User login
M. Alexander Otto began his reporting career early in 1999 covering the pharmaceutical industry for a national pharmacists' magazine and freelancing for the Washington Post and other newspapers. He then joined BNA, now part of Bloomberg News, covering health law and the protection of people and animals in medical research. Alex next worked for the McClatchy Company. Based on his work, Alex won a year-long Knight Science Journalism Fellowship to MIT in 2008-2009. He joined the company shortly thereafter. Alex has a newspaper journalism degree from Syracuse (N.Y.) University and a master's degree in medical science -- a physician assistant degree -- from George Washington University. Alex is based in Seattle.
VIDEO: What’s new in AAP’s pediatric hypertension guidelines
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
SAN FRANCISCO – The American Academy of Pediatrics recently released new hypertension guidelines for children and adolescents.
Some of the advice is similar to the group’s last effort in 2004, but there are a few key changes that clinicians need to know, according to lead author Joseph Flynn, MD, professor of pediatrics and chief of nephrology at Seattle Children’s Hospital. He explained what they are, and the reasons behind them, in an interview at the joint hypertension scientific sessions sponsored by the American Heart Association and the American Society of Hypertension (Pediatrics. 2017 Aug 21. doi: 10.1542/peds.2017-1904).
The prevalence of pediatric hypertension, he said, now rivals asthma.
EXPERT ANALYSIS FROM THE AHA/ASH JOINT SCIENTIFIC SESSIONS
Postpartum sepsis risk persists after 6 weeks
PARK CITY, UTAH – The risk of sepsis after delivery persists beyond 6 weeks, the traditional point at which women are thought to be in the clear, according to investigators from Stanford (Calif.) University.
The team analyzed 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from 2008-2012; 199 (39%) were at or before 6 weeks postpartum, and 310 (61%) were after 6 weeks, out to a year.
“Going into this, our view was that sepsis cases before 6 weeks would be due to obstetrical causes, and cases after 6 weeks would be due to [nonobstetrical causes],” said senior investigator Ronald Gibbs, MD, clinical professor of obstetrics and gynecology at Stanford. But that’s not what the team found. 
In both the early and late admission groups, early preterm delivery was one of the leading risks for postpartum sepsis and other risk factors were largely the same. Pyelonephritis and pneumonia were by far the most common diagnoses in both groups, accounting for more than 70% of cases. The rank order of causative organisms was the same whether women presented before 6 weeks or after: gram-negative bacteria, staphylococcus, and streptococcus.
“In view of this, we think the risk for sepsis goes beyond 6 weeks,” Dr. Gibbs said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. Although women were admitted largely for nonuterine infections, “the reservoir of infection could be in the uterus,” with later seeding to the urinary tract or lungs. “I think there’s a chronic intrauterine infection that sets women up for” both early preterm birth and later sepsis, he added.
“These late admissions would probably go to a nonobstetrical service, but we are thinking that there may be a pelvic origin related to something that went on at delivery. I can’t really say that we ought to change our practice, but it sets the stage for looking at that. Finding that late [admissions for sepsis] have a lot in common with the early admissions and are probably related to the pregnancy really reorders the thinking,” Dr. Gibbs said.
The team found that among women who were delivered at 24-28 weeks, the adjusted odds ratio was 8.6 (95% confidence interval[CI], 4.4-17.1) for early and 4.2 (95% CI, 1.9-9.0) for late postpartum sepsis admission, even after delivery mode, maternal comorbidities, maternal age, “and everything else we could think of” were controlled for, said lead investigator Megan Foeller, MD, a maternal-fetal medicine fellow at Stanford.
A body mass index above 35 kg/m2 also increased the risk for sepsis admission, as did government-provided insurance, primary cesarean delivery, a failed trial of labor after a previous cesarean, and four or more previous deliveries.
Postoperative infection, acute hepatic failure, acute renal failure, acute respiratory failure, and heart failure during the delivery hospitalization greatly increased the risk of subsequent sepsis, as well.
The findings help define a group of women who likely need especially close follow-up after delivery to prevent sepsis, Dr. Foeller said.
Sepsis was defined in the study by ICD-9 codes for septicemia plus acute organ dysfunction.
There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
PARK CITY, UTAH – The risk of sepsis after delivery persists beyond 6 weeks, the traditional point at which women are thought to be in the clear, according to investigators from Stanford (Calif.) University.
The team analyzed 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from 2008-2012; 199 (39%) were at or before 6 weeks postpartum, and 310 (61%) were after 6 weeks, out to a year.
“Going into this, our view was that sepsis cases before 6 weeks would be due to obstetrical causes, and cases after 6 weeks would be due to [nonobstetrical causes],” said senior investigator Ronald Gibbs, MD, clinical professor of obstetrics and gynecology at Stanford. But that’s not what the team found.
In both the early and late admission groups, early preterm delivery was one of the leading risks for postpartum sepsis and other risk factors were largely the same. Pyelonephritis and pneumonia were by far the most common diagnoses in both groups, accounting for more than 70% of cases. The rank order of causative organisms was the same whether women presented before 6 weeks or after: gram-negative bacteria, staphylococcus, and streptococcus.
“In view of this, we think the risk for sepsis goes beyond 6 weeks,” Dr. Gibbs said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. Although women were admitted largely for nonuterine infections, “the reservoir of infection could be in the uterus,” with later seeding to the urinary tract or lungs. “I think there’s a chronic intrauterine infection that sets women up for” both early preterm birth and later sepsis, he added.
“These late admissions would probably go to a nonobstetrical service, but we are thinking that there may be a pelvic origin related to something that went on at delivery. I can’t really say that we ought to change our practice, but it sets the stage for looking at that. Finding that late [admissions for sepsis] have a lot in common with the early admissions and are probably related to the pregnancy really reorders the thinking,” Dr. Gibbs said.
The team found that among women who were delivered at 24-28 weeks, the adjusted odds ratio was 8.6 (95% confidence interval[CI], 4.4-17.1) for early and 4.2 (95% CI, 1.9-9.0) for late postpartum sepsis admission, even after delivery mode, maternal comorbidities, maternal age, “and everything else we could think of” were controlled for, said lead investigator Megan Foeller, MD, a maternal-fetal medicine fellow at Stanford.
A body mass index above 35 kg/m2 also increased the risk for sepsis admission, as did government-provided insurance, primary cesarean delivery, a failed trial of labor after a previous cesarean, and four or more previous deliveries.
Postoperative infection, acute hepatic failure, acute renal failure, acute respiratory failure, and heart failure during the delivery hospitalization greatly increased the risk of subsequent sepsis, as well.
The findings help define a group of women who likely need especially close follow-up after delivery to prevent sepsis, Dr. Foeller said.
Sepsis was defined in the study by ICD-9 codes for septicemia plus acute organ dysfunction.
There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
PARK CITY, UTAH – The risk of sepsis after delivery persists beyond 6 weeks, the traditional point at which women are thought to be in the clear, according to investigators from Stanford (Calif.) University.
The team analyzed 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from 2008-2012; 199 (39%) were at or before 6 weeks postpartum, and 310 (61%) were after 6 weeks, out to a year.
“Going into this, our view was that sepsis cases before 6 weeks would be due to obstetrical causes, and cases after 6 weeks would be due to [nonobstetrical causes],” said senior investigator Ronald Gibbs, MD, clinical professor of obstetrics and gynecology at Stanford. But that’s not what the team found.
In both the early and late admission groups, early preterm delivery was one of the leading risks for postpartum sepsis and other risk factors were largely the same. Pyelonephritis and pneumonia were by far the most common diagnoses in both groups, accounting for more than 70% of cases. The rank order of causative organisms was the same whether women presented before 6 weeks or after: gram-negative bacteria, staphylococcus, and streptococcus.
“In view of this, we think the risk for sepsis goes beyond 6 weeks,” Dr. Gibbs said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. Although women were admitted largely for nonuterine infections, “the reservoir of infection could be in the uterus,” with later seeding to the urinary tract or lungs. “I think there’s a chronic intrauterine infection that sets women up for” both early preterm birth and later sepsis, he added.
“These late admissions would probably go to a nonobstetrical service, but we are thinking that there may be a pelvic origin related to something that went on at delivery. I can’t really say that we ought to change our practice, but it sets the stage for looking at that. Finding that late [admissions for sepsis] have a lot in common with the early admissions and are probably related to the pregnancy really reorders the thinking,” Dr. Gibbs said.
The team found that among women who were delivered at 24-28 weeks, the adjusted odds ratio was 8.6 (95% confidence interval[CI], 4.4-17.1) for early and 4.2 (95% CI, 1.9-9.0) for late postpartum sepsis admission, even after delivery mode, maternal comorbidities, maternal age, “and everything else we could think of” were controlled for, said lead investigator Megan Foeller, MD, a maternal-fetal medicine fellow at Stanford.
A body mass index above 35 kg/m2 also increased the risk for sepsis admission, as did government-provided insurance, primary cesarean delivery, a failed trial of labor after a previous cesarean, and four or more previous deliveries.
Postoperative infection, acute hepatic failure, acute renal failure, acute respiratory failure, and heart failure during the delivery hospitalization greatly increased the risk of subsequent sepsis, as well.
The findings help define a group of women who likely need especially close follow-up after delivery to prevent sepsis, Dr. Foeller said.
Sepsis was defined in the study by ICD-9 codes for septicemia plus acute organ dysfunction.
There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
AT IDSOG
Key clinical point:
Major finding: Of 506 cases of sepsis hospitalization following delivery, 199 (39%) cases were at or before postpartum week 6, and 310 (61%) were after week 6.
Data source: A database review of 506 sepsis hospitalizations following delivery, culled from almost 2 million live births in California from the period of 2008-2012.
Disclosures: There was no industry funding for the work and the investigators reported having no relevant financial disclosures.
Capillary leakage predicts hysterectomy in postpartum group A strep
PARK CITY, UTAH – Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.
The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.
The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.
“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.
The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.
It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.
Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.
Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.
There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.
PARK CITY, UTAH – Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.
The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.
The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.
“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.
The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.
It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.
Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.
Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.
There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.
PARK CITY, UTAH – Systemic capillary leakage – which involves acute respiratory distress, ascites, pleural effusion, and abdominal distention – significantly increases the risk of hysterectomy in women with postpartum group A Streptococcus infection, according to findings from a single-site study.
The investigators at the University of Utah in Salt Lake City analyzed 71 cases of culture-proven infection at the university since 1991. They compared the 33 women who had hysterectomies, ICU admissions, pressor support, or mechanical ventilation with the 38 women who did not.
The goal was to identify predictors of poor outcomes and clarify when hysterectomy is the appropriate clinical decision. “These are young women, and it might have been their first pregnancy. You don’t want to remove their uterus if they don’t need it, but we know if women get really sick, they need that source control within 6-12 hours of presentation,” said Jennifer Kaiser, MD, the study’s lead investigator and an ob.gyn. fellow at the University of Utah.
“Capillary leak is an important objective clinical parameter that should be evaluated and considered with due exigency. I think this has not been well recognized,” Dr. Kaiser said at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology. The finding “should prompt you to mobilize a team for hysterectomy, or if you are at a smaller hospital, to think about transporting the patient to a higher level hospital that can perform hysterectomy and offer ICU care,” she added.
The investigators also found that a traditional marker for severe infection – uterine and cervical motion tenderness – did not predict adverse outcomes among the 71 women. Many patients with severe disease don’t actually have tenderness, Dr. Kaiser said.
It also didn’t matter whether the organism was isolated from the uterus or the blood. It’s sometimes thought uterine positivity predicts “worse prognosis, but that didn’t pan out,” she said.
Capillary leakage was a concern in 27 (82%) of the 33 women who had adverse outcomes, compared with 7 (18%) of the women who fared better, and included acute respiratory distress (30% versus 0%); ascites (73% versus 3%); pleural effusion (58% versus 5%), and abdominal distention (61% versus 18%). In total, 21 of the 33 women with adverse outcomes (64%) had hysterectomies. There were no deaths in the group.
Postpartum group A Streptococcus infections are more common in Utah than in other parts of the country, and it’s not known why. The next step for the investigators is to look at genealogies and genetic factors that may predispose women to severe infections, Dr. Kaiser said.
There was no industry funding for the work and Dr. Kaiser reported having no relevant financial disclosures.
AT IDSOG
Key clinical point:
Major finding: Signs of capillary leakage were predictive of adverse outcomes (OR 19.93, 95% CI 5.96-66.57, P less than .0001), specifically hysterectomy (OR 51.43, 95% CI 6.29-420.41, P less than .002).
Data source: A review of 71 cases of culture-proven infection at the University of Utah.
Disclosures: There was no industry funding for the work and the lead investigator reported having no relevant financial disclosures.
Study: Don’t separate NAS infants from moms
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from, in one study, a mean of almost $45,000 per NAS infant stay to just over $10,000.
Data source: A meta-analysis of six studies.
Disclosures: The investigators had no relevant financial disclosures.
How to reduce NICU transfers for asymptomatic hypoglycemia
NASHVILLE, TENN. – At the University of North Carolina at Chapel Hill, many infants who would previously have been transferred to the NICU for asymptomatic hypoglycemia now are staying with their moms, thanks to a new protocol that holds off on blood glucose testing until infants are fed for the first time and glucose homeostasis can begin.
Not too long ago, the university realized it had a problem that’s probably familiar to other institutions: Its system to monitor newborns at risk for hypoglycemia – those born to diabetic mothers, or who are small or large for gestational age – put too many infants with asymptomatic hypoglycemia into the NICU when they didn’t really need to be there.
Nurse practitioners “were tired of transferring babies they felt were responsive to feeding and did not actually require NICU care,” and “a growing number of families were unhappy with being separated from infants that were well-appearing and feeding well at a time when moms were trying to establish breast feeding and bonding. There was frustration with our protocol,” which “seemed rigid and outdated,” said Ashley Sutton, MD, a pediatric hospitalist at the university.
To fix the problem, Dr. Sutton and others on a multidisciplinary team implemented the American Academy of Pediatrics’ 2011 guidelines for monitoring glucose homeostasis in late-preterm and term newborns at-risk for hypoglycemia, with an additional mandate to initiate immediate, continual skin-to-skin contact at delivery (Pediatrics. 2011 Mar;127[3]:575-9).
Under the new system, children are fed with either their mom’s or a donor’s breast milk within an hour of birth, and the initial glucose check comes at 90 minutes; infants are transferred if blood glucose remains below 25 mg/dL after the second feeding. After 4 hours of life, glucose levels below 35 mg/dL trigger an evaluation for symptoms, not necessarily an automatic NICU transfer.
Labor and delivery nurses also are empowered “to immediately feed the baby no matter what number [they are] seeing,” Dr. Sutton said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The efforts have made a difference. The transfer rate for at-risk infants has fallen from 17% to 3%, and skin-to-skin contact is initiated within the first hour of life in 64%, up from 45%. Feeding of at-risk infants within the first hour has increased from 43% to 61%, and the first glucose check comes at an average of 97 minutes. The number of unnecessary NICU transfers of at-risk infants has fallen sharply.
Meanwhile, there’s been no increase in sepsis evaluations, adverse events, readmissions, and the rates of symptomatic hypoglycemia.
Dr. Sutton and her colleagues had no industry disclosures. The work was funded by the National Institutes of Health.
NASHVILLE, TENN. – At the University of North Carolina at Chapel Hill, many infants who would previously have been transferred to the NICU for asymptomatic hypoglycemia now are staying with their moms, thanks to a new protocol that holds off on blood glucose testing until infants are fed for the first time and glucose homeostasis can begin.
Not too long ago, the university realized it had a problem that’s probably familiar to other institutions: Its system to monitor newborns at risk for hypoglycemia – those born to diabetic mothers, or who are small or large for gestational age – put too many infants with asymptomatic hypoglycemia into the NICU when they didn’t really need to be there.
Nurse practitioners “were tired of transferring babies they felt were responsive to feeding and did not actually require NICU care,” and “a growing number of families were unhappy with being separated from infants that were well-appearing and feeding well at a time when moms were trying to establish breast feeding and bonding. There was frustration with our protocol,” which “seemed rigid and outdated,” said Ashley Sutton, MD, a pediatric hospitalist at the university.
To fix the problem, Dr. Sutton and others on a multidisciplinary team implemented the American Academy of Pediatrics’ 2011 guidelines for monitoring glucose homeostasis in late-preterm and term newborns at-risk for hypoglycemia, with an additional mandate to initiate immediate, continual skin-to-skin contact at delivery (Pediatrics. 2011 Mar;127[3]:575-9).
Under the new system, children are fed with either their mom’s or a donor’s breast milk within an hour of birth, and the initial glucose check comes at 90 minutes; infants are transferred if blood glucose remains below 25 mg/dL after the second feeding. After 4 hours of life, glucose levels below 35 mg/dL trigger an evaluation for symptoms, not necessarily an automatic NICU transfer.
Labor and delivery nurses also are empowered “to immediately feed the baby no matter what number [they are] seeing,” Dr. Sutton said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The efforts have made a difference. The transfer rate for at-risk infants has fallen from 17% to 3%, and skin-to-skin contact is initiated within the first hour of life in 64%, up from 45%. Feeding of at-risk infants within the first hour has increased from 43% to 61%, and the first glucose check comes at an average of 97 minutes. The number of unnecessary NICU transfers of at-risk infants has fallen sharply.
Meanwhile, there’s been no increase in sepsis evaluations, adverse events, readmissions, and the rates of symptomatic hypoglycemia.
Dr. Sutton and her colleagues had no industry disclosures. The work was funded by the National Institutes of Health.
NASHVILLE, TENN. – At the University of North Carolina at Chapel Hill, many infants who would previously have been transferred to the NICU for asymptomatic hypoglycemia now are staying with their moms, thanks to a new protocol that holds off on blood glucose testing until infants are fed for the first time and glucose homeostasis can begin.
Not too long ago, the university realized it had a problem that’s probably familiar to other institutions: Its system to monitor newborns at risk for hypoglycemia – those born to diabetic mothers, or who are small or large for gestational age – put too many infants with asymptomatic hypoglycemia into the NICU when they didn’t really need to be there.
Nurse practitioners “were tired of transferring babies they felt were responsive to feeding and did not actually require NICU care,” and “a growing number of families were unhappy with being separated from infants that were well-appearing and feeding well at a time when moms were trying to establish breast feeding and bonding. There was frustration with our protocol,” which “seemed rigid and outdated,” said Ashley Sutton, MD, a pediatric hospitalist at the university.
To fix the problem, Dr. Sutton and others on a multidisciplinary team implemented the American Academy of Pediatrics’ 2011 guidelines for monitoring glucose homeostasis in late-preterm and term newborns at-risk for hypoglycemia, with an additional mandate to initiate immediate, continual skin-to-skin contact at delivery (Pediatrics. 2011 Mar;127[3]:575-9).
Under the new system, children are fed with either their mom’s or a donor’s breast milk within an hour of birth, and the initial glucose check comes at 90 minutes; infants are transferred if blood glucose remains below 25 mg/dL after the second feeding. After 4 hours of life, glucose levels below 35 mg/dL trigger an evaluation for symptoms, not necessarily an automatic NICU transfer.
Labor and delivery nurses also are empowered “to immediately feed the baby no matter what number [they are] seeing,” Dr. Sutton said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The efforts have made a difference. The transfer rate for at-risk infants has fallen from 17% to 3%, and skin-to-skin contact is initiated within the first hour of life in 64%, up from 45%. Feeding of at-risk infants within the first hour has increased from 43% to 61%, and the first glucose check comes at an average of 97 minutes. The number of unnecessary NICU transfers of at-risk infants has fallen sharply.
Meanwhile, there’s been no increase in sepsis evaluations, adverse events, readmissions, and the rates of symptomatic hypoglycemia.
Dr. Sutton and her colleagues had no industry disclosures. The work was funded by the National Institutes of Health.
AT PHM 2017
Key clinical point:
Major finding: After making that and other changes, the transfer rate for at-risk infants at a major academic center fell from 17% to 3%, without an increase in rates of symptomatic hypoglycemia and adverse events.
Data source: Quality improvement project at the University of North Carolina at Chapel Hill.
Disclosures: The investigators had no financial disclosures. The work was funded by the National Institutes of Health.
Axillary thermometry is the best choice for newborns
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: The average distance of an axillary temperature from the axillary mean of 98.32º F was only 0.32º F, while the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F, and for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Data source: Head-to-head thermometry study in more than 200 infants aged 12-72 hours.
Disclosures: There was no outside funding, and Dr. Nadkarni had no relevant financial disclosures.
Consider routine penicillin allergy testing in obstetrics
PARK CITY, UTAH – When attendees at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology were asked if their institutions test to confirm alleged penicillin allergies, the only hands that went up were from clinicians at Duke University.
That’s a problem, according to Robert Heine, MD, a maternal-fetal medicine specialist at Duke, in Durham, N.C. “We, as a group, need to be doing [penicillin] allergy testing,” he said.
It’s become clear in recent years that patients who say they have a penicillin allergy often don’t have one, or remember a mild reaction from childhood that doesn’t preclude the use of beta-lactam antibiotics as adults. For decades, however, clinicians have taken those claims at face value, and duly noted them in charts and switched patients to non–beta-lactam antibiotics that don’t work as well.
That’s what happened at Duke in 2014. A total of 81 women with documented penicillin allergies were put on gentamicin and clindamycin to protect against cesarean wound infections and 16% ended up with infections anyway. Among the 864 women who received cefazolin – the first-line cesarean prophylaxis choice at Duke – the infection rate was 7%.
“Beta-lactam antibiotic prophylaxis reduced the risk of surgical site infections after cesareans by 60%,” said Benjamin Harris, MD, the lead investigator and an ob.gyn. resident at Duke, who presented the findings at the meeting.
When the investigators took a closer look at the 81 women who reported penicillin allergies, most of them had rashes and other mild reactions noted in their charts.
Findings such as those led Dr. Heine to push for routine testing. “I brought Duke into it kicking and screaming,” he said. The biggest obstacle was concern over liability, specifically that pregnant women would go into anaphylaxis and deliver prematurely, he said.
After a lot of lobbying, Dr. Heine and his colleagues started routine penicillin allergy testing in March 2016. There hasn’t been a single reaction among the 80-plus pregnant women tested so far, he reported.
Duke administrators were also concerned about reimbursement, but it hasn’t turned out to be a problem. Reimbursements from public and private payers “cover our costs,” a little over $100 per test, Dr. Heine said.
Dr. Heine said he can imagine outpatient testing at some point, but for now women are checked into triage. They get a fetal heart tone before 24 weeks, and a fetal heart rate monitor afterward. “We try to do it before 20 weeks so we don’t have to worry about the fetus,” he said.
When penicillin allergies are in the chart, or women say they are allergic, ask what type of reaction they had in the past. Type 1 reactions should be confirmed with testing. It’s okay to skip testing and give beta-lactams for non–type 1 reactions, but “if a woman has a non–type 1, and they’re already set up for testing, I’m going to do it anyway because getting the penicillin allergy off her chart is good for her and her life,” Dr. Heine said.
Dr. Heine and Dr. Harris reported having no financial disclosures.
PARK CITY, UTAH – When attendees at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology were asked if their institutions test to confirm alleged penicillin allergies, the only hands that went up were from clinicians at Duke University.
That’s a problem, according to Robert Heine, MD, a maternal-fetal medicine specialist at Duke, in Durham, N.C. “We, as a group, need to be doing [penicillin] allergy testing,” he said.
It’s become clear in recent years that patients who say they have a penicillin allergy often don’t have one, or remember a mild reaction from childhood that doesn’t preclude the use of beta-lactam antibiotics as adults. For decades, however, clinicians have taken those claims at face value, and duly noted them in charts and switched patients to non–beta-lactam antibiotics that don’t work as well.
That’s what happened at Duke in 2014. A total of 81 women with documented penicillin allergies were put on gentamicin and clindamycin to protect against cesarean wound infections and 16% ended up with infections anyway. Among the 864 women who received cefazolin – the first-line cesarean prophylaxis choice at Duke – the infection rate was 7%.
“Beta-lactam antibiotic prophylaxis reduced the risk of surgical site infections after cesareans by 60%,” said Benjamin Harris, MD, the lead investigator and an ob.gyn. resident at Duke, who presented the findings at the meeting.
When the investigators took a closer look at the 81 women who reported penicillin allergies, most of them had rashes and other mild reactions noted in their charts.
Findings such as those led Dr. Heine to push for routine testing. “I brought Duke into it kicking and screaming,” he said. The biggest obstacle was concern over liability, specifically that pregnant women would go into anaphylaxis and deliver prematurely, he said.
After a lot of lobbying, Dr. Heine and his colleagues started routine penicillin allergy testing in March 2016. There hasn’t been a single reaction among the 80-plus pregnant women tested so far, he reported.
Duke administrators were also concerned about reimbursement, but it hasn’t turned out to be a problem. Reimbursements from public and private payers “cover our costs,” a little over $100 per test, Dr. Heine said.
Dr. Heine said he can imagine outpatient testing at some point, but for now women are checked into triage. They get a fetal heart tone before 24 weeks, and a fetal heart rate monitor afterward. “We try to do it before 20 weeks so we don’t have to worry about the fetus,” he said.
When penicillin allergies are in the chart, or women say they are allergic, ask what type of reaction they had in the past. Type 1 reactions should be confirmed with testing. It’s okay to skip testing and give beta-lactams for non–type 1 reactions, but “if a woman has a non–type 1, and they’re already set up for testing, I’m going to do it anyway because getting the penicillin allergy off her chart is good for her and her life,” Dr. Heine said.
Dr. Heine and Dr. Harris reported having no financial disclosures.
PARK CITY, UTAH – When attendees at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology were asked if their institutions test to confirm alleged penicillin allergies, the only hands that went up were from clinicians at Duke University.
That’s a problem, according to Robert Heine, MD, a maternal-fetal medicine specialist at Duke, in Durham, N.C. “We, as a group, need to be doing [penicillin] allergy testing,” he said.
It’s become clear in recent years that patients who say they have a penicillin allergy often don’t have one, or remember a mild reaction from childhood that doesn’t preclude the use of beta-lactam antibiotics as adults. For decades, however, clinicians have taken those claims at face value, and duly noted them in charts and switched patients to non–beta-lactam antibiotics that don’t work as well.
That’s what happened at Duke in 2014. A total of 81 women with documented penicillin allergies were put on gentamicin and clindamycin to protect against cesarean wound infections and 16% ended up with infections anyway. Among the 864 women who received cefazolin – the first-line cesarean prophylaxis choice at Duke – the infection rate was 7%.
“Beta-lactam antibiotic prophylaxis reduced the risk of surgical site infections after cesareans by 60%,” said Benjamin Harris, MD, the lead investigator and an ob.gyn. resident at Duke, who presented the findings at the meeting.
When the investigators took a closer look at the 81 women who reported penicillin allergies, most of them had rashes and other mild reactions noted in their charts.
Findings such as those led Dr. Heine to push for routine testing. “I brought Duke into it kicking and screaming,” he said. The biggest obstacle was concern over liability, specifically that pregnant women would go into anaphylaxis and deliver prematurely, he said.
After a lot of lobbying, Dr. Heine and his colleagues started routine penicillin allergy testing in March 2016. There hasn’t been a single reaction among the 80-plus pregnant women tested so far, he reported.
Duke administrators were also concerned about reimbursement, but it hasn’t turned out to be a problem. Reimbursements from public and private payers “cover our costs,” a little over $100 per test, Dr. Heine said.
Dr. Heine said he can imagine outpatient testing at some point, but for now women are checked into triage. They get a fetal heart tone before 24 weeks, and a fetal heart rate monitor afterward. “We try to do it before 20 weeks so we don’t have to worry about the fetus,” he said.
When penicillin allergies are in the chart, or women say they are allergic, ask what type of reaction they had in the past. Type 1 reactions should be confirmed with testing. It’s okay to skip testing and give beta-lactams for non–type 1 reactions, but “if a woman has a non–type 1, and they’re already set up for testing, I’m going to do it anyway because getting the penicillin allergy off her chart is good for her and her life,” Dr. Heine said.
Dr. Heine and Dr. Harris reported having no financial disclosures.
AT IDSOG
Key clinical point:
Major finding: Among 81 women with documented penicillin allergies who received gentamicin and clindamycin, 16% developed surgical site infections. In contrast, among the 864 women who received cefazolin, the infection rate was 7%.
Data source: A single-center review at Duke University.
Disclosures: The investigators reported having no relevant financial disclosures.
Copper IUDs increase bacterial vaginosis risk
PARK CITY, UTAH – Copper IUDs really do increase the risk of bacterial vaginosis (BV), according to a longitudinal study of 234 women in Harare, Zimbabwe.
This notion has “always been a little bit controversial; it’s commonly believed by some and refuted by others,” but the findings from the new research “are real and generalizable,” said Sharon Hillier, PhD, the study’s senior investigator and the director of reproductive infectious disease research at Magee-Womens Hospital of the University of Pittsburgh.
The African women in this study were all free of HIV and sexually transmitted infections; on average, they were about 26 years old; and most were married and sexually active. As part of a larger look into the role of vaginal dysbiosis in HIV acquisition, they were given five options for contraception: three kinds of injectables; one implant; and the nonhormonal copper IUD.
The women were divided almost evenly among the five options. The researchers followed them for 6 months with routine vaginal swabs and polymerase chain reaction testing during the follicular phase of menses. Women who opted for the copper IUD were slightly less likely to report being married and sexually active.
Almost a third of the women had BV at baseline, a little higher than the prevalence in American women.
Women who opted for hormonal contraceptives had no change in BV prevalence or vaginal microbiota.
However, BV prevalence in women who opted for the copper IUD increased from 27% at baseline to 34% at 30 days, 39% at 90 days, and 44% at 180 days. There was an increase in concentrations of Gardnerella vaginalis and Atopobium vaginae that was not seen in the hormonal contraception groups. Overall, copper IUDs showed a twofold increase in the relative risk of BV.
“I don’t think there’s anything here that’s particularly alarming. This would not dissuade me from recommending a copper IUD. It’s a very effective and safe nonhormonal way of having long-acting reversible contraception, but if a woman gets a copper IUD and she has recurrent BV, you need to understand that the IUD may be playing a role,” Dr. Hillier said in an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
The increased risk is probably because IUDs cause heavier and longer menstrual bleeding, which is known to disturb the vaginal microbiome. Work is underway to see if removing the IUD reverses the effects, Dr. Hillier said.
Most of the women in the study opted to keep their IUDs in place after 6 months.
The Gates Foundation supported the work. Dr. Hillier is a consultant for Merck and Symbiomix and a researcher for Becton Dickinson and Cepheid.
PARK CITY, UTAH – Copper IUDs really do increase the risk of bacterial vaginosis (BV), according to a longitudinal study of 234 women in Harare, Zimbabwe.
This notion has “always been a little bit controversial; it’s commonly believed by some and refuted by others,” but the findings from the new research “are real and generalizable,” said Sharon Hillier, PhD, the study’s senior investigator and the director of reproductive infectious disease research at Magee-Womens Hospital of the University of Pittsburgh.
The African women in this study were all free of HIV and sexually transmitted infections; on average, they were about 26 years old; and most were married and sexually active. As part of a larger look into the role of vaginal dysbiosis in HIV acquisition, they were given five options for contraception: three kinds of injectables; one implant; and the nonhormonal copper IUD.
The women were divided almost evenly among the five options. The researchers followed them for 6 months with routine vaginal swabs and polymerase chain reaction testing during the follicular phase of menses. Women who opted for the copper IUD were slightly less likely to report being married and sexually active.
Almost a third of the women had BV at baseline, a little higher than the prevalence in American women.
Women who opted for hormonal contraceptives had no change in BV prevalence or vaginal microbiota.
However, BV prevalence in women who opted for the copper IUD increased from 27% at baseline to 34% at 30 days, 39% at 90 days, and 44% at 180 days. There was an increase in concentrations of Gardnerella vaginalis and Atopobium vaginae that was not seen in the hormonal contraception groups. Overall, copper IUDs showed a twofold increase in the relative risk of BV.
“I don’t think there’s anything here that’s particularly alarming. This would not dissuade me from recommending a copper IUD. It’s a very effective and safe nonhormonal way of having long-acting reversible contraception, but if a woman gets a copper IUD and she has recurrent BV, you need to understand that the IUD may be playing a role,” Dr. Hillier said in an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
The increased risk is probably because IUDs cause heavier and longer menstrual bleeding, which is known to disturb the vaginal microbiome. Work is underway to see if removing the IUD reverses the effects, Dr. Hillier said.
Most of the women in the study opted to keep their IUDs in place after 6 months.
The Gates Foundation supported the work. Dr. Hillier is a consultant for Merck and Symbiomix and a researcher for Becton Dickinson and Cepheid.
PARK CITY, UTAH – Copper IUDs really do increase the risk of bacterial vaginosis (BV), according to a longitudinal study of 234 women in Harare, Zimbabwe.
This notion has “always been a little bit controversial; it’s commonly believed by some and refuted by others,” but the findings from the new research “are real and generalizable,” said Sharon Hillier, PhD, the study’s senior investigator and the director of reproductive infectious disease research at Magee-Womens Hospital of the University of Pittsburgh.
The African women in this study were all free of HIV and sexually transmitted infections; on average, they were about 26 years old; and most were married and sexually active. As part of a larger look into the role of vaginal dysbiosis in HIV acquisition, they were given five options for contraception: three kinds of injectables; one implant; and the nonhormonal copper IUD.
The women were divided almost evenly among the five options. The researchers followed them for 6 months with routine vaginal swabs and polymerase chain reaction testing during the follicular phase of menses. Women who opted for the copper IUD were slightly less likely to report being married and sexually active.
Almost a third of the women had BV at baseline, a little higher than the prevalence in American women.
Women who opted for hormonal contraceptives had no change in BV prevalence or vaginal microbiota.
However, BV prevalence in women who opted for the copper IUD increased from 27% at baseline to 34% at 30 days, 39% at 90 days, and 44% at 180 days. There was an increase in concentrations of Gardnerella vaginalis and Atopobium vaginae that was not seen in the hormonal contraception groups. Overall, copper IUDs showed a twofold increase in the relative risk of BV.
“I don’t think there’s anything here that’s particularly alarming. This would not dissuade me from recommending a copper IUD. It’s a very effective and safe nonhormonal way of having long-acting reversible contraception, but if a woman gets a copper IUD and she has recurrent BV, you need to understand that the IUD may be playing a role,” Dr. Hillier said in an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology.
The increased risk is probably because IUDs cause heavier and longer menstrual bleeding, which is known to disturb the vaginal microbiome. Work is underway to see if removing the IUD reverses the effects, Dr. Hillier said.
Most of the women in the study opted to keep their IUDs in place after 6 months.
The Gates Foundation supported the work. Dr. Hillier is a consultant for Merck and Symbiomix and a researcher for Becton Dickinson and Cepheid.
AT IDSOG
Key clinical point:
Major finding: Baterial vaginosis prevalence in women who opted for the copper IUD increased from 27% at baseline to 34% at 30 days, 39% at 90 days, and 44% at 180 days.
Data source: A longitudinal cohort study of 234 women.
Disclosures: The Gates Foundation supported the work. The senior investigator is a consultant for Merck and Symbiomix and a researcher for Becton Dickinson and Cepheid.
VIDEO: How to catch postpartum necrotizing fasciitis in time
PARK CITY, UTAH – , and it’s easy to misdiagnose at first.
There’s no pus, and the skin can look mostly normal with just a little swelling. The tipoff is pain that seems out of proportion to the clinical signs.
David Eschenbach, MD, chair of the department of obstetrics and gynecology at the University of Washington, Seattle, knows the infection well. In an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he shared his insights on how physicians can recognize and treat postpartum necrotizing fasciitis in time to limit the damage.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
PARK CITY, UTAH – , and it’s easy to misdiagnose at first.
There’s no pus, and the skin can look mostly normal with just a little swelling. The tipoff is pain that seems out of proportion to the clinical signs.
David Eschenbach, MD, chair of the department of obstetrics and gynecology at the University of Washington, Seattle, knows the infection well. In an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he shared his insights on how physicians can recognize and treat postpartum necrotizing fasciitis in time to limit the damage.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
PARK CITY, UTAH – , and it’s easy to misdiagnose at first.
There’s no pus, and the skin can look mostly normal with just a little swelling. The tipoff is pain that seems out of proportion to the clinical signs.
David Eschenbach, MD, chair of the department of obstetrics and gynecology at the University of Washington, Seattle, knows the infection well. In an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he shared his insights on how physicians can recognize and treat postpartum necrotizing fasciitis in time to limit the damage.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT IDSOG
VIDEO: When to turn to surgery in postpartum uterine infection
PARK CITY, UTAH – When postpartum infections don’t respond to antibiotics, doctors and surgeons need to move fast; surgery – often hysterectomy – is the only thing that will save the woman’s life.
The problem is that with today’s antibiotics, doctors may have never encountered the situation, and sometimes continue to treat with antibiotics until it’s too late.
In Seattle, physicians turn to David Eschenbach, MD, chair of the department of obstetrics and gynecology at the University of Washington, for advice on when it’s time to give up on antibiotics and go to the OR. It’s a difficult decision, especially when patients are young.
In an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Dr. Eschenbach shared what he’s learned from decades of experience in dealing with one of the most devastating postpartum complications.
PARK CITY, UTAH – When postpartum infections don’t respond to antibiotics, doctors and surgeons need to move fast; surgery – often hysterectomy – is the only thing that will save the woman’s life.
The problem is that with today’s antibiotics, doctors may have never encountered the situation, and sometimes continue to treat with antibiotics until it’s too late.
In Seattle, physicians turn to David Eschenbach, MD, chair of the department of obstetrics and gynecology at the University of Washington, for advice on when it’s time to give up on antibiotics and go to the OR. It’s a difficult decision, especially when patients are young.
In an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Dr. Eschenbach shared what he’s learned from decades of experience in dealing with one of the most devastating postpartum complications.
PARK CITY, UTAH – When postpartum infections don’t respond to antibiotics, doctors and surgeons need to move fast; surgery – often hysterectomy – is the only thing that will save the woman’s life.
The problem is that with today’s antibiotics, doctors may have never encountered the situation, and sometimes continue to treat with antibiotics until it’s too late.
In Seattle, physicians turn to David Eschenbach, MD, chair of the department of obstetrics and gynecology at the University of Washington, for advice on when it’s time to give up on antibiotics and go to the OR. It’s a difficult decision, especially when patients are young.
In an interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Dr. Eschenbach shared what he’s learned from decades of experience in dealing with one of the most devastating postpartum complications.
AT IDSOG
