A survey of practices in infectious diseases by obstetrician-gynecologists

Prevalence of Urinary Tract Infection Among Pregnant Women and its Complications in Their Newborns During the Birth in the Hospitals of Dezful City, Iran, 2012 - 2013

BACKGROUND

Urinary tract infection (UTI) is the most common disorder caused by bacterial agents in pregnancy, which can lead to important complications in newborn of such mothers in case of inappropriate diagnosis and treatment.

OBJECTIVES

The purpose of this study was to study the prevalence of UTI among pregnant women and its complications in their newborns during the birth in the hospitals of Dezful City, Iran, during 2012 - 2013.

PATIENTS AND METHODS

In this cross-sectional retrospective study, 1132 women admitted to Dr. Ganjavian and Ayatollah Nabavi Hospitals in Dezful City, Iran, during 2012 - 2013 were randomly allocated into the case and control groups and were matched based on their age, numbers of pregnancy, sex and diseases of their children. UTI was the only difference between the two groups.

RESULTS

Twenty-two thousand six hundred deliveries occurred within the course of this study. Due to UTI, 5% of deliveries led to hospitalization of mothers (1132 patients).Weight and height of newborn infants of mothers afflicted with UTI (P < 0.001) were significantly lower compared to newborns of healthy women (P < 0.001). There was a significant association between the two groups of pregnant women with UTI in terms of type of delivery (normal and caesarean section) (P < 0.008).

CONCLUSIONS

The lower incidence of UTI in pregnant women compared to other areas of Iran represents the role of climate and weather in the prevalence of UTI. In addition, the increased number of low-birth-weight infants had a remarkable correlation with UTI, which can influence the health of the next generation.

Inadequate syphilis screening among women with prenatal care in a community with a high syphilis incidence

OBJECTIVES AND GOAL

This study was designed to evaluate the extent to which pregnant women in a community with a high syphilis incidence were screened for syphilis according to standard recommendations of twice during prenatal care and at labor and delivery.

STUDY DESIGN

Labor and delivery records from 4 hospitals in Miami-Dade County, Florida, were abstracted to obtain maternal and prenatal care characteristics and syphilis screening practices.

RESULTS

Of the 1991 women, records indicated that 1655 (83%) were screened at least once during prenatal care, 220 (11%) were screened twice during prenatal care before delivery, and 184 (9%) were screened twice during prenatal care and at delivery. Attending a private clinic, having more than adequate prenatal care and having private insurance were associated with not being screened at least twice before delivery.

CONCLUSIONS

Few women were screened according to standard recommendations, and provider or institutional-related factors affected adequacy of screening.

Knowledge About Sexually Transmitted Diseases in Women Among Primary Care Physicians

OBJECTIVES

Little is known about sexually transmitted disease (STD) knowledge of primary care providers. The objectives of this study were to determine the knowledge about the management of STDs among primary care physicians and to identify physician characteristics associated with possession of STD knowledge.

STUDY

A self-administered questionnaire was mailed to a random sample of 1600 obstetrician/gynecologists, pediatricians, family physicians, and internists practicing in Pennsylvania. Information on physician and patient demographics was gathered, and we assessed knowledge and practice patterns concerning the management of STDs in young women.

RESULTS

Physician knowledge regarding the evaluation and management of women with or at risk for STDs was associated with female gender (odds ratio [OR]: 2.1; 95% confidence interval [CI]: 1.4-3.2), age < or =40 (OR: 2.3; 95% CI: 1.4-3.6), and metropolitan practice location (OR: 1.7; 95% CI: 1.1-2.6). Familiarity with the Center for Disease Control and Prevention's (CDC's) STD treatment guidelines was independently associated with STD knowledge (OR: 2.0; 95% CI: 1.2, 3.3). Physicians with good STD knowledge were more likely to report routinely screening at-risk women for Chlamydia trachomatis (OR: 3.9; 95% CI: 2.3-6.8).

CONCLUSIONS

Inadequacies in physician knowledge may serve as a barrier to the appropriate diagnosis and treatment of STDs. Interventions to improve STD management practices should include continuing medical education and distribution of CDC's STD treatment guidelines to primary care providers.

Estimating prenatal syphilis and HIV screening rates for commercially insured women

OBJECTIVE

Although routine serologic testing for syphilis and human immunodeficiency virus (HIV) for all pregnant women is recommended by the Centers for Disease Control and Prevention and many health professional organizations, little is known about the extent of prenatal syphilis and HIV screening rates among commercially insured pregnant women.

METHODS

A claims database for a large commercially insured population was analyzed to estimate syphilis and HIV screening rates for pregnant women who were continuously enrolled in the same health insurance plan during 1998 and 1999 in 13 U.S. states. Diagnostic and procedural services were used to determine pregnancy status, receipt of prenatal care, and syphilis and HIV testing during pregnancy.

RESULTS

Of 13,250 identified pregnancies, 12,156 (92%) were among women who had prenatal visits; 8368 (63%) included claims for syphilis testing; and 4411 (33%) included claims for HIV testing. Of the 8368 pregnancies with syphilis testing, 6326 (76%) included syphilis tests that were performed during the initial prenatal visit. Of the 4411 pregnancies with HIV testing, 3168 (72%) included HIV testing on the initial prenatal visit. Of 4249 pregnancies with syphilis and HIV testing, 3146 (74%) included HIV testing and syphilis testing on the initial prenatal visit.

CONCLUSIONS

Most HIV and syphilis tests had been provided during initial prenatal visits among women who had HIV and syphilis testing. Prenatal screening rates for syphilis and HIV identified through claims were lower than expected. This may be due to deficiencies in documentation of syphilis and HIV screening in administrative databases or actual screening rates. Further investigation is needed to determine how accurately claims data can measure actual screening practices.

America's Health Centers: reducing racial and ethnic disparities in perinatal care and birth outcomes

OBJECTIVE

To examine whether community health centers (CHCs) reduce racial/ethnic disparities in perinatal care and birth outcomes, and to identify CHC characteristics associated with better outcomes.

BACKGROUND

Despite great national wealth, the U.S. continues to rank poorly relative to other industrialized nations on infant mortality and other birth outcomes, and with wide inequities by race/ethnicity. Disparities in primary care (including perinatal care) may contribute to disparities in birth outcomes, which may be addressed by CHCs that provide safety-net medical services to vulnerable populations.

METHODS

Data are from annual Uniform Data System reports submitted to the Bureau of Primary Health Care over six years (1996-2001) by about 700 CHCs each year.

RESULTS

Across all years, about 60% of CHC mothers received first-trimester prenatal care and more than 70% received postpartum and newborn care. In 2001, Asian mothers were the most likely to receive both postpartum and newborn care (81.7% and 80.3%), followed by Hispanics (75.0% and 76.3%), blacks (70.8% and 69.9%), and whites (70.7% and 66.7%). In 2001, blacks had higher rates of low birth weight (LBW) babies (10.4%), but the disparity in rates for blacks and whites was smaller in CHCs (3.3 percentage points) compared to national disparities for low-socioeconomic status mothers (5.8 percentage points) and the total population (6.2 percentage points). In CHCs, greater perinatal care capacity was associated with higher rates of first-trimester prenatal care, which was associated with a lower LBW rate.

CONCLUSION

Racial/ethnic disparities in certain prenatal services and birth outcomes may be lower in CHCs compared to the general population, despite serving higher-risk groups. Within CHCs, increasing first-trimester prenatal care use through perinatal care capacity may lead to further improvement in birth outcomes for the underserved.

State laws regarding prenatal syphilis screening in the United States

OBJECTIVE

The purpose of this study was to assess the frequency and pattern of state laws or regulations regarding prenatal syphilis serologic screening in the United States in 2001.

STUDY DESIGN

We surveyed the United States for existing laws and regulations regarding serologic screening for syphilis during pregnancy. Testing was compared with 2000 state rates of syphilis in women and newborn infants, with states that had syphilis high morbidity areas, and with national 2000 and 2010 objectives for rates of syphilis.

RESULTS

Forty-six of the 50 states (90%) and the District of Columbia have laws regarding antenatal syphilis screening. Thirty-four of the 46 statutes (76%) mandate one prenatal test, usually at the first prenatal visit or early in pregnancy. Twelve laws (26%) include third-trimester testing for all or high-risk women. The presence of high morbidity areas, incidence of early syphilis in women, and rates of congenital syphilis are associated with increasing frequency of legislated antepartum screening.

CONCLUSION

Only 90% of states have statutes that require antepartum syphilis screening, and there is variation in the content of the statutes about the number and timing of tests. States with a heavy burden of infectious syphilis in women tend to require more prenatal testing.

Changes in early-onset group B beta hemolytic streptococcus disease with changing recommendations for prophylaxis

OBJECTIVE

To determine the incidence of early-onset group B beta hemolytic streptococcal (EOGBS) infection and the association between changes in the incidence and intrapartum antibiotic prophylaxis (IAP).

STUDY DESIGN

A retrospective population survey of infants with GBS at < 7 days of age with a nested case-control study of non-GBS infants over the same time period, January 1985 to December 1998. The incidence of GBS and maternal antibiotic treatment during labor was analyzed as a function of time period: prior to publication of guidelines for prevention of EOGBS (1985-1992), following AAP/ACOG guidelines (1993-1995), and following CDC consensus guidelines (1996-1998).

RESULTS

Fifty-six cases of EOGBS infection occurred among 53,088 live births. The incidence declined from 1.5/1000 before any guidelines to 0.67/1000 after AAP/ACOG guidelines (p = 0.004), and continued to decline after the CDC consensus statement (0.28/1000) (p = 0.38). IAP remained stable (33% of at risk mothers) until after introduction of the CDC consensus guidelines (59%, p = 0.02).

CONCLUSION

IAP did not fully explain the decline in EOGBS incidence in our center.

Practice trends in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 1995--2000

Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women's health and reproductive concerns during the childbearing years. Newer responsibilities-for example, in primary care, gerontology, and genetics-require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women's health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Neonatal sepsis workups in infants >/=2000 grams at birth: A population-based study

BACKGROUND

Few data are available on the outcome of neonatal sepsis evaluations in an era when intrapartum antibiotic therapy is common.

METHODS

We identified all newborns weighing >/=2000 g at birth who were ever evaluated for suspected bacterial infection at 6 Kaiser Permanente hospitals between October 1995 and November 1996, reviewed their records and laboratory data, and tracked them to 1 week after discharge. We analyzed the relationship between key predictors and the presence of neonatal bacterial infection.

RESULTS

Among 18 299 newborns >/=2000 g without major congenital anomalies, 2785 (15.2%) were evaluated for sepsis with a complete blood count and/or blood culture. A total of 62 (2.2%) met criteria for proven, probable, or possible bacterial infection: 22 (.8%) had positive cultures and 40 (1.4%) had clinical evidence of bacterial infection. We tracked all but 10 infants (.4%) to 7 days postdischarge. There were 67 rehospitalizations (2.4%; 2 for group B streptococcus bacteremia). Among 1568 infants who did not receive intrapartum antibiotics, initial asymptomatic status was associated with decreased risk of infection (adjusted odds ratio [AOR]:.26; 95% confidence interval [CI]:.11-.63), while chorioamnionitis (AOR: 2. 40; 95% CI: 1.15-5.00), low absolute neutrophil count (AOR: 2.84; 95% CI: 1.50-5.38), and meconium-stained amniotic fluid (AOR: 2.23; 95% CI: 1.18-4.21) were associated with increased risk. Results were similar among 1217 infants who were treated, except that maternal chorioamnionitis was not significantly associated with neonatal infection.

CONCLUSIONS

The risk of bacterial infection in asymptomatic newborns is low. Evidence-based observation and treatment protocols could be defined based on a limited set of predictors: maternal fever, chorioamnionitis, initial neonatal examination, and absolute neutrophil count. Many missed opportunities for treating mothers and infants exist.

Chemoprophylaxis of early-onset group B streptococcal disease in 1999

The evolution of the guidelines for selective intrapartum chemoprophylaxis (SIC) of group B streptococcal early-onset disease is reviewed here. To assess the benefits of the risk-based and culture-based strategies for prevention, observational studies since 1996 are summarized. The effect of chorioamnionitis on group B streptococcal early-onset disease, despite SIC, is emphasized. Optimal management remains controversial, and alternative strategies for the selection of women for chemoprophylaxis and for the management of infants are discussed.

The capture rate of at-risk term newborns for early-onset group B streptococcal sepsis determined by a risk factor approach

OBJECTIVE

Currently, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend that health care providers for pregnant women implement 1 of 2 strategies for the potential prevention of early-onset neonatal group B streptococcal sepsis. Both algorithms recommend intrapartum antibiotic chemoprophylaxis for patients delivered of their neonates at <37 weeks' gestation. The basic difference lies in the management of the term pregnancy. One protocol suggests treatment of all patients with term pregnancies with a positive culture for group B Streptococcus obtained at 35 to 37 weeks' gestation. The second approach recommends treatment on the basis of risk factors of membrane rupture of >/=18 hours' duration or intrapartum temperature of >/=38 degrees C. The capture rate of at-risk neonates determined by the risk factor strategy is quoted as being approximately 70%; however, the basis for this percentage was from studies that used slightly different definitions than the current guidelines and never separated the term from the preterm newborn. Our objective was to prospectively collect every case of blood culture-proven early-onset neonatal group B streptococcal sepsis and determine whether risk factors, as currently defined, were present that might have warranted maternal intrapartum antibiotic chemoprophylaxis.

STUDY DESIGN

A prospective study was initiated on July 1, 1987, and completed on December 31, 1996. Every patient that was delivered of a neonate in whom early-onset group B streptococcal sepsis developed was analyzed in detail for possible intrapartum risk factors.

RESULTS

A total of 49 cases of early-onset group B streptococcal sepsis occurred in 46,959 deliveries. Of these 49 newborns, 9 (18%) were delivered at <37 weeks' gestation. The remaining 40 newborns were delivered at term, and only 12 (30%) were delivered with an intrapartum risk factor of either membrane rupture of >/=18 hours' duration or temperature of >/=38 degrees C or both.

CONCLUSIONS

On the basis of the data from this study and the current literature, the risk factor approach with the current guideline recommendations would capture <50% of the term newborns in whom sepsis develops.

Preventing neonatal group B streptococcal disease: cost-effectiveness in a health maintenance organization and the impact of delayed hospital discharge for newborns who received intrapartum antibiotics

OBJECTIVES

To estimate the cost and health benefits of implementing a risk factor-based prevention strategy for early-onset neonatal group B streptococcal (GBS) disease, using baseline assumptions and costs from a health maintenance organization. With the risk factor-based strategy, intrapartum antibiotics (IPAs) would be provided to women with fever, prolonged rupture of membranes, or preterm labor. A second objective was to determine the impact of an increased length of stay for well term infants with mothers who received IPAs.

METHODS

We used decision analysis to compare the costs and benefits of the prevention strategy with usual obstetric practice for a cohort of 100 000 women and their newborn infants. We derived baseline values from a previous study based on chart review and automated cost data from a health maintenance organization in Northern California. In sensitivity analyses, we varied baseline assumptions, including additional costs for observing well term infants who received IPAs.

RESULTS

If adherence to guidelines were 100%, 17% of mothers would receive IPAs at a cost of $490,000; $1.6 million would be saved by preventing 66 GBS cases (64% reduction). The net savings would be $1.1 million and 61 life-years. The net cost is sensitive to the cost of caring for well infants who received IPAs. If each term infant of a mother who received IPAs had 1 more day of observation than other term infants, there would be a net cost of $8.1 million; the cost per GBS case prevented would be $120,000 and the cost per life-year saved would be $130,000.

CONCLUSIONS

Implementation in a health maintenance organization of a risk factor-based strategy to prevent neonatal GBS disease can prevent substantial disease and be cost saving. However, if the length of hospital stay were extended among well term infants whose mothers received IPAs, the strategy would be relatively costly compared with other medical interventions.

Assessment of office-based care of sexually transmitted diseases and vaginitis and antibiotic decision-making by obstetrician-gynecologists

OBJECTIVE

Survey office-based obstetric-gynecologic practitioners regarding their knowledge of infectious disease care and antibiotic use.

METHODS

A survey questionnaire of multiple-choice questions was mailed to Fellows of the American College of Obstetricians and Gynecologists about clinical entities for which recommendations have undergone recent changes or about which there was a lack of consensus in a prior similar survey (Gibbs RS, McGregor JA, Mead PB, et al.: Obstet Gynecol 83:631-636, 1994).

RESULTS

Respondents indicated that oral metronidazole was their most frequent choice to treat bacterial vaginosis. Ampicillin (57%) was used more often than penicillin (39%) for intrapartum group B streptococcus prophylaxis. Azithromycin was preferred (61%) over erythromycin-base (38%) for chlamydia treatment during pregnancy. There were several modes of practice that deviated from accepted care: 27% and 29% did not screen for chlamydia and gonorrhea, respectively, in pregnancy; 17% used cultures for Gardnerella vaginalis to diagnose bacterial vaginosis; 25% considered quinolones to be safe in pregnancy; 93% felt metronidazole should never be used in pregnancy; and the majority (66%) would send a patient treated successfully for pelvic cellulitis home with an oral antibiotic.

CONCLUSION

Respondents' infectious disease knowledge and practices in obstetrics and gynecology is appropriate in treating sexually transmitted diseases, bacterial vaginosis, and group B streptococcus. Numerous deficiencies still exist in screening for sexually transmitted diseases in pregnancy and diagnosing bacterial vaginosis, as well as in the choice of antibiotics to use or avoid for certain infections.

Factors associated with appropriate physician management of sexually transmitted diseases in an urban Canadian center

BACKGROUND AND OBJECTIVES

To explore physicians' management of selected sexually transmitted diseases (STDs), because previous studies suggest that physicians' management practices could be improved.

GOALS

To determine the estimated annual incidence of STD seen by family/general practitioners (FPs), gynecologists (GYNs) and urologists (UROLs), adequacy of STD management practices, and any associations with demographic and other characteristics.

STUDY DESIGN

A self-administered questionnaire was mailed to GYNs, UROLs, and a random sample of FPs in Hamilton, Ontario.

RESULTS

Eighty-one of 102 (79.4%) FPs, 27 of 32 (84.4%) GYNs, and 7 of 8 (87.5%) UROLs responded. Vaginitis, male urethritis, and genital warts in women were the most frequently observed STDs. The treatment of bacterial vaginosis and pelvic inflammatory disease were most frequently at variance with published guidelines.

CONCLUSIONS

Deficiencies exist in physicians' management of both common and potentially serious STD problems.