Universal prenatal HIV screening: are we there yet?

The objectives of this study were to determine the prevalence of and factors associated with prenatal HIV screening and the availability of HIV test results in medical records in Pittsburgh, PA, USA. Three hundred postpartum women were surveyed about demographics and prenatal care provider(s) and practice setting and were asked to recall prenatal HIV screening and reasons for accepting or declining a HIV test. Medical records were reviewed for documentation of HIV results. Overall, 65% of women reported screening. White race, higher annual household income and fewer lifetime sexual partners were independently associated with decreased likelihood of prenatal HIV screening. Provider presentation of screening as standard practice and provider encouragement were associated with prenatal HIV screening. Only 38% of medical records contained HIV results at the time of labour. Universal and routine offering of prenatal HIV screening as standard practice, in conjunction with encouragement from health-care providers, may increase patient acceptability and the uptake of prenatal HIV screening.

Self-collected vaginal swabs for the detection of multiple sexually transmitted infections in adolescent girls.

OBJECTIVE: To evaluate the use of self-collected vaginal swabs to test for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, and to describe the acceptability of this technique to adolescents. DESIGN: Comparison of a new protocol for sexually transmitted infection (STI) testing with the current standard of care, using the same subjects. Survey of attitudes regarding the self-collection technique. SETTING: A juvenile correctional facility in western Pennsylvania. PARTICIPANTS: Convenience sample of 133 detainees, 12-17 years of age. INTERVENTION: Girls were invited to undergo STI screening using a self-collected vaginal swab. Polymerase chain reaction was used to test this specimen for each of the above three infections. Pelvic exams and endocervical testing were performed at the discretion of the physician performing the intake physical, independent of the study. MAIN OUTCOME MEASURES: The number of infections diagnosed using the self-testing protocol, compared to the number diagnosed using standard practices; acceptability of the self-collection technique. RESULTS: Twenty-four percent of sexually active subjects had one or more infections diagnosed by self-testing: 11.3% had C. trachomatis, 8.5% had N. gonorrhoeae, and 11.7% had T. vaginalis. Only 30% of subjects with infections had pelvic exams while detained; therefore 70% of girls with infections would have been missed in the absence of the self-testing option. The self-collection technique was acceptable to 95% of subjects. CONCLUSIONS: STI testing using self-collected vaginal specimens is highly acceptable to adolescent girls, and can dramatically increase the detection rate for these three treatable infections when pelvic exams are not performed.

Self-collection of vaginal swabs for the detection of Chlamydia, gonorrhea, and trichomoniasis: opportunity to encourage sexually transmitted disease testing among adolescents.

BACKGROUND: Many sexually transmitted diseases (STDs) are prevalent among adolescents, yet compliance to undergo STD testing by this population is suboptimal. Efforts to enhance compliance with testing among at-risk youth are needed. GOAL: To determine the feasibility and acceptability of self-collection of vaginal swabs for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among high-school students attending a school health clinic. STUDY DESIGN: Enrolled in the study were 228 female students between the ages of 15 and 19 years. Each student self-collected a single vaginal swab that was tested for C trachomatis, N gonorrhoeae, and T vaginalis by polymerase chain reaction amplification. Acceptability of self-collection of vaginal swabs was assessed. RESULTS: The prevalence of any STD was 18%. Trichomoniasis, chlamydia, and gonorrhea were diagnosed in 10%, 8%, and 2% of students, respectively. Nearly 13% of females who had never previously had a gynecologic examination tested positive for an STD, and 51% of infected students would not have pursued testing by traditional gynecologic examination if self-collection was not offered. Self-collection of vaginal swabs was almost uniformly reported as easy to perform (99%) and preferable to a gynecologic examination (84%). Nearly all (97%) stated that they would undergo testing at frequent intervals if self-testing were available. CONCLUSIONS: Self-collected vaginal swabs for STD testing can be easily implemented in a high-school setting with high acceptability among students, enabling the detection of many STDs that would otherwise remain undetected and untreated.

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians.

PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.

Levels of vaginal secretory leukocyte protease inhibitor are decreased in women with lower reproductive tract infections.

OBJECTIVE: Secretory leukocyte protease inhibitor contributes resistance to primary human immunodeficiency virus infection in the oral cavity. However, the levels of this inhibitor in the genital tract of women with sexually transmitted diseases or vaginitis are not well described. The objective was to determine vaginal inhibitor levels in women with symptomatic and asymptomatic genital infections. STUDY DESIGN: We tested 207 nonpregnant women for Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, Candida species, and bacterial vaginosis by standard methods. A second group of symptom-free pregnant women (N = 231) was also studied. Secretory leukocyte protease inhibitor was measured by enzyme-linked immunosorbent assay, and results were compared by nonparametric methods. RESULTS: Vaginal levels of secretory leukocyte protease inhibitor in both groups were significantly lower in women with any sexually transmitted disease than in those without infection (P<.0001). Patients with bacterial vaginosis and those with bacterial vaginosis with yeast vaginitis also had decreased levels (P<.025). CONCLUSIONS: Levels of secretory leukocyte protease inhibitor in vaginal fluid are decreased in women with lower genital tract infection. This may represent a common mechanism of increasing susceptibility to infection with human immunodeficiency virus.

A comparative trial of imipenem versus ceftazidime in the release of endotoxin and cytokine generation in patients with gram-negative urosepsis. Urosepsis Study Group.

Evidence from in vitro experiments and animal and human studies indicate that antibiotic therapy may induce the release of endotoxin from the outer membrane of Gram-negative bacteria. Antibiotics that bind preferentially to penicillin-binding protein-2 (PBP-2)--such as imipenem--are associated with little release of endotoxin, while antibiotics that preferentially bind to PBP-3--such as ceftazidime--are associated with far greater release of endotoxin. We conducted a randomized, multicenter, double-blind study comparing imipenem to ceftazidime in patients with urinary tract infections caused by Gram-negative bacilli associated with signs and symptoms of systemic inflammation. A total of 33 patients were randomized to receive either imipenem (n = 14) or ceftazidime (n = 19) for initial treatment for urosepsis. No differences in plasma endotoxin, interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha) or urine endotoxin, IL-6 or IL-8 levels were found between the two treatment groups within the first 8 h after antibiotic administration. We conclude that, if differences exist with respect to endotoxin release by these two antimicrobial agents, these differences are not readily demonstrable in this clinical study with carefully defined patients with Gram-negative urinary tract infections.

The infrequent use of office-based diagnostic tests for vaginitis.

OBJECTIVE: This study was undertaken to determine physician use of simple office-based tests in the evaluation of women with vulvovaginal symptoms. STUDY DESIGN: A medical record review of 52 women seeking care at a referral-based vaginitis clinic was performed. The evaluation performed and the care management were recorded for 150 previous physician-provided office visits. RESULTS: A microscopic assessment of vaginal fluid was not performed in 37% of office visits, and 42% of physicians did not perform microscopy as part of any evaluation of vaginitis. Whiff amine tests and measurement of vaginal pH were rarely performed (3% of office visits). Treatment without adequate evaluation of the etiology of the symptoms occurred in 54% of visits in which medication was prescribed. CONCLUSIONS: In our study population the evaluation and care provided to women presenting for evaluation of vulvovaginal symptoms were suboptimal. The use of simple inexpensive office-based tests can optimize the assessment of vaginal infections and should be encouraged.

The use of once-daily dosing of gentamicin in obstetrics and gynecology.

Gentamicin is a widely-used antimicrobial agent for obstetric and gynecologic infections. Renewed excitement in this antibiotic has arisen from recent information supporting less frequent dosing. In this symposium, we will describe the pharmacokinetics of gentamicin and review new information advocating the use of once-daily administration of gentamicin.

The pharmacokinetics of once-daily dosing with gentamicin in women with postpartum endometritis.

OBJECTIVE: To evaluate the pharmacokinetics and cost of once-daily dosing with gentamicin in women with postpartum endometritis. METHODS: Gentamicin in a single daily dose of 4.5 mg/kg was administered intravenously to 10 women with postpartum endometritis. Peak and trough gentamicin levels were measured, and nephrotoxicity and clinical ototoxicity were monitored. Pharmacokinetic data were analyzed, and a cost analysis of once-daily gentamicin administration was performed. RESULTS: The mean elimination constant was 0.105 +/- 0.008 L/h, and the mean volume of distribution was 0.34 +/- 0.07 L/kg. Mean peak gentamicin levels exceeded 11 mg/L, and all trough levels were < 0.3 mg/L. Cost savings of 44% were achieved with once-daily dosing of gentamicin, compared with traditional thrice-daily dosing. CONCLUSIONS: Once-daily dosing with gentamicin in women with postpartum endometritis achieves therapeutic peak levels without drug accumulation. Substantial cost savings are realized with this dosing regimen.

Factors predicting upper genital tract inflammation among women with lower genital tract infection.

We sought to identify factors that discriminate between women with a lower genital tract infection and women with a lower genital tract infection and endometritis. This study enrolled women at risk for or having a lower genital tract infection with Chlamydia trachomatis or Neisseria gonorrhoeae and measured behavioral and clinical factors. Women were identified through contact tracing of male partners, presentation with cervicitis, or presentation with symptoms of pelvic inflammatory disease and classified as (1) having a lower genital tract infection without endometritis, (2) having a lower genital tract infection with endometritis, (3) having no lower genital tract infection with endometritis, and (4) having neither a lower genital tract infection nor endometritis. The primary comparison was between women having a lower genital tract infection without endometritis to women having a lower genital tract infection and endometritis. Women with a lower genital tract infection and endometritis were older and reported a history of more sexually transmitted diseases (70.0% vs. 56.7%), abdominal pain (82.2% vs. 60.0%), and use of barrier methods of contraception (28.9% vs. 8.6%) than women with a lower genital tract infection alone. The regression model found that women with a lower genital tract infection and endometritis were 7.1 times (95% CI = 2.2-23.0) more likely to report abdominal pain and 4.6 times (95% CI = 1.5-14.9) more likely to use barrier methods of contraception than women with a lower genital tract infection alone. These results suggest that behavioral factors, in addition to symptoms, can be used to identify women with and without upper genital tract involvement.

Amniotic fluid defensins: potential markers of subclinical intrauterine infection.

Human neutrophil peptides 1-3 (defensins) are granule constituents released from activated neutrophils. We hypothesized that amniotic fluid (AF) defensin levels are elevated in preterm labor (PTL) patients with subclinical intrauterine infection (IUI). AF samples were obtained from 203 pregnant patients with varying clinical characteristics. Defensin levels were measured by enzyme-linked immunosorbent assay. Median AF defensin levels were fourfold to 24-fold higher in patients with IUI than in preterm and term controls. Among patients with subclinical IUI, the degree of AF defensin elevation was greater in those with a positive AF culture. AF defensin levels increased exponentially with increasing severity of histologic chorioamnionitis. An AF defensin level of > 2,500 ng/mL identified 88% of patients with a positive AF culture, whereas a level of > 400 ng/mL identified 85% of all infected patients. AF defensin levels accurately identify patients with subclinical IUI, as defined by a positive AF culture or placental histology.

Polymerase chain reaction analysis of distal vaginal specimens: a less invasive strategy for detection of Trichomonas vaginalis.

We compared polymerase chain reaction (PCR) analysis of specimens obtained from the distal vagina with wet mount microscopy and culture of specimens from the posterior vaginal fornix. One or all three techniques revealed that 61 (20.3%) of 300 women tested were positive for Trichomonas vaginalis. PCR analysis of distal vaginal specimens detected 56 (91.8%) of 61 infections, while wet mount microscopy and culture detected 49 (80.3%) of 61 infections. Results of this study may impact the approach to testing for T. vaginalis by eliminating the requirement of a vaginal speculum examination. The distal vagina is an appropriate testing site for T. vaginalis by PCR analysis.

Oral contraception and the recognition of endometritis.

OBJECTIVE: Oral contraceptive use has been associated with a lower risk of symptomatic pelvic inflammatory disease but a higher risk of chlamydial cervicitis. To explain these seemingly contradictory findings, we asked whether oral contraceptive use was more common among women with unrecognized endometritis than among women with recognized endometritis. STUDY DESIGN: A multicenter case-control study was performed. Women without signs of pelvic inflammatory disease were ascertained through contact tracing of partners with sexually transmitted diseases or through presentation with cervicitis. Women with symptomatic pelvic inflammatory disease met a set of standard clinical criteria. We compared the 43 cases without signs of pelvic inflammatory disease but with endometritis ("unrecognized endometritis") with the 111 controls with recognized pelvic inflammatory disease and endometritis ("recognized endometritis"). RESULTS: Women with unrecognized endometritis were 4.3 times (95% confidence interval 1.6 to 11.7) more likely than women with recognized endometritis to use oral contraceptives. CONCLUSION: Future studies need to fully characterize the risks and benefits of oral contraceptives in relation to sexually transmitted diseases.

The vaginal introitus: a novel site for Chlamydia trachomatis testing in women.

OBJECTIVE: We evaluated the vaginal introitus as a noninvasive sampling site for testing for Chlamydia trachomatis. STUDY DESIGN: Swabs from the vaginal introitus were obtained from 300 women attending a sexually transmitted diseases clinic and tested for the presence of Chlamydia trachomatis by polymerase chain reaction. Additionally, 200 of these women self-collected an additional introitus swab and submitted a urine sample for polymerase chain reaction testing. These samples were compared with polymerase chain reaction, culture, and enzyme immunoassay for Chlamydia trachomatis from endocervical samples and polymerase chain reaction and culture on urethral swabs. Patients were determined to be infected with Chlamydia trachomatis by a positive culture result from any site or a confirmed positive result by polymerase chain reaction with an alternate primer. RESULTS: The sensitivity of vaginal introitus swabs obtained by health care providers for the detection of urogenital Chlamydia trachomatis was 92% (95% confidence interval 83 to 100), greater than polymerase chain reaction, culture, or enzyme immunoassay of the cervix or urethra. The sensitivity by polymerase chain reaction of patient self-collected swabs was 81%. Sampling of the vaginal introitus, by both health care workers and the patient herself, performed as well as commonly used diagnostic tests that require vaginal speculum examination. The sensitivity of polymerase chain reaction testing of urine samples was 73%. CONCLUSION: The vaginal introitus represents a highly effective noninvasive specimen collection site for Chlamydia trachomatis testing by polymerase chain reaction. Self-collection of introitus specimens may revolutionize sexually transmitted disease testing by eliminating the need for a speculum examination by skilled health care personnel.

Diagnosis of male Chlamydia trachomatis urethritis by polymerase chain reaction.

BACKGROUND AND OBJECTIVES: A quick and highly sensitive diagnostic test would be valuable in the diagnosis of Chlamydia trachomatis. GOAL OF THIS STUDY: We compared a new polymerase chain reaction (PCR) technique to Chlamydiazyme (Abbott, North Chicago, IL) in the detection of male chlamydial urethritis, and evaluated the performance of PCR on urine samples. STUDY DESIGN: Urethral samples for analysis by PCR and Chlamydiazyme were obtained from 474 unselected patients attending a sexually transmitted diseases (STD) clinic. Urine samples were analyzed by PCR from 362 of these patients. RESULTS: Twenty seven (5.7%) urethral samples were positive by Chlamydiazyme, while 64 (13.5%) were positive by PCR. After resolution of discrepant results, the sensitivity of PCR on urethral swabs was 98.4% and the specificity was 99.0%, with positive and negative predictive values of 93.8% and 99.8%, respectively. These same measures for Chlamydiazyme were 43.5%, 100%, 100%, and 92.2%, respectively. The sensitivity of PCR on urine samples was 87.1%, the specificity was 98.0%, and the positive and negative predictive values were 90.0% and 97.4%, respectively. CONCLUSIONS: This PCR test is more sensitive than Chlamydiazyme in detecting male urethral chlamydial infections in an STD clinic population, and appears to be equally efficacious on urethral swabs and urine samples.

Torulopsis glabrata pelvic abscess and fungemia.

BACKGROUND: Serious infections caused by Torulopsis glabrata, once rarely encountered, have become common over the last 3 decades. The most frequent manifestations of serious fungal infections include septicemia, endocarditis, hepatosplenic infections, and meningitis. We report a case of fungemia and pelvic abscess caused by T glabrata following gynecologic surgery. CASE: A 43-year-old woman developed fever, abdominal pain, and abdominal distention following a total abdominal hysterectomy and right salpingo-oophorectomy. Empirical treatment with broad-spectrum antimicrobial agents was not successful. Three sets of blood cultures were positive for T glabrata, and radiologic investigations revealed pelvic and lesser sac fluid collections. Cultures of the pelvic abscess grew T glabrata. Treatment was changed to amphotericin B, with complete clinical recovery. CONCLUSION: Serious T glabrata infections are rare following gynecologic surgery, especially in immunocompetent patients. Given the morbidity and mortality associated with these infections, aggressive treatment with amphotericin B and drainage of abscesses is warranted.

Rapid polymerase chain reaction-based test for the detection of female urogenital chlamydial infections.

OBJECTIVE: The purpose of this study was to evaluate the Amplicor Chlamydia trachomatis Test (Roche Molecular Systems, Branchburg, NJ), a polymerase chain reaction (PCR)-based technique, as a screening test for the detection of female urogenital C. trachomatis infections, comparing it to an enzyme immunoassay method. METHODS: Endocervical specimens for PCR and Chlamydiazyme (Abbott Laboratories, North Chicago, IL) analysis were obtained from 328 unselected patients at the outpatient Sexually Transmitted Diseases Clinic at the Allegheny County Health Department, Pittsburgh, PA. In addition, urethral swabs for PCR analysis were obtained from 256 of these patients. RESULTS: By PCR analysis, the prevalence of urogenital chlamydial infections was 15.6% and that of cervical chlamydial infections was 10.7%. The sensitivity of PCR in the detection of endocervical chlamydial infections was 89.7% and the specificity was 100%. The positive and negative predictive values of PCR were 100% and 99%, respectively. The sensitivity of Chlamydiazyme in the detection of cervical infections was 61.5% and the specificity was 99.7%, with a positive predictive value of 96.0%. Among all patients with urogenital chlamydial infections, concomitant infections in the urethra and cervix occurred in 52.5%, whereas the urthra or cervix was solely infected in 35.0% and 12.5%, respectively. CONCLUSIONS: This PCR-based technique is a rapid screening tool for the diagnosis of urogenital chlamydial infections and is more sensitive than Chlamydiazyme for endocervical infections in a sexually transmitted disease clinic population.

Progress in the management of tuboovarian abscesses.

The last 20 years have witnessed remarkable improvements in the treatment of tuboovarian abscesses. Gone are the days of significant mortality associated with ruptured and unruptured TOAs. Broad-spectrum antibiotics have enabled patients to be treated solely with medical therapy, avoiding the need for surgery. Operative intervention is still necessary in 25% of cases of unruptured TOAs, but the combination of conservative surgical procedures, such as unilateral salpingo-oophorectomy, and broad-spectrum antimicrobial agent therapy have reduced the need for total abdominal hysterectomy with bilateral salpingo-oophorectomy greatly. Although fertility after TOAs is compromised significantly, new advances in reproductive technology, including in vitro fertilization and donor egg transplantation, represent reproductive options for these women. Percutaneous drainage and laparoscopic treatment of TOAs are becoming popular treatment options, but prospective studies urgently are needed to assess their efficacy.