Oluwatosin Goje

Endomyometritis after cesarean delivery in the era of antibiotic prophylaxis: incidence and risk factors

Abstract Purpose: To identify the rate of postpartum endomyometritis (PPE) after cesarean delivery (CD) in the era of antibiotic prophylaxis and determine risk factors. Methods: A single institution retrospective study was performed in women undergoing CD. Data regarding obstetrical and surgical variables were collected. Diagnosis of PPE was made clinically. Results: Among 2419 patients, the rate of PPE was 1.6% (n = 38) and was associated with lower age (27.0 versus 31.0; p < .001). 65.7% of patients having chorioamnionitits developed PPE, but only 5.4% of patients without PPE had chorioamnionitis (p < .001). On multivariate analysis, PPE was higher in emergent versus scheduled CD (OR: 5.89; p = .0081). There was no difference in PPE for cefazolin 2 g versus 1 g (OR: 1.91; p = .17) or 3 g versus 1 g (OR: 3.69; p = .29), gentamicin/clindamycin versus cefazolin (OR: 5.60; p < .001) had higher PPE. Women with PPE were more likely to have labor arrest (OR: 4.336; p = .001), sexually transmitted infection during the pregnancy (OR: 4.197; p = .02) or blood transfusion (OR: 9.50; p < .0001). Conclusions: While the overall rate of PPE was low, several risk factors were identified. Preoperative diagnosis of chorioamnionitits is associated with a higher rate of PPE. Further studies are needed to identify optimal regimens for antimicrobial prophylaxis in women undergoing CD.

Mycoplasma genitalium: An Emerging Sexually Transmitted Infection

Mycoplasma genitalium has been recognized as a cause of male urethritis, and there is now evidence suggesting that it causes cervicitis and pelvic inflammatory disease in women. M. genitalium is a slow growing organism, and, with the advent of nucleic acid amplification test (NAAT), more studies are being performed, and knowledge about the pathogenicity of this organism elucidated. With NAAT detection, treatment modalities have been studied, and the next challenge is to determine the most effective antimicrobial therapy. Doxycycline, the first-line antibiotic for urethritis, is largely ineffective in the treatment of M. genitalium and furthermore, resistance to macrolide has also emerged. The most effective drug is Moxifloxacin although there are emerging reports of resistance to it in various parts of the world. This paper not only highlights the current research and knowledge, but also reviews the diversity of health implications on the health of men and women infected with M. genitalium. Alternate antibiotics and the impact of M. genitalium on infertility are areas that require more studies as we continue to research into this microorganism.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

Abstract Purpose: To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution. Methods: This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors. Results: In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6–3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3–6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0–9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05–1.09; p = .02), asthma (OR 1.9; 95%CI 1.1–3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1–3.2; p = .02) were associated with increased SSI. Conclusions: Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

Catheter-associated urinary tract infection (CAUTI) after term cesarean delivery: incidence and risk factors at a multi-center academic institution.

Abstract Purpose: The purpose of this study is to identify the rate of catheter-associated urinary tract infection (CAUTI) after Cesarean delivery (CD) and to determine if any factors increase risk of infection. Methods: A retrospective cohort study was performed at a multi-center institution for patients who underwent CD in 2013. All patients had urinary catheters inserted before surgery. Diagnosis followed IDSA guidelines with culture growing greater than 103 CFU of bacteria per mL with symptoms or symptomatic urinary tract infections treated at provider discretion. Statistical analysis was assessed with Chi-square and Student’s t-test followed by logistic regression. Results: Of 2419 patients, 36 patients developed CAUTI (1.5%). In the 24 (66.7%) cases diagnosed by IDSA guidelines, Escherichia coli was the most common causative organism (54.1%); followed by Enterococcus faecalis (16.7%), Streptococccus agalactiae (8.3%), and Group A Streptococcus (8.3%). Longer operative time (OR 1.013; 95% 1.002–1.023; p = .02) and pregnancies complicated by STI (OR 4.15; 95% CI 1.11–15.0; p < .05) were associated with higher rates of CAUTI. Conclusions: The overall rate of CAUTI after CD was low at 1.5%. Escherichia coli was the most common causative pathogen. Identification of the patients at high risk for CAUTI allows for risk reduction measures.

A model to predict risk of postpartum infection after Caesarean delivery

Abstract Purpose: The purpose of this study is to build and validate a statistical model to predict infection after caesarean delivery (CD). Methods: Patient and surgical variables within 30 d of CD were collected on 2419 women. Postpartum infection included surgical site infection, urinary tract infection, endomyometritis and pneumonia. The data were split into model development and internal validation (1 January–31 August; N = 1641) and temporal validation subsets (1 September–31 December; N = 778). Logistic regression models were fit to the data with concordance index and calibration curves used to assess accuracy. Internal validation was performed with bootstrapping correcting for bias. Results: Postoperative infection occurred in 8% (95% CI 7.3–9.9), with 5% meeting CDC criteria for surgical site infections (SSI) (95% CI 4.1–5.8). Eight variables were predictive for infection: increasing BMI, higher number of prior Caesarean deliveries, emergent Caesarean delivery, Caesarean for failure to progress, skin closure using stainless steel staples, chorioamnionitis, maternal asthma and lower gestational age. The model discriminated between women with and without infection on internal validation (concordance index = 0.71 95% CI 0.67–0.76) and temporal validation (concordance index = 0.70, 95% CI 0.62, 0.78). Conclusions: Our model accurately predicts risk of infection after CD. Identification of patients at risk for postoperative infection allows for individualized patient care and counseling.

Prevalence and Clinical Significance of Mycoplasma genitalium inGynecologic Patients

Objective: Mycoplasma genitalium has been recognized as a cause of male urethritis, and there is now evidence suggesting it causes cervicitis and pelvic inflammatory disease (PID) in women. Methods: Prevalence, risk factors and co-infections with other sexually transmitted pathogens were collected in a cross-sectional study looking at 400 women at the gynecologic clinics of a university medical center in the United States. Bacterial vaginosis and trichomoniasis were diagnosed using Amsel’s criteria, gram stain and trichomonas culture respectively. Cervicitis and PID were clinically diagnosed. After testing for Chlamydia trachomatis and Neisseria gonorrhoeae, the residual cervical swab transport medium (Gen-Probe/Hologic®) was stored at -70°C. Stored samples were later analyzed for M. genitalium by a research use only transcription-mediated amplification assay using procedures similar to those established for APTIMA Combo2 assay for C. trachomatis and N. gonorrhoeae (Gen-Probe/Hologic®). Results: The overall prevalence of infection with C. trachomatis, N. gonorrhoeae, T. vaginalis and M. genitalium was found to be 7.8%, 1.8%, 10.43% and 8.9%, respectively. Prevalence of M. genitalium was comparable to that of C. trachomatis and greater than the prevalence of N. gonorrhoeae. Univariate analysis of M. genitalium status showed that participants with lower condom use had an increased probability of M. genitalium (p=0.037). Conclusion: Prevalence of M. genitalium was comparable to C. trachomatis in our study, but more research is needed to clarify pathogenicity.

Invasive squamous cell carcinoma of the vulva clinically mimicking a diabetic ulcer: A potential diagnostic pitfall

Background: Vulvar cancer is an uncommon disease with significant morbidity and mortality. Chronic conditions such as hypertension and diabetes may overshadow and can delay the timely diagnosis of vulvar cancer. While chronic and poorly managed diabetes may present with non-healing ulcers, vulvar cancer may also present as a persistent vulvar lesion or ulcer of the lower genital tract. Case: Patient is a 49 year-old woman who presented with a persistent non-healing vulvar ulcer thought to be secondary to poorly controlled diabetes. This was later uncovered to be her initial presentation of vulvar carcinoma. Conclusion: Our report presents a case where the diagnosis of vulvar squamous cell carcinoma required high clinical suspicion and ultimately biopsy of the questionable lesion, which is not routinely performed on ulcers secondary to chronic conditions like diabetes due to fear of poor wound healing. Correspondence to: Oluwatosin Jaiyeoba Goje, OB/GYN and Women’s Health Institute, Cleveland Clinic, 9500 Euclid Avenue A81, Cleveland, OH, USA, Tel: (216) 444-5857; E-mail: gojeoo@ccf.org Received: May 02, 2017; Accepted: May 15, 2017; Published: May 17, 2017 Introduction Vulvar cancer is an uncommon diagnosis representing less than 0.6% of cancer diagnoses in the United States [1]. The 5-year survival rate of the vulvar cancer remains approximately 70% [2]. 80% of vulvar cancer diagnoses are in women >50 years old. Given this ageproportionate increase in vulvar cancer prevalence, the diagnosis may be complicated by a number of chronic disorders such as lichen sclerosis and planus as well as systemic manifestations of diseases such as hypertension/peripheral arterial disease and diabetes mellitus [3]. Yet, given the low incidence of vulvar cancer and epidemiologic data, diabetes and hypertension have not been shown to conclusively be risk factors of this malignancy [4]. We present a case of 49-year-old woman who initially presented with a non-healing ulcer attributed to her poorly controlled diabetes, yet this delayed her diagnosis and treatment of stage IIIC metastatic vulvar squamous cell carcinoma.