Biomedical subjects
Katherine T Chen
Publications and source records attributed to Katherine T Chen.
Inappropriate use of antibiotic prophylaxis to prevent infective endocarditis in obstetric patients.
OBJECTIVE: To evaluate infective endocarditis prophylaxis practices during the intrapartum period and to assess obstetric providers' adherence to the American Heart Association and American College of Obstetrics and Gynecology guidelines for infective endocarditis prophylaxis. METHODS: We performed a chart review of pharmacy, electronic nursing, and physician records to report this case series of obstetric patients who received infective endocarditis prophylaxis during the intrapartum period at a single tertiary referral care center during a 1-year study period from August 1, 2004, to July 31, 2005. RESULTS: Fifty patients received antibiotics for infective endocarditis prophylaxis. Three of the 50 patients who received infective endocarditis prophylaxis had high-risk cardiac lesions and three other patients had moderate-risk cardiac lesions and evidence for intrapartum infection. Thus, only six patients (12.0%, 95% confidence interval 4.5%-24.3%) met the American Heart Association and American College of Obstetricians and Gynecologists criteria for an appropriate indication for infective endocarditis prophylaxis. Of these six patients who had an appropriate indication for infective endocarditis prophylaxis, only three (50.0%, 95% confidence interval 11.8%-88.2%) received appropriate antibiotic regimens. CONCLUSION: Antibiotics are frequently given to obstetric patients during pregnancy. Although many obstetric patients receive antibiotics for recommended indications, some patients, as our study shows, do not. A concerted effort by all practitioners and institutions to reduce the amount of inappropriate antibiotics given to obstetric patients will have positive public health effects in addition to benefiting individual mothers and neonates.
Prevalence of methicillin-sensitive and methicillin-resistant Staphylococcus aureus in pregnant women.
OBJECTIVE: To estimate the extent of Staphylococcus aureus vaginal-rectal colonization among pregnant women as severe S aureus infections have emerged in pregnant and postpartum women and infants. METHODS: We conducted a prospective surveillance study for methicillin-sensitive S aureus and methicillin-resistant S aureus on all routine de-identified vaginal-rectal prenatal group B streptococcus (GBS) screening cultures submitted to the microbiology laboratory of a tertiary-care facility from January to July 2005. Standard microbiologic techniques and molecular analyses were used to detect community-associated methicillin-resistant S aureus strains. As opposed to health care-associated methicillin-resistant S aureus isolates, community-associated methicillin-resistant S aureus isolates were defined as those possessing the type IV or type V staphylococcal chromosomal cassette mec element and usually lacking a multidrug-resistant phenotype. RESULTS: A total of 2,963 GBS screening cultures were analyzed, from which 743 (25.1%, 95% confidence interval [CI] 23.5-26.7%) GBS isolates and 507 (17.1%, 95% CI 15.7-18.5%) S aureus isolates were identified. Group B streptococcus colonization was significantly associated with S aureus colonization (prevalence odds ratio 2.1, 95% CI 1.7-2.5, P < .001). Of the S aureus isolates, 14 (2.8%, 95% CI 1.4-4.2%) were methicillin-resistant, and 13 of these were determined to be community-associated methicillin-resistant S aureus. CONCLUSION: The prevalence of S aureus colonization identified in GBS screening cultures from pregnant women was substantial and associated with GBS co-colonization. Although we do not advocate routine screening of pregnant women for methicillin-sensitive S aureus and methicillin-resistant S aureus colonization, we recommend continued monitoring of both methicillin-sensitive S aureus and methicillin-resistant S aureus infections in this population and their infants.
Mother to child transmission of HIV in China.
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Hepatitis C virus coinfection and HIV load, CD4+ cell percentage, and clinical progression to AIDS or death among HIV-infected women: Women and Infants Transmission Study.
BACKGROUND: Despite previous study, it remains unclear whether hepatitis C virus (HCV) coinfection affects the progression of human immunodeficiency virus (HIV) type 1 infection. The Women and Infants Transmission Study provided an opportunity to assess this issue. METHODS: Longitudinal data on 652 HIV-1-infected women enrolled in the study before the availability of highly active antiretroviral therapy (HAART; 1989-1995) were analyzed. Random effects models were used to determine whether HCV coinfection was associated with different CD4+ cell percentages and HIV-1 RNA levels over time, and Cox proportional hazards models were used to compare the rates of clinical progression to acquired immunodeficiency syndrome (AIDS) or death. RESULTS: Of 652 women, 190 (29%) were HCV infected. During follow-up, 19% of women were exposed to HAART. After controlling for indicators of disease progression (CD4+ cell percentages and HIV-1 RNA levels determined closest to the time of delivery in pregnant women), ongoing drug use, receipt of antiretroviral therapy, and other important covariates, no differences were detected in the HIV-1 RNA levels, but the CD4+ cell percentages were slightly higher in HCV-infected women than in HCV-uninfected women. During follow-up, 48 women had progression to a first clinical AIDS-defining illness (ADI), and 26 died with no documented antecedent ADI. In multivariable analyses, HCV-infected participants did not have faster progression to a first class C AIDS-defining event or death (relative hazard, 0.75; 95% confidence interval, 0.37-1.53). CONCLUSIONS: In this cohort, the rate of clinical progression of HIV-1 infection was not greater for HCV-infected women.
No increase in rates of early-onset neonatal sepsis by antibiotic-resistant group B Streptococcus in the era of intrapartum antibiotic prophylaxis.
OBJECTIVE: The aim of this study was to assess the rate of early-onset neonatal sepsis by antibiotic-resistant group B Streptococcus. STUDY DESIGN: The time-trend study was conducted at a tertiary care center over the following periods: no protocol for group B Streptococcus prophylaxis (1990 to 1992), risk-based protocol (1993 to 1996), and screening-based protocol (1997 to 2002). RESULTS: A total of 120,952 neonates were born with 118 cases of group B Streptococcus early-onset neonatal sepsis. The rate of group B Streptococcus early-onset neonatal sepsis decreased significantly (from 2.0 to 1.1 to 0.4 per 1000 births, P < .0001). No group B Streptococcus isolate was resistant to ampicillin, penicillin, cefazolin, or vancomycin. From 1997 to 2002, there were 3 clindamycin-resistant group B Streptococcus isolates (14%). The rate of erythromycin-resistant group B Streptococcus early-onset neonatal sepsis did not change (from 0.14 to 0.03 to 0.08 per 1000 births, P = .6). However, cases of erythromycin-resistant group B Streptococcus early-onset neonatal sepsis accounted for an increasing proportion of the remaining cases of group B Streptococcus early-onset neonatal sepsis (from 7.0% to 2.6% to 23.8%, P = .07). CONCLUSION: We found no increase in rates of antibiotic-resistant group B Streptococcus early-onset neonatal sepsis.
Previous maternal infection with Toxoplasma gondii and the risk of fetal death.
OBJECTIVE: The purpose of this study was to assess the association between previous maternal Toxoplasma gondii (T gondii) infection and risk of fetal death. STUDY DESIGN: This was a population-based prospective cohort of 29,912 pregnant women without acute T gondii infection in Norway. RESULTS: In the study population, 2937 (9.8%) women had evidence of previous maternal T gondii infection, and 299 (1.0%) had fetal deaths. We found no association between previous T gondii infection and risk of fetal death at > or = 20 weeks of gestation. We did find a trend for an increased risk of fetal death at > or = 16 and <20 weeks of gestation. However, we noted no association between previous T gondii infection and risk of fetal death at all birth weight categories (> or = 1000, > or = 500 and <1000, and <500 g). CONCLUSION: These data do not indicate an increased risk of fetal death at > or = 20 weeks of gestation in women with previous maternal T gondii infection.
Genital herpes simplex virus infection and perinatal transmission of human immunodeficiency virus.
OBJECTIVE: To assess the risk of perinatal human immunodeficiency virus (HIV) transmission in HIV-infected women clinically diagnosed with genital herpes simplex virus (HSV) infection during pregnancy. METHODS: This retrospective analysis included 402 HIV-infected pregnant women who enrolled from 1994-1999 in a multicenter prospective cohort study in New York City, who delivered a liveborn singleton infant with known HIV infection status, and who had information on diagnosis of genital HSV infection during pregnancy. Study participants were determined to have genital HSV infection during pregnancy by documentation of clinical diagnosis. RESULTS: Forty-six (11.4%) of the study participants delivered HIV-infected infants. Twenty-one (5.2%) had clinical diagnosis of genital HSV infection in pregnancy. Six (28.6%) of the 21 HIV-infected women with a clinical diagnosis of genital HSV infection delivered an HIV-infected infant. In univariate analyses, HIV-infected pregnant women with clinical diagnosis of genital HSV infection during pregnancy had a significantly increased risk of perinatal HIV transmission (odds ratio 3.4, 95% confidence interval 1.3-9.3; P = .02). When other factors associated with perinatal HIV transmission were included in a logistic regression model (lack of zidovudine therapy during pregnancy or delivery, prolonged rupture of membranes, and preterm delivery), clinical diagnosis of genital HSV infection during pregnancy remained a significant independent predictor of perinatal HIV transmission (adjusted odds ratio 4.8, 95% confidence interval 1.3-17.0; P = .02). CONCLUSION: Clinical diagnosis of genital HSV infection during pregnancy in HIV-infected women may be a risk factor for perinatal HIV transmission. If future studies confirm this association, therapy to suppress genital HSV reactivation during pregnancy may be a strategy to reduce perinatal HIV transmission.
Pulmonary Kaposi's sarcoma in pregnancy.
Kaposi's sarcoma in human immunodeficiency virus (HIV) -infected women, often misdiagnosed, has an aggressive clinical course, with high rates of visceral involvement and decreased survival. We describe the first case of isolated pulmonary Kaposi's sarcoma in pregnancy. A nulliparous woman was diagnosed with AIDS after presenting at 25 weeks gestation with a cough and multiple pulmonary nodules. Extensive pulmonary evaluation was nondiagnostic until thorascopic lung biopsy revealed Kaposi's sarcoma. Despite combination antiretroviral therapy, her malignancy progressed. Labor was induced at 33.5 weeks gestation for nonreassuring fetal testing. She received chemotherapy postpartum and remains in remission. Pulmonary Kaposi's sarcoma should be considered in the differential diagnosis of HIV-infected obstetric patients with respiratory compromise. Definitive diagnosis is necessary given the aggressive clinical course that is potentially responsive to therapy.
The role of intrapartum fever in identifying asymptomatic term neonates with early-onset neonatal sepsis.
OBJECTIVE: To assess the role of intrapartum fever in identifying asymptomatic term neonates with early-onset neonatal sepsis. STUDY DESIGN: Retrospective review of all term neonates with sepsis over a 7-year period to evaluate the significance of symptoms at delivery and intrapartum sepsis risks factors in identifying neonates with sepsis. RESULTS: Fifty-three of 90 term neonates with sepsis (59%) were asymptomatic at delivery. Thirty-five of 53 asymptomatic term neonates (66%) met criteria for sepsis evaluations and 18 (34%) were evaluated when symptoms developed after delivery. Among the 35 asymptomatic term neonates meeting criteria for sepsis evaluations, 14 (40%) had evaluations because of intrapartum fever. Thus, 14 of 53 (26%) asymptomatic term neonates with sepsis (30% of GBS sepsis and 11% of non-GBS sepsis) would not have been evaluated if intrapartum fever were ignored. CONCLUSION: Over half of term neonates with sepsis were asymptomatic at delivery. Intrapartum fever was helpful in identifying over a quarter of asymptomatic term neonates with sepsis.