), treatment with
cephapirin was not a signicant predictor of CIDR treatment (OR =
0.59, P = 0.18) in the 42 cows within the two herds that used it.
Excluding CIDR-treated cows left 349 cows for reproductive analysis.
For reproductive outcomes, for the analysis of VV, the sample size was
reduced such that cows that were VV-negative, but treated because
they were Metricheck positive were removed (n = 13), leaving 336
cows in three categories:
VV positive control cows (n = 113, 33.6%)
VV positive treated cows (n = 113, 33.6%)
VV-negative untreated cows (n = 110, 32.7%).
For the analysis of Metricheck, the sample size was similarly reduced
by the cows that were Metricheck-negative, but treated because they
were VV positive (n = 8), leaving 341 cows in three categories:
Metricheck positive control cows (n = 120, 35.2%)
Metricheck positive treated cows (n = 118, 34.6%)
Metricheck negative untreated cows (n = 103, 30.2%).
Tables 5 to 7 show the eect on reproductive outcomes of a negative
test status and treatment of positive cows with intrauterine cephapirin
compared with positive untreated cows. Method of detection/
treatment category had no signicant eect on proportion of cows
Table 1. Prevalence of disease conditions in 404 enrolled cows by age group (some cows had more than one condition)
Age group
Dystocia
Milk fever
Induction
Vulval discharge
Dead calf
Twins
RFM
2 years
3 years
48 years
>8 years
Total
77
60
228
39
404
59.7%
43.3%
37.7%
43.6%
43.3%
0.0%
0.0%
12.7%
15.4%
8.7%
3.9%
45.0%
42.1%
38.5%
34.9%
20.8%
10.0%
4.8%
0.0%
8.2%
33.8%
40.0%
34.6%
28.2%
34.7%
2.6%
1.7%
5.7%
12.8%
5.2%
9.1%
26.7%
23.7%
17.9%
20.8%
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VV score
Metricheck score
First procedure
VV
Metricheck
Total
VV
Metricheck
Total
VV
Metricheck
Total
VV
Metricheck
Total
VV
Metricheck
Total
Total
0
55
54
109
14
12
26
4
4
8
73 (36.1%)
70 (34.7%)
143 (35.4%)
4
8
12
27
21
48
9
7
16
1
1
2
41 (20.3%)
37 (18.3%)
78 (19.3%)
2
1
3
7
12
19
23
22
45
3
4
7
35 (17.3%)
39 (19.3%)
74 (18.3%)
Total
4
1
5
14
11
25
35
44
79
53 (26.2%)
56 (27.7%)
109 (27.0%)
61 (30.2%)
63 (31.2%)
124 (30.7%)
52 (25.7%)
46 (27.8%)
98 (24.2%)
50 (24.7%)
44 (24.3%)
94 (23.3%)
39 (19.3%)
49 (24.3%)
88 (21.8%)
202
202
404
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Table 2. Distribution of Metricheck and visual vaginoscopy (VV) scores and the procedure with which cows were rst examined
VV rst: kappa = 0.59 (95% CI 0.500.67), quadratic weighted kappa = 0.82 (95% CI 0.770.88).
Metricheck rst: kappa = 0.59 (95% CI 0.510.68), quadratic weighted kappa = 0.86 (95% CI 0.810.90).
Overall: kappa = 0.59 (95% CI 0.530.65), quadratic weighted kappa = 0.84 (95% CI 0.810.88).
Table 3. Distribution of Metricheck and visual vaginoscopy (VV) status for cows and the procedure with which cows were rst examined
VV statusa
Metricheck status
First procedure
Test + ve
VV
Metricheck
Total
VV
Metricheck
Total
VV
Metricheck
Total
Test - ve
Total
Test + ve
Test - ve
Total
123
123
246
6
9
15
129 (63.9%)
132 (65.3%)
261 (64.6%)
18
16
34
55
54
109
73 (36.1%)
70 (34.7%)
143 (35.4%)
141 (69.8%)
139 (68.8%)
280 (69.3%)
61 (30.2%)
63 (31.2%)
124 (30.7%)
202
202
404
VV rst: kappa = 0.73 (95% CI 0.630.83), McNemar P = 0.014, adjusted McNemar P = 0.09.
Metricheck rst: kappa = 0.72 (95% CI 0.620.82), McNemar P = 0.16, adjusted McNemar P = 0.37.
Overall: kappa = 0.73 (95% CI 0.660.80), McNemar P = 0.007, adjusted McNemar P = 0.17.
a
Coded as test + ve if score > 0 and test - ve if score = 0.
submitted for service within 3 weeks of mating start date (P > 0.3)
(data not shown). An increased proportion of cows were pregnant
within 6 weeks of mating start in the two groups of cows with vaginal
pus that were treated and cows without vaginal pus that were not
treated, compared with cows that had vaginal pus but were not treated.
The hazard for pregnancy with time from mating start date is shown
in Table 8.
2009 The Authors
Journal compilation 2009 Australian Veterinary Association
Both VV and the Metricheck device were equally eective in predicting cows not pregnant within 42 days of mating start date (sensitivity
60.6% and specicity of 62.5% in the case of VV; 64.5% and 60.4% for
Metricheck).
Unadjusted proportion of cows pregnant within 6 weeks of mating
start date according to VV/Metricheck status and treatment group by
dierent CMSDI quartiles is shown in Figure 3. Although the unad-
373
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Table 4. Descriptive statistics and model estimates for a positive Metricheck or VV status from multiple logistic regression (n = 404)
Metrichecka
Age (years)
2
3
48
>8
CEI (weeks)
Herd (6 herds)
Constant
VVb
Age (years)
2
3
48
>8
CEI (weeks)
BCS
4.5
>4.5
Herd (6 herds)
Constant
Proportion positive
77
60
228
39
0.84
0.78
0.64
0.54
Coe
SE
P value
OR
95% CI
Risk ratio
95% CI
0.006
0.303
1.074
1.187
0.660
0.466
0.363
0.483
0.183
2.762
0.671
0.5
0.003
0.014
<0.001
0.005
1.00
0.74
0.34
0.31
0.52
1.84
0.70
0.79
0.74
1.00
0.94
0.78
0.73
0.82
0.80
0.67
0.54
0.74
1.11
0.89
0.98
0.91
0.34
0.25
0.20
0.34
1.78
0.89
1.19
0.68
1.00
0.93
0.80
0.80
0.78
0.76
0.67
0.59
0.69
1.14
0.95
1.08
0.87
1.01
2.78
1.18
1.02
1.36
0.30
0.17
0.12
0.36
0.084
77
60
228
39
0.77
0.72
0.61
0.54
129
275
0.71
0.62
0.249
0.751
0.723
0.731
0.420
0.325
0.458
0.179
0.5
0.021
0.11
<0.001
0.517
0.257
0.044
1.00
0.78
0.47
0.49
0.48
1.68
1.00
0.006
2.027
0.629
VV/treatment groupa
Positive/control
Positive/treatment
Negative/control
Metricheck/treatment groupb
Positive/control
Positive/treatment
Negative/control
Proportion
conceived
Coe
SE
P value
103
108
104
0.24
0.39
0.43
0.674
0.816
0.320
0.330
0.036
0.013
0.10
110
111
97
0.32
0.47
0.56
0.450
0.623
0.310
0.323
0.15
0.054
OR
95% CI
Risk ratio
95% CI
0.033
1.00
1.96
2.26
1.05
1.18
3.68
4.32
1.00
1.52
1.64
1.02
1.09
2.27
2.47
1.00
1.57
1.87
0.86
0.99
2.88
3.51
1.00
1.32
1.45
0.90
0.98
1.94
2.15
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VV/treatment groupa
Positive/control
Positive/treatment
Negative/control
Metricheck/treatment groupb
Positive/control
Positive/treatment
Negative/control
Proportion pregnant
Coe
SE
P value
113
113
110
0.32
0.48
0.55
0.696
0.835
0.286
0.294
0.015
0.005
0.003
120
118
103
0.32
0.47
0.56
0.708
0.956
0.278
0.295
0.011
0.001
OR
95% CI
Risk ratio
95% CI
0.010
1.00
2.01
2.31
1.15
1.30
3.51
4.10
1.00
1.49
1.58
1.08
1.14
2.05
2.19
1.00
2.03
2.60
1.18
1.46
3.50
4.64
1.00
1.50
1.67
1.10
1.22
2.06
2.31
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Table 6. Descriptive statistics and model estimates for proportion of cows pregnant within 6 weeks of mating start date by VV, Metricheck and
treatment status groups from multiple logistic regression models that also included herd and the calving to mating start date interval
Table 7. Descriptive statistics and model estimates for proportion of cows pregnant within 21 weeks of mating start date, by VV, Metricheck and
treatment status groups from multiple logistic regression models that also included herd
VV/treatment groupa
Positive/control
Positive/treatment
Negative/control
Metricheck/treatment groupb
Positive/control
Positive/treatment
Negative/control
Proportion pregnant
Coe
SE
P value
110
112
110
0.63
0.77
0.76
0.696
0.535
0.312
0.321
0.026
0.096
0.2
118
117
102
0.65
0.75
0.75
0.522
0.405
0.300
0.320
0.082
0.020
OR
95% CI
Risk ratio
95% CI
0.06
1.00
2.01
1.71
1.09
0.91
3.70
3.20
1.00
1.21
1.17
1.02
0.98
1.44
1.39
1.00
1.69
1.50
0.94
0.80
3.04
2.81
1.00
1.15
1.12
0.98
0.94
1.36
1.33
Table 8. Hazard ratios for pregnancy following mating start date for
visual vaginoscopic (VV) or Metricheck status and treatment groups as
derived from Cox proportional hazard models stratied by herd and
accounting for calving to mating start date interval and body condition
score
VV/treatment groupa
Positive/control
Positive/treatment
Negative/control
Metricheck/treatment groupb
Positive/control
Positive/treatment
Negative/control
Hazard
ratio
113
113
110
1.00
1.47
1.54
120
118
103
1.00
1.37
1.43
P value
95% CI
0.022
0.019
0.012
0.066
1.06
1.10
2.03
2.17
0.049
0.035
1.00
1.02
1.86
2.00
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In the case of VV, there was clearly a large and signicant improvement in the key reproductive performance parameters of proportion
of cows pregnant within 6 or 21 weeks of mating start date for treated
positive cows compared with untreated positive control cows. There
was also a signicant improvement in proportion of cows that conceived to their rst service to articial insemination and hazard for
pregnancy post mating start date. There was no signicant dierence
between VV-negative cows and VV positive treated cows; however, the
study lacked power in assessing the small dierences observed.
Within the subset of at risk cows examined in each herd, those with a
positive Metricheck or VV status were more likely to be rst calving
primiparous cows, and VV positive cows had lighter BCS, so the
incidence of reproductive tract infection may be reduced by addressing these risk factors. BCS has been recognised as a major factor
inuencing reproductive performance and was linked to uterine
infections in our previous trial.13 Body condition at the time of calving
has been previously shown to be associated with neutrophil function
and susceptibility to uterine infections.32,33
The association between a higher prevalence of vaginal discharge
detected using the Metricheck device or VV in primiparous cows
agrees with our previous research,13 but diers from others who found
no age disposition for endometritis,34 or an increased incidence of
endometritis with age, which was thought to be related to an impairment of neutrophil function with age.35 There was a higher proportion
of primiparous cows admitted to the trial because of dystocia and
visible vulval discharge compared with older cows. Therefore, it may
be one or both of these factors that is associated with a greater likelihood of having pus detectable within the anterior vagina by either
method used if the association is not specically related to age.
A path analysis for the associations of periparturient disease, age, BCS,
reproductive examination ndings and reproductive performance
cannot be produced from this data, as the subset of cows deemed to be
at high risk of uterine inammation was selected from herds for
examination. A further study examining all cows within herds will be
required to fully understand any association between at risk conditions, age, body condition and other variables of interest such as breed
and milk production.
The ndings of this trial conrm previous work that purulent or
mucopurulent vaginal discharge is associated with reduced reproductive performance in dairy cows examined using VV.We also found that
a diagnosis of vaginal discharge can be made using the Metricheck
device, which gives similar results to VV in terms of actual scores, as
well as its ability to predict cows with reduced reproductive performance. Also, cows with purulent or mucopurulent vaginal discharge 7
to 28 days after calving, regardless of when they calved within the
normal calving season in seasonal herds, was associated with reduced
reproductive performance.
2009 The Authors
Journal compilation 2009 Australian Veterinary Association
Acknowledgments
We thank the herd owners and managers who participated in this
study and the anonymous reviewers for their constructive comments.
We also thank Intervet Australia Ltd for providing Metricheck devices
and product for the trial.
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PRODUCTION ANIMALS
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were self-curing. The current study shows that even within the subset
of early calving cows there is a signicant improvement in treated
test-positive cows compared with untreated test-positive cows for
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BSAVA manual of rodents and ferrets. E Keeble and A Meredith, editors. 350 pp. A$190.00. ISBN 978-1-905319-08-4
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