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1.  Intrapartum Antibiotic Prophylaxis and Early-Onset Neonatal Sepsis Patterns 
Objective: To compare the relative effects of intrapartum antibiotic prophylaxis regimens on patterns of early-onset neonatal sepsis.
Methods: We performed an historical cohort study of 17 187 infants born at our center from September 1993 to February 2000. A risk-based strategy was employed prior to July 1996 and a screening-based strategy was utilized thereafter. Ampicillin was utilized prior to March 1995 and penicillin was used thereafter.
Results: There were 75 cases of neonatal sepsis, 34 (4.10/1000) in the risk-based era and 41 (4.63/1000) in the screening-based era (p = 0.62). There were fewer ampicillin-resistant isolates during the risk-based than the screening-based era (32 versus 61%; p = 0.014). The only significant change in organism-specific sepsis rates was an increase in the rate of infection caused by coagulase-negative staphylococci in the screening-based era (0.36 versus 1.46/1000; p = 0.018), but 75% of infants infected with these organisms were not exposed to ß-lactam antibiotics within 72 h prior to delivery. For the risk- and screening-based eras, respectively, the rates of Gram-negative sepsis (1.21 versus 1.46/1000; p = 0.65) and the proportions of Gram-negative pathogens that were ampicillin-resistant (70 versus 77%; p = 1.0) were similar. The drug employed for prophylaxis did not appear to affect the pattern of sepsis cases.
Conclusion: In our patient population, coagulase-negative staphylococci have become the most common cause of early-onset neonatal sepsis. The cause of this shift in pathogen prevalence is uncertain and seemingly unrelated to intrapartum antibiotic exposure.
PMCID: PMC1852291  PMID: 15108869
2.  Is Perioperative Hypothermia a Risk Factor for Post-Cesarean Infection? 
Objective: To determine whether hypothermia during Cesarean delivery is a risk factor for postoperative infection.
Methods: An historical cohort investigation was conducted on all women delivered by Cesarean at our center during 2001. Initial recovery-room temperature, taken via the oral or axillary route, was used as a surrogate for intraoperative temperature. Adding 0.5°C to axillary temperatures generated oral temperature equivalents. Women with chorioamnionitis were excluded, as were those with an initial recovery-room temperature that exceeded 37.9°C or was recorded more than 20 minutes after the end of surgery. Prophylactic antibiotics (cefazolin, 1 g) were given during Cesarean delivery.
Results: A total of 42 women (7.6%) were diagnosed with postoperative infections. Infections included endometritis (n= 25), wound abscess (n = 7), wound cellulitis (n = 7) and urinary tract infection (UTI) (n = 4). No cases of septic pelvic thrombophlebitis or pelvic abscess occurred. One woman had both endometritis and a UTI. Mean temperatures were higher, rather than lower, for women who subsequently had postoperative infections compared with those who did not (36.4 ± 0.8°Cvs. 35.9 ± 0.7°C; p < 0.001). Mean temperatures for the various postoperative infections were as follows: endometritis, 36.5 ± 0.8°C (p < 0.001 vs. uninfected group); wound abscess 36.0 ± 0.8°C (p = 0.63); wound cellulitis, 36.3 ± 0.6°C (p = 0.14); UTI, 36.7 ± 0.9°C (p = 0.04).
Conclusions: Women who develop post-Cesarean infections have higher initial recovery-room temperatures than those who do not develop such infections. This suggests the presence of subclinical infection at the time of Cesarean. Evaluating whether intraoperative warming has any role during Cesarean delivery requires a randomized clinical trial.
PMCID: PMC1852275  PMID: 14627212
3.  Antimicrobial susceptibility of Gram-negative uropathogens isolated from obstetric patients. 
OBJECTIVE: To evaluate the antimicrobial susceptibility of Gram-negative uropathogens isolated from pregnant women. METHODS: We performed a snapshot cohort study of women receiving care in the University of Florida prenatal clinics during March 2000. Subjects with asymptomatic bacteriuria or cystitis were identified and the antimicrobial susceptibility of each pathogen was recorded. Data were analyzed using chi-square, Fisher's exact test and ninety-five percent confidence intervals, as appropriate. RESULTS: Ninety-five positive cultures were identified. Isolates were more often susceptible to trimethoprim-sulfamethoxazole (TMP-SMX) (87%) and nitrofurantoin (89%) than to ampicillin (72%) (p < 0.03). Escherichia coli accounted for 71 (75%) cases and was more often susceptible to nitrofurantoin (100%) than to TMP-SMX (87%) (p < 0.01). Proteus isolates were all susceptible to TMP-SMX and resistant to nitrofurantoin (p < 0.01). CONCLUSIONS: Both TMP-SMX and nitrofurantoin are superior to ampicillin for empiric treatment of lower urinary tract infection in pregnant women. Nitrofurantoin is superior to TMP-SMX for treatment of infections caused by E. coli. For suspected or confirmed cases caused by Proteus organisms, TMP-SMX is the preferred agent.
PMCID: PMC1784614  PMID: 12625967
4.  Performance Characteristics of Putative Tests for Subclinical Chorioamnionitis 
Objective: To evaluate amniotic fluid glucose, matrix metalloproteinase (MMP)-9, interleukin (IL)-6, and IL-12 for diagnosing subclinical chorioamnionitis in women with preterm labor.
Methods: Forty-four women in preterm labor at 22–35 weeks gestation with suspected subclinical chorioamnionitis underwentamniocentesis.Amniotic fluid analysis included Gram stain, culture, and determination of glucose, MMP-9, IL-6, and IL-12 concentrations. Median values of these analytes were compared using the Mann-Whitney U test. Sensitivity, specificity, and positive and negative predictive values were calculated for tests using a positive amniotic fluid culture or delivery within 24 hours as the key outcome variables
Results: Amniotic fluid concentrations of glucose, MMP-9, and IL-6 correlated closely with positive culture or delivery within 24 hours. IL-12 concentrations did not correlate with either a positive culture or delivery within 24 hours.
Conclusions: Amniotic fluid glucose, MMP-9, and IL-6 reliably predict microbial invasion of the amniotic cavity or imminent delivery. IL-12 values did not correlate with amniotic fluid culture results or imminent delivery.
PMCID: PMC1784661  PMID: 11916177
5.  Varicella Vaccine 
PMCID: PMC2364467  PMID: 18476068
6.  Ethical Issues Associated With Routine Screening and Prophylaxis for Group B Streptococcus in Pregnancy 
An increased awareness of the impact of group B streptococcus (GBS) infection on neonatal outcome has prompted several seemingly discordant committee recommendations. Intrapartum antibiotics are effective in reducing the risk of neonatal morbidity when administered to a colonized woman who has a clinical condition that places her neonate at high risk for early-onset sepsis. However, less is known about the efficacy of prophylactic antibiotics in the colonized woman who does not have obvious risk factors. Some authorities have suggested that providers refrain from administering intrapartum antibiotics to colonized women who do not have any of these risk factors, primarily due to concerns about potential adverse reactions, selection of resistant pathogens, and cost-effectiveness. These recommendations may conflict with the desires of an informed woman who weighs the real, albeit low, risk for serious neonatal disease against the lower perceived risk of adverse maternal sequelae from allergic reactions to the antimicrobial agents. Selective prophylaxis for GBS disease that is limited to the colonized parturient with risk factors has the potential for creating conflict because maternal beneficence-based obligations of the physician may be at odds with maternal autonomy-based obligations. We believe that, given all currently available information, providers have a moral obligation to discuss GBS screening and treatment issues with patients. The potential for conflict between patient and physician at the time of delivery can be minimized through the use of preventive ethics, allowing patients to develop advance directives regarding intrapartum management within the confines of reasonable and cost-effective care. Until a consensus is reached among experts, the most prudent approach would be to address such issues proactively and individualize care based upon the overall estimation and anticipation of risk as well as the patient's specific desires.
PMCID: PMC2364458  PMID: 18476063
7.  Granulocyte Colony-Stimulating Factor in Amniotic Fluid 
Objective: The purpose of this study was to determine if granulocyte colony-stimulating factor (G-CSF) is normally present in amniotic fluid and then to determine if amniotic-fluid G-CSF levels are affected by labor and intrauterine infection.
Methods: Amniotic fluid was collected from 35 patients in 4 groups: no labor, early labor, late labor, and labor plus chorioamnionitis. G-CSF levels were measured by enzyme-linked immunosorbent assay (ELISA).
Results: The mean amniotic-fluid G-CSF concentrations prior to labor were lower than during labor (0.49 ± 0.25 ng/ml for prior to labor vs. 1.83 ± 1.0 ng/ml for labor, P < 0.001). With chorioamnionitis, the mean levels were elevated compared with normal labor (25.0 ± 4.8 ng/ml for chorioamnionitis vs. 1.83 ± 1.0 ng/ml for normal labor, P < 0.0001). In early and late labor, G-CSF was higher than prior to labor (0.49 ± 0.25 ng/ml for no labor vs. 1.48 ± 1.0 ng/ml for early labor, P < 0.02, vs. 2.2 ± 0.8 ng/ml for late labor, P < 0.0005). The mean concentrations in early and late labor were not different.
Conclusions: G-CSF is present in amniotic fluid and increased with labor. When labor is complicated by chorioamnionitis, G-CSF is significantly elevated.
PMCID: PMC2364441  PMID: 18476037
8.  Incidence of Chorioamnionitis in Patients With Meconium-stained Amniotic Fluid 
Objective: The goal of this study was to determine if meconium staining of the amniotic fluid (MSAF) is a marker for chorioamnionitis.
Methods: In a retrospective, case-control investigation, we studied 100 patients with MSAF. Each patient was matched with a control who delivered during the same period but did not have MSAF. Subjects and controls were matched for age, parity, gestational age, mode of delivery, duration of rupture of membranes (ROM), length of internal monitoring, and number of examinations before and after ROM. The incidence of chorioamnionitis in controls and study patients was compared. The diagnosis of chorioamnionitis was based on clinical examination.
Results: Thirteen of the 200 patients [6.5%, 95% confidence interval (CI), 2.5–10.5%] developed chorioamnionitis. Of the 100 women with MSAF, 10 (10%, 95% CI, 4–16) were infected compared with only 3 controls (3%, 95% CI, 0–6, P = 0.04). The odds ratio (OR) for this comparison was 3.3, and the 95% CI was 1.02–10.63.
Conclusions: MSAF is associated with an increased frequency of chorioamnionitis. Several factors could explain this association. Infection may cause fetal stress, leading to the release of meconium. MSAF may enhance the growth of bacteria by providing a rich medium of essential nutrients or growth stimulants. MSAF also may impair the host immune system so that chemotaxis or phagocytosis is diminished, thus allowing accelerated growth of microorganisms.
PMCID: PMC2364391  PMID: 18475394
9.  Role of Bacterial Vaginosis in Peripartum Infections 
Objective: The purpose of this prospective investigation was to determine if the presence of bacterial vaginosis (BV) at the time of delivery was associated with the development of maternal and neonatal infection.
Methods: Vaginal fluid was collected from 390 laboring patients. Smears of the vaginal secretions were gram stained, and slides were scored and interpreted as normal, intermediate, and BV based on Gram's stain criteria. Results of the Gram's stains were correlated with the clinical diagnoses of chorioamnionitis, endometritis, and neonatal sepsis.
Results: Eighty-eight percent of patients were term and 12% were preterm. The overall prevalence of BV was 30%. The frequency of BV was similar in both term and preterm women. BV was significantly more prevalent among nonwhites than whites (37% vs. 25%, P = 0.005). Maternal characteristics such as mean age, parity, status of the membranes, mean duration of labor, mean duration of ruptured membranes, mean length of fetal monitoring, mean number of vaginal examinations, and mode of delivery were similar in patients with BV, intermediate, and normal Gram's stains. Forty-seven (12%) women developed peripartum infection. The frequencies of chorioamnionitis or endometritis in women with BV or intermediate Gram's stains were 19/116 (16.4%) and 11/63 (17.5%), respectively. The frequency in each of the 2 groups was significantly increased compared with the rate in women with normal Gram's stains: 17/211 (8.1%), [P = 0.034, OR = 2.0 (95% CI, 1.07–3.73) for BV and P = 0.054, OR = 2.1 (95% CI, 1.12–3.94) for intermediate Gram's stain]. The incidence of suspected or confirmed neonatal infection was significantly higher in mothers with intermediate Gram's stains compared with mothers with normal Gram's stains (P = 0.02, OR = 2.18, 95% CI, 1.12–3.94), while no difference in incidence was observed between mothers with BV and normal Gram's stains (P > 0.05). The rate of neonatal infection directly correlated with maternal group B streptococcal colonization rather than with BV.
Conclusions: In this population, patients with BV and intermediate Gram's stains had an increased frequency of peripartum infection.
PMCID: PMC2364380  PMID: 18475388
10.  Assessment of the Value of Routine Blood Cultures in the Evaluation and Treatment of Patients With Chorioamnionitis 
Objective: The objective of this investigation was to determine the usefulness of blood cultures in evaluating patients with chorioamnionitis who were treated in accordance with a specific antibiotic protocol.
Methods: We reviewed the records of 539 patients with chorioamnionitis who delivered at our facility over a 3 year period (July 1, 1989–June 30, 1992). Patients had one set of aerobic and anaerobic blood cultures at the time of their initial assessment. They were treated initially with ampicillin or vancomycin plus gentamicin. Those who required cesarean delivery also received clindamycin postoperatively. Patients who had a poor initial response to therapy were treated empirically with selected antibiotics targeted against likely resistant organisms until the results of bacteriologic cultures were available. Bacteremic patients had repeat blood cultures while on therapy. We analyzed the medical records to determine the frequency with which blood culture results led to meaningful changes in patient management. We also compared the duration of febrile morbidity in bacteremic vs. nonbacteremic patients.
Results: Thirty-nine of 538 patients (7.2%, 95% confidence interval [CI] 5.2–9.2%) had positive blood cultures. In only one patient did the result of the blood culture definitively alter therapy. This patient had a fever of unknown origin, and the finding of a positive blood culture ultimately led to the diagnosis of chorioamnionitis. The mean duration of febrile morbidity was not significantly different in bacteremic vs. nonbacteremic patients (2.03 vs. 1.74 days). None of the repeat blood cultures was positive. The cost of blood cultures in the study population was $72,759.00.
Conclusions: The routine use of blood Cultures in the assessment of patients with chorioamnionitis rarely provides information that justifies a change in clinical management when patients are treated in accordance with the specific antibiotic protocol outlined in this investigation.
PMCID: PMC2364378  PMID: 18475375
11.  Cytomegalovirus Infection in Pregnancy 
Cytomegalovirus (CMV) infection is of great importance to obstetrician-gynecologists because maternal infection is relatively common and can result in severe injury to the fetus. The greatest risk to the fetus occurs when the mother develops a primary CMV infection in the first trimester. Forty to 50% of infants delivered to mothers with primary CMV infections will have congenital infections. Of these neonates, 5–18% will be overtly symptomatic at birth. Approximately 30% of severely infected infants die, and 80% have severe neurologic morbidity. Eighty-five to 90% of infants will be asymptomatic, and 10–15% of these babies subsequently have sequelae such as visual and auditory defects. If the mother develops a recurrent or reactivated CMV infection during pregnancy, the risk of a severe congenital infection is very low. Perinatal infection, as opposed to congenital infection, may result from exposure to the virus during delivery or lactation and rarely leads to serious sequelae. Antimicrobial therapy and immunotherapy for CMV are, at present, unsatisfactory. Therefore, all patients, pregnant women in particular, must be educated about preventive measures.
PMCID: PMC2364375  PMID: 18475382
12.  Varicella in Pregnancy: Five Priorities for Clinicians 
PMCID: PMC2364338  PMID: 18475338
13.  Sheathing of the Endovaginal Ultrasound Probe: Is It Adequate? 
The purpose of this prospective investigation was to compare two methods for sheathing of the endovaginal ultrasound-probe. The study was conducted over a 7-month period in 1991–1992. In the first half of the investigation, latex examination gloves were used to sheath the endovaginal probe; during the second half of the investigation, latex condoms were used. Following the ultrasound examination, the probes were inspected for gross contamination by the ultrasonographer. The sheaths were then tested for perforations by filling them with water to twice their usual volume and observing for leaks. Fifty unused gloves and condoms were similarly tested to determine the prevalence of preexisting defects. One hundred twenty-eight gloves and 102 condoms from patients were tested. Four gloves (3.1%, 95% C.I. 1.6–4.6%) and seven condoms (6.9%, 95% C.I. 4.4–9.4%) had perforations (NS). When the probe was covered by a glove, one instance of visible contamination occurred (0.78%, 95% C.I. 0–1.6%) compared with eight instances when the probe was covered with a condom (7.8%, 95% C.I. 5.2–10.4%, P < .007). The prevalance of preexisting defects in the 50 unused gloves was 2%, which is not significantly different from the prevalence in used gloves. There were no defects in the 50 unused condoms compared with 7 in the used condoms (P = .057). Visible contamination of the endovaginal probe with blood or genital tract secretions is more likely when condoms are used as sheaths. However, even gloves provide imperfect coverage of the probe, illustrating the need for thorough decontamination of the endovaginal instrument after each use.
PMCID: PMC2364667  PMID: 18476204
14.  Effect of Isoflurane on Neutrophil Phagocytic Function During Pregnancy 
Objective: General anesthesia has been considered an independent risk factor for postcesarean infection, but the mechanism for this association has not been delineated. The purpose of this prospective investigation was to determine if phagocytic response of neutrophils was impaired by in vitro exposure to isoflurane, a commonly used anesthetic.
Methods: Twelve milliliter venous blood samples were withdrawn from 18 term patients during labor. Neutrophils were separated by Ficoll gradient centrifugation. Aliquots of 2 × 106 neutrophils/ml were exposed to anesthesia using an airtight modular incubator chamber through which a 0.5% isoflurane:50% N2O + 50% O2 mixture flowed at a rate of 4 l/min for 90 min at 37℃. Neutrophils were assayed for phagocytosis by incubation with Escherichia coli conjugated with fluorescein isothiocyanate for 30 min at 37℃. Phagocytosis was assessed by flow cytometry. Neutrophils from the same patient that were not exposed to anesthesia served as controls.
Results: The mean percentage of phagocytizing neutrophils in the isoflurane-treated group was 82.8 ± 24 compared to 83.5 ± 22 in the control group. The difference between the two groups was not significant.
Conclusions: In vitro exposure to the general anesthetic isoflurane for 90 min does not significantly alter the phagocytic capacity of neutrophils.
PMCID: PMC2364300  PMID: 18475326

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