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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.
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
Metronidazole clears PID anaerobes with no drop in antibiotic compliance
PARK CITY, UTAH – Adding metronidazole to ceftriaxone/doxycycline for acute pelvic inflammatory disease (PID) improved clearance of endometrial anaerobes and reduced the frequency of pelvic tenderness at 30 days, without reducing overall antibiotic compliance, in a randomized, placebo-controlled trial conducted at the University of Pittsburgh.
Anaerobic organisms are associated with endometritis, but guidelines from the Centers for Disease Control and Prevention have been equivocal about adding metronidazole to standard antibiotic regimens, citing a lack of data. CDC currently recommends treatment “with or without metronidazole.”
“Finally, we have data. This work has been needed to be done for over a decade. This is a huge contribution to the literature,” said Cheryl Walker, MD, of the department of obstetrics and gynecology at the University of California, Davis; she moderated the study presentation.
All 233 women in the study received ceftriaxone 250 mg (intramuscular) once and doxycycline 100 mg orally twice a day for 14 days; 116 were randomized to metronidazole 500 mg orally twice a day for 14 days, and 117 to matching placebo.
At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar.
Meanwhile, all of the women taking metronidazole cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, while one-third of women in the placebo group did not (P = .02).
Many clinicians hesitate to give metronidazole for PID out of concern that the drug’s gastrointestinal side effects will cause women to quit their antibiotic regimens early, but that wasn’t a problem in the Pittsburgh study. Compliance and adverse events were similar in both groups; 53.8% of the women taking metronidazole, for instance, versus 47.1% of women in the placebo arm, reported gastrointestinal side effects (P = .57).
“When we unmasked the treatment arms and showed there was really no difference, it was very surprising. When we looked at compliance at a level of 75% of drugs taken – we used blister packs and self-report – 90% of women in each arm took at least 75% of the medication,” Dr. Wiesenfeld said. Metronidazole side effects didn’t have much of an impact in the study, he added.
The women were a mean age of 23 years old; 59% were black, 28% were white, and 15% had private insurance. The groups were well balanced, with similar clinical presentations and prevalence of chlamydia (15%), gonorrhea (7%), Mycoplasma genitalium (18%), bacterial vaginosis (55%) and Trichomonas vaginalis (8.9%). Pregnant women and those requiring hospitalization were among those excluded from the study.
The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. Dr. Wiesenfeld reported having no relevant disclosures.
PARK CITY, UTAH – Adding metronidazole to ceftriaxone/doxycycline for acute pelvic inflammatory disease (PID) improved clearance of endometrial anaerobes and reduced the frequency of pelvic tenderness at 30 days, without reducing overall antibiotic compliance, in a randomized, placebo-controlled trial conducted at the University of Pittsburgh.
Anaerobic organisms are associated with endometritis, but guidelines from the Centers for Disease Control and Prevention have been equivocal about adding metronidazole to standard antibiotic regimens, citing a lack of data. CDC currently recommends treatment “with or without metronidazole.”
“Finally, we have data. This work has been needed to be done for over a decade. This is a huge contribution to the literature,” said Cheryl Walker, MD, of the department of obstetrics and gynecology at the University of California, Davis; she moderated the study presentation.
All 233 women in the study received ceftriaxone 250 mg (intramuscular) once and doxycycline 100 mg orally twice a day for 14 days; 116 were randomized to metronidazole 500 mg orally twice a day for 14 days, and 117 to matching placebo.
At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar.
Meanwhile, all of the women taking metronidazole cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, while one-third of women in the placebo group did not (P = .02).
Many clinicians hesitate to give metronidazole for PID out of concern that the drug’s gastrointestinal side effects will cause women to quit their antibiotic regimens early, but that wasn’t a problem in the Pittsburgh study. Compliance and adverse events were similar in both groups; 53.8% of the women taking metronidazole, for instance, versus 47.1% of women in the placebo arm, reported gastrointestinal side effects (P = .57).
“When we unmasked the treatment arms and showed there was really no difference, it was very surprising. When we looked at compliance at a level of 75% of drugs taken – we used blister packs and self-report – 90% of women in each arm took at least 75% of the medication,” Dr. Wiesenfeld said. Metronidazole side effects didn’t have much of an impact in the study, he added.
The women were a mean age of 23 years old; 59% were black, 28% were white, and 15% had private insurance. The groups were well balanced, with similar clinical presentations and prevalence of chlamydia (15%), gonorrhea (7%), Mycoplasma genitalium (18%), bacterial vaginosis (55%) and Trichomonas vaginalis (8.9%). Pregnant women and those requiring hospitalization were among those excluded from the study.
The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. Dr. Wiesenfeld reported having no relevant disclosures.
PARK CITY, UTAH – Adding metronidazole to ceftriaxone/doxycycline for acute pelvic inflammatory disease (PID) improved clearance of endometrial anaerobes and reduced the frequency of pelvic tenderness at 30 days, without reducing overall antibiotic compliance, in a randomized, placebo-controlled trial conducted at the University of Pittsburgh.
Anaerobic organisms are associated with endometritis, but guidelines from the Centers for Disease Control and Prevention have been equivocal about adding metronidazole to standard antibiotic regimens, citing a lack of data. CDC currently recommends treatment “with or without metronidazole.”
“Finally, we have data. This work has been needed to be done for over a decade. This is a huge contribution to the literature,” said Cheryl Walker, MD, of the department of obstetrics and gynecology at the University of California, Davis; she moderated the study presentation.
All 233 women in the study received ceftriaxone 250 mg (intramuscular) once and doxycycline 100 mg orally twice a day for 14 days; 116 were randomized to metronidazole 500 mg orally twice a day for 14 days, and 117 to matching placebo.
At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar.
Meanwhile, all of the women taking metronidazole cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, while one-third of women in the placebo group did not (P = .02).
Many clinicians hesitate to give metronidazole for PID out of concern that the drug’s gastrointestinal side effects will cause women to quit their antibiotic regimens early, but that wasn’t a problem in the Pittsburgh study. Compliance and adverse events were similar in both groups; 53.8% of the women taking metronidazole, for instance, versus 47.1% of women in the placebo arm, reported gastrointestinal side effects (P = .57).
“When we unmasked the treatment arms and showed there was really no difference, it was very surprising. When we looked at compliance at a level of 75% of drugs taken – we used blister packs and self-report – 90% of women in each arm took at least 75% of the medication,” Dr. Wiesenfeld said. Metronidazole side effects didn’t have much of an impact in the study, he added.
The women were a mean age of 23 years old; 59% were black, 28% were white, and 15% had private insurance. The groups were well balanced, with similar clinical presentations and prevalence of chlamydia (15%), gonorrhea (7%), Mycoplasma genitalium (18%), bacterial vaginosis (55%) and Trichomonas vaginalis (8.9%). Pregnant women and those requiring hospitalization were among those excluded from the study.
The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. Dr. Wiesenfeld reported having no relevant disclosures.
AT IDSOG
Key clinical point:
Major finding: At 30 days, just 8% in the metronidazole group had pelvic tenderness, compared with 22.3% in the placebo arm (P = .006); clinical outcomes were otherwise similar. All of the women taking metronidazole also completely cleared Atopobium vaginae, anaerobic gram-negative rods, and anaerobic gram-positive cocci, but one-third of women on placebo did not (P = .02).
Data source: Randomized, placebo-controlled trial with 233 women.
Disclosures: The work was funded by the National Institutes of Health. Hologic donated laboratory reagents. The lead investigator reported having no relevant disclosures.
VIDEO: How to prevent, manage perinatal HIV infection
PARK CITY, UTAH – Despite notable progress in recent years, . Early recognition and treatment of HIV infection in pregnancy, prophylaxis for at-risk women, and retention of infected women in postpartum HIV care remain important goals, but they aren’t always met.
In a wide-ranging interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Gweneth Lazenby, MD, associate professor of obstetrics and gynecology at the Medical University of South Carolina, Charleston, explained what to do to improve the situation. Among the many pearls she shared: One HIV test isn’t enough for at-risk women.
PARK CITY, UTAH – Despite notable progress in recent years, . Early recognition and treatment of HIV infection in pregnancy, prophylaxis for at-risk women, and retention of infected women in postpartum HIV care remain important goals, but they aren’t always met.
In a wide-ranging interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Gweneth Lazenby, MD, associate professor of obstetrics and gynecology at the Medical University of South Carolina, Charleston, explained what to do to improve the situation. Among the many pearls she shared: One HIV test isn’t enough for at-risk women.
PARK CITY, UTAH – Despite notable progress in recent years, . Early recognition and treatment of HIV infection in pregnancy, prophylaxis for at-risk women, and retention of infected women in postpartum HIV care remain important goals, but they aren’t always met.
In a wide-ranging interview at the annual scientific meeting of the Infectious Diseases Society for Obstetrics and Gynecology, Gweneth Lazenby, MD, associate professor of obstetrics and gynecology at the Medical University of South Carolina, Charleston, explained what to do to improve the situation. Among the many pearls she shared: One HIV test isn’t enough for at-risk women.
AT IDSOG
