Gweneth B. Lazenby

An Association Between Trichomonas vaginalis and High-Risk Human Papillomavirus in Rural Tanzanian Women Undergoing Cervical Cancer Screening

OBJECTIVE The goal of this study was to determine the prevalence of vaginitis and its association with high-risk human papillomavirus (HR HPV) in women undergoing cervical cancer screening in rural Tanzania. METHODS For the purpose of cervical cancer screening, cytology and HR HPV polymerase chain reaction data were collected from 324 women aged between 30 and 60 years. Microscopy and gram stains were used to detect yeast and bacterial vaginosis. Cervical nucleic acid amplification test specimens were collected for the detection of Trichomonas vaginalis (TV), Chlamydia trachomatis, and Neisseria gonorrhoeae. RESULTS The majority of women were married (320 of 324) and reported having a single sexual partner (270 of 324); the median age of participants was 41 years. HR HPV was detected in 42 participants. Forty-seven percent of women had vaginitis. Bacterial vaginosis was the most common infection (32.4%), followed by TV (10.4%), and yeast (6.8%). In multivariable logistic regression analysis, TV was associated with an increased risk of HR HPV (odds ratio, 4.2 [95% CI, 1.7-10.3]). Patients with TV were 6.5 times more likely to have HPV type 16 than patients negative for TV (50% vs 13.3%) (odds ratio, 6.5 [95% CI, 1.1-37]). CONCLUSIONS Among rural Tanzanian women who presented for cervical cancer screening, Trichomonas vaginitis was significantly associated with HR HPV infection (specifically type 16).

Recommendations and rationale for the treatment of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is one of the most common serious infections of nonpregnant women of reproductive age. Management of PID is directed at containment of infection. Goals of therapy include the resolution of clinical symptoms and signs, the eradication of pathogens from the genital tract and the prevention of sequelae including infertility, ectopic pregnancy and chronic pelvic pain. The choice of an antibiotic regimen used to treat PID relies upon the appreciation of the polymicrobial etiology of this ascending infection including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and other lower genital tract endogenous anaerobic and facultative bacteria, many of which are associated with bacterial vaginosis. Currently available evidence and the CDC treatment recommendations support the use of broad-spectrum antibiotic regimens that adequately cover the above named microorganisms. The outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline. Clinically severe PID should prompt hospitalization and imaging to rule out a tubo–ovarian abscess. Parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly Gram-negative aerobes and anaerobes, should be implemented.

Pregnancy intentions among women living with HIV in the United States.

Background:The number of HIV-infected women giving birth in the United States is increasing. Research on pregnancy planning in HIV-infected women is limited. Methods:Between January 1 and December 30, 2012, pregnant women with a known HIV diagnosis before conception at 12 US urban medical centers completed a survey including the London Measure of Unplanned Pregnancy (LMUP) scale. We assessed predictors of LMUP category (unplanned/ambivalent versus planned pregnancy) using bivariate and multivariable analyses. Results:Overall, 172 women met inclusion criteria and completed a survey. Based on self-report using the LMUP scale, 23% women had an unplanned pregnancy, 58% were ambivalent, and 19% reported a planned pregnancy. Women were at lower risk for an unplanned or ambivalent pregnancy if they had previously given birth since their HIV diagnosis [adjusted relative risk (aRR) = 0.67, 95% confidence interval (CI): 0.47 to 0.94, P = 0.02], had seen a medical provider in the year before the index pregnancy (aRR = 0.60, 95% CI: 0.46 to 0.77, P < 0.01), or had a patient-initiated discussion of pregnancy intentions in the year before the index pregnancy (aRR = 0.63, 95% CI: 0.46 to 0.77, P < 0.01). Unplanned or ambivalent pregnancy was not associated with age, race/ethnicity, or educational level. Conclusions:In this multisite US cohort, patient-initiated pregnancy counseling and being engaged in medical care before pregnancy were associated with a decreased probability of unplanned or ambivalent pregnancy. Interventions that promote healthcare engagement among HIV-infected women and integrate contraception and preconception counseling into routine HIV care may decrease the risk of unplanned pregnancy among HIV-infected women in the United States.

Prevention, Diagnosis, and Treatment of Gynecologic Surgical Site Infections

Surgical site infections (SSIs) have a significant effect on patient care and medical costs. This article outlines the risks that lead to SSIs and the preventive measures, including antimicrobial prophylaxis, which decrease the incidence of infection. This article also reviews the diagnosis and treatment of gynecologic SSIs.

A cost-effectiveness analysis of anal cancer screening in HIV-positive women.

Objective Anal cancer rates have increased in HIV+ patients. The prevalence of anal intraepithelial neoplasias (AINs) and progression to anal cancer in HIV+ men who have sex with men has been well described, and screening is cost-effective. Our objective was to determine whether anal cancer screening in HIV+ women is cost-effective. Materials and Methods A Markov model analysis of 100 HIV+ women was constructed. All women had a CD4 count less than 200 and were assumed to be on antiretrovirals. Rates of AIN were based on previous studies. Progression rates were extrapolated from previous data on HIV+ men who have sex with men. The 5-year model included 3 screening approaches: none, annual, and biennial. Anoscopy and biopsy were performed after an abnormal cytologic result. Low-grade AIN was followed with repeat cytology, and high-grade AIN was treated surgically. Anal cancer was treated surgically followed by chemotherapy and radiation. Sensitivity analyses (SAs) were performed to account for variable rates of AIN progression, anal cancer mortality, and anal cancer and HIV quality-adjusted life years. Results The incremental cost-effectiveness ratio of biennial anal cancer screening compared to no screening was

Cost-effectiveness of maternal treatment to prevent perinatal hepatitis B virus transmission.

34,763. Cost-effectiveness was maintained across all assumptions in SA except for decreased progression rate of high-grade AIN to anal cancer. Conclusions Biennial anal cancer screening in HIV+ women with CD4 counts less than 200 is cost-effective. Annual screening was not cost-effective, likely because of the slow progression of AIN to anal cancer. Further data on rates of AIN progression in HIV+ women based on CD4 count are needed to determine whether screening is cost-effective in women with higher CD4 counts.

Methicillin-resistant Staphylococcus aureus colonization among women admitted for preterm delivery.

OBJECTIVE: To estimate the cost-effectiveness of maternal lamivudine or hepatitis B immune globulin (HBIG) treatment, in addition to standard neonatal immunoprophylaxis, for the prevention of perinatal hepatitis B virus transmission. METHODS: A decision-tree model was created to estimate the cost-effectiveness of maternal administration of either lamivudine or HBIG in the third trimester to prevent perinatal hepatitis B transmission compared with no maternal treatment. The model was first estimated for each treatment using overall transmission rates, and then stratified by maternal hepatitis B virus DNA viral load. RESULTS: The model estimated that for each 100 hepatitis B surface antigen positive pregnant women treated with lamivudine, 9.7 cases of chronic hepatitis B virus infections are prevented, with a cost-savings of

Correlation of Leukorrhea and Trichomonas vaginalis Infection

5,184 and 1.3 life-years gained per patient treated. For HBIG, 9.5 cases of chronic hepatitis B virus infections are prevented for each 100 pregnant women treated, with a cost-savings of

Cost-effectiveness analysis of annual Trichomonas vaginalis screening and treatment in HIV-positive women to prevent HIV transmission.

5,887 and 1.2 life-years gained per patient treated. Under baseline assumptions, lamivudine remains cost-saving unless the reduction in perinatal transmission is less than 18.5%, and HBIG remains cost-saving unless the reduction in perinatal transmission is less than 9.6%. CONCLUSION: In this decision analysis, administration of lamivudine or HBIG to hepatitis B surface antigen positive pregnant women for the prevention of perinatal transmission of hepatitis B is cost-savings across a wide range of assumptions. LEVEL OF EVIDENCE: III

The cost of Medicaid savings: the potential detrimental public health impact of neonatal circumcision defunding.

OBJECTIVE Methicillin-resistant Staphylococcus aureus infection is associated with morbidity in the neonatal intensive care unit. The purpose of this study was to determine the relationship between preterm maternal methicillin-resistant S aureus colonization and subsequent colonization and infection in premature neonates. STUDY DESIGN We conducted a prospective cohort study of 422 women admitted for preterm delivery. Methicillin-resistant S aureus cultures were collected from mothers and their neonates admitted to neonatal intensive care unit. We determined the proportion of women and neonates colonized with methicillin-resistant S aureus and examined possible factors associated with colonization and infection. RESULTS Fifteen of 422 (3.6%) women were found to be colonized with methicillin-resistant S aureus. Thirteen of 212 (6.1%) neonates admitted to neonatal intensive care unit were methicillin-resistant S aureus colonized and 3 of 13 (23.1%) developed a methicillin-resistant S aureus infection. We identified 1 methicillin-resistant S aureus colonized maternal-neonatal pair. The infant became methicillin-resistant S aureus positive 30 days after admission and did not develop a methicillin-resistant S aureus infection. CONCLUSION These findings suggest that maternal methicillin-resistant S aureus colonization is not a significant risk factor for vertical transmission of neonatal methicillin-resistant S aureus colonization.