Background.

Infants born to mothers who are colonized with group B streptococcus (GBS) but received <4 hours of intrapartum antibiotic prophylaxis (IAP) are at-risk for presenting later with sepsis. We assessed if <4 hours of maternal IAP for GBS are associated with an increased incidence of clinical neonatal sepsis. Materials and Methods. A retrospective cohort study of women-infant dyads undergoing IAP for GBS at ≥37-week gestation who presented in labor from January 1, 2003 through December 31, 2007 was performed. Infants diagnosed with clinical sepsis by the duration of maternal IAP received (< or ≥4-hours duration) were determined.

Results.

More infants whose mothers received <4 hours of IAP were diagnosed with clinical sepsis, 13 of 1,149 (1.1%) versus 15 of 3,633 (0.4%), P = .03. Multivariate logistic regression analysis showed that treatment with ≥4 hours of IAP reduced the risk of infants being diagnosed with clinical sepsis by 65%, adjusted relative risk 0.35, CI 0.16-0.79, and P = .01.

Conclusion.

The rate of neonatal clinical sepsis is increased in newborns of GBS colonized mothers who receive <4 hours compared to ≥4 hours of IAP.

While 6- to 12-month courses of isoniazid for tuberculosis prevention are considered safe in pregnant women, the effects of longer-term isoniazid prophylaxis or isoniazid in combination with antiretroviral therapy (ART) are not established in human-immunodeficiency-virus-(HIV-) infected women who experience pregnancy during the course of therapy.Nested study of pregnancy outcomes among HIV-infected women participating in a placebo-controlled, TB-prevention trial using 36 months daily isoniazid. Pregnancy outcomes were collected by interview and record review.Among 196 pregnant women, 103 (52.6%) were exposed to isoniazid during pregnancy; all were exposed to antiretroviral drugs. Prior to pregnancy they had received a median of 341 days (range 1-1095) of isoniazid. We observed no isoniazid-associated hepatitis or other severe isoniazid-associated adverse events in the 103 women. Pregnancy outcomes were 132 term live births, 42 premature births, 11 stillbirths, 8 low birth weight, 6 spontaneous abortions, 4 neonatal deaths, and 1 congenital abnormality. In a multivariable model, neither isoniazid nor ART exposure during pregnancy was significantly associated with adverse pregnancy outcome (adjusted odds ratios 0.6, 95% CI: 0.3-1.1 and 1.8, 95% CI 0.9-3.6, resp.).Long-term isoniazid prophylaxis was not associated with adverse pregnancy outcomes, such as preterm delivery, even in the context of ART exposure.

To determine the validity of a novel Group B Streptococcus (GBS) diagnostic assay for the detection of GBS in antepartum patients.Women were screened for GBS colonization at 35 to 37 weeks of gestation. Three vaginal-rectal swabs were collected per patient; two were processed by traditional culture (commercial laboratory versus in-house culture), and the third was processed by an immunoblot-based test, in which a sample is placed over an antibody-coated nitrocellulose membrane, and after a six-hour culture, bound GBS is detected with a secondary antibody.356 patients were evaluated. Commercial processing revealed a GBS prevalence rate of 85/356 (23.6%). In-house culture provided a prevalence rate of 105/356 (29.5%). When the accelerated GBS test result was compared to the in-house GBS culture, it demonstrated a sensitivity of 97.1% and a specificity of 88.4%. Interobserver reliability for the novel GBS test was 88.2%.The accelerated GBS test provides a high level of validity for the detection of GBS colonization in antepartum patients within 6.5 hours and demonstrates a substantial agreement between observers.

To investigate adherence to the 2002 Centers for Disease Control and Prevention (CDC) guidelines for perinatal group B streptococci (GBS) prevention in penicillin-allergic obstetric patients.This is a retrospective cohort study of penicillin-allergic obstetric patients who tested positive for GBS and delivered at our institution in 2010. Electronic medical records were reviewed for the nature of the penicillin allergy, documentation of having previously tolerated cephalosporins, gestational age at delivery, type of delivery, antimicrobial sensitivity testing, and antibiotics administered. Antimicrobial sensitivity testing and "appropriate" antibiotic choice, which was determined using 2002 CDC guidelines, were analyzed.Intrapartum antibiotic prophylaxis was administered in 97.8% (95% confidence interval [CI] 93.5-99.5%) of patients, but it was considered appropriate in only 62.2% (95% CI 53.8-70.0%) of patients. Clindamycin was the most commonly used antibiotic, but 26.4% (95% CI 16.3-39.7%) of patients who received clindamycin did not have confirmation of susceptibility via antimicrobial sensitivity testing. Overall, the sensitivity testing was performed in only 65.5% (95% CI 56.2-73.7%) of patients in whom it was indicated.Compliance with CDC guidelines for performing antimicrobial sensitivity testing and choosing an appropriate antibiotic in GBS-positive penicillin-allergic women continues to be suboptimal. Institution of measures to increase adherence is necessary.

We have identified a CD8⁺CXCR5⁺ T cell that prevents the development of oviduct dilation following C. muridarum genital infection. Phenotypic studies show that CD8⁺CXCR5⁺ cells express markers of T regulatory cells (FoxP3, CD25, and GITR) but do not express a necessary component of cytotoxic cells (perforin). Cxcr5⁻/⁻ mice have significantly lower numbers of CD8⁺ cells and lack the CD8⁺CXCR5⁺ population while the total number of CD4⁺ cells is equivalent between mouse strains. The transfer of CD8⁺ splenocytes from WT mice reduces the oviduct dilation seen in Cxcr5⁻/⁻ mice following C. muridarum infection. Future studies will investigate the mechanism by which this cell type regulates genital tract pathology.

Objective.

To examine practice patterns for diagnosis and treatment of chorioamnionitis among US obstetricians. Study Design. We distributed a mail-based survey to members of the American College of Obstetricians and Gynecologists, querying demographics, practice setting, and chorioamnionitis management strategies. We performed univariable and multivariable analyses.

Results.

Of 500 surveys distributed, 53.8% were returned, and 212 met study criteria and were analyzed. Most respondents work in group practice (66.0%), perform >100 deliveries per year (60.0%), have been in practice >10 years (77.3%), and work in a nonuniversity setting (85.1%). Temperature plus one additional criterion (61.3%) was the most common diagnostic strategy. Over 25 different primary antibiotic regimens were reported, including use of a single agent by 30.0% of respondents. A wide range of postpartum antibiotic duration was reported from no postpartum treatment (34.5% after vaginal delivery, 11.3% after cesarean delivery) to 48 hours of postpartum treatment (24.7% after vaginal delivery, 32.1% after cesarean delivery). No practitioner characteristic was independently associated with diagnostic or therapeutic strategies in multivariable analysis.

Conclusion.

There is a wide variation in contemporary clinical practices for the management of chorioamnionitis. This may represent a dearth of level I evidence. Future prospective clinical trials may provide more evidence-based practice recommendations for diagnosis and treatment of chorioamnionitis.

Recent studies suggest that acquisition of HIV-1 infection during pregnancy and breastfeeding is associated with a high risk of HIV mother-to-child transmission. This study evaluates risk factors associated with HIV acquisition during pregnancy in women delivering at a large metropolitan medical facility located in the south of Brazil. From February to August 2009, our group conducted a cross-sectional study assessing women's risk for HIV acquisition by administering an oral survey to peripartum women. Of 2465 participants, 42% (n = 1046) knew that partner had been tested for HIV. During pregnancy, 82% (n = 2022) of participants never used condoms; yet 97% (n = 2399) practiced vaginal sex. Multivariate logistic regression analysis showed that patients with more years of education, in a relationship for more than 1 year, and who knew their own HIV status were more likely to know their partners' HIV status (P < 0.05). Those who were in relationship for more than 1 year and were married/living together were more likely to be comfortable discussing HIV testing with partners (P < 0.05). In conclusion, women in Brazil are at risk of HIV-infection during pregnancy as they remain sexually active, often do not know their sexual partner's HIV status, and have minimal condom use.

In 1999, prevention of mother-to-child transmission (pMTCT) using antiretrovirals was introduced in the Dominican Republic (DR). Highly active antiretroviral therapy (HAART) was introduced for immunosuppressed persons in 2004 and for pMTCT in 2008. To assess progress towards MTCT elimination, data from requisitions for HIV nucleic acid amplification tests for diagnosis of HIV infection in perinatally exposed infants born in the DR from 1999 to 2011 were analyzed. The MTCT rate was 142/1,274 (11.1%) in 1999-2008 and 12/302 (4.0%) in 2009-2011 (P < .001), with a rate of 154/1,576 (9.8%) for both periods combined. This decline was associated with significant increases in the proportions of women who received prenatal HAART (from 12.3% to 67.9%) and infants who received exclusive formula feeding (from 76.3% to 86.1%) and declines in proportions of women who received no prenatal antiretrovirals (from 31.9% to 12.2%) or received only single-dose nevirapine (from 39.5% to 19.5%). In 2007, over 95% of DR pregnant women received prenatal care, HIV testing, and professionally attended delivery. However, only 58% of women in underserved sugarcane plantation communities (2007) and 76% in HIV sentinel surveillance hospitals (2003-2005) received their HIV test results. HIV-MTCT elimination is feasible but persistent lack of access to critical pMTCT measures must be addressed.