Kate Johnson

AMSTERDAM — Two drugs that inhibit uterine contractions might provide a novel approach to improving implantation rates in patients undergoing IVF, according to early research reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“Contractions of the uterus are more frequent in IVF cycles compared to normal menstrual cycles, and a higher frequency of contractions around the time of embryo transfer is associated with a more negative impact on pregnancy outcomes,” reported Dr. Christophe Blockeel of the center for reproductive medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.

“We've learned that uterine contractions are actually in many cases expelling somewhere between 15% to 50% of embryos after transfer,” commented Roger Pierson, Ph.D., a collaborator in the study, and professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan (Sask).

“Regardless of which catheter you use, or whether or not you use ultrasound, you are still irritating the uterus and it doesn't matter how gentle you are, some women are going to respond with advanced uterine contractions,” he said in an interview.

The study, which was conducted in oocyte donors and was funded by Ferring Pharmaceuticals, examined the effect of the selective oxytocin antagonist barusiban and the mixed oxytocin/vasopressin antagonist atosiban versus placebo on luteal phase uterine contractions.

The study participants were 125 oocyte donors who had undergone controlled ovarian stimulation, oocyte retrieval, and luteal phase supplementation with progeste progesterone. Women were randomized to either barusiban (41 women, IV bolus 9 mg, IV infusion 2.16 mg/h); atosiban (42 women, IV bolus 6.75 mg, IV infusion 18 mg/h); or placebo on day 2 after oocyte retrieval.

Transvaginal ultrasounds lasting at least 5 minutes were obtained after retrieval on day 1, 14 times on day 2 (pretreatment, 8 times before mock embryo transfer, 3 times after mock embryo transfer, and 2 times post infusion), and on Day 5.

With both medications, the frequency of uterine contractions remained stable during the first 2 days after retrieval, followed by a significant decrease noted in both treatment groups that lasted for about 3 hours.

“These medications are quite short acting, so they need to be administered an hour or two before transfer just to get the uterus settled to facilitate implantation,” explained Dr. Pierson, who is also a consultant for Ferring.

Without the control medication the frequency of uterine contractions can be as high as 6 or 7 per minute after embryo transfer, he said, adding that the ideal is somewhere around 1 to 1.5 contractions per minute.

“This is a very new approach to improving implantation and quite different,” he explained. While atosiban is already used to treat preterm labor, barusiban was specifically developed to treat uterine contractions in IVF, and another similar medication is being developed by the company.

“Both barusiban and atosiban are very well tolerated drugs; however, toxicology tests are still needed before we can use these drugs in patients undergoing embryo transfer rather than donors,” Dr. Blockeel said. Optimal dosing also needs further investigation.

AMSTERDAM — Two drugs that inhibit uterine contractions might provide a novel approach to improving implantation rates in patients undergoing IVF, according to early research reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“Contractions of the uterus are more frequent in IVF cycles compared to normal menstrual cycles, and a higher frequency of contractions around the time of embryo transfer is associated with a more negative impact on pregnancy outcomes,” reported Dr. Christophe Blockeel of the center for reproductive medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.

“We've learned that uterine contractions are actually in many cases expelling somewhere between 15% to 50% of embryos after transfer,” commented Roger Pierson, Ph.D., a collaborator in the study, and professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan (Sask).

“Regardless of which catheter you use, or whether or not you use ultrasound, you are still irritating the uterus and it doesn't matter how gentle you are, some women are going to respond with advanced uterine contractions,” he said in an interview.

The study, which was conducted in oocyte donors and was funded by Ferring Pharmaceuticals, examined the effect of the selective oxytocin antagonist barusiban and the mixed oxytocin/vasopressin antagonist atosiban versus placebo on luteal phase uterine contractions.

The study participants were 125 oocyte donors who had undergone controlled ovarian stimulation, oocyte retrieval, and luteal phase supplementation with progeste progesterone. Women were randomized to either barusiban (41 women, IV bolus 9 mg, IV infusion 2.16 mg/h); atosiban (42 women, IV bolus 6.75 mg, IV infusion 18 mg/h); or placebo on day 2 after oocyte retrieval.

Transvaginal ultrasounds lasting at least 5 minutes were obtained after retrieval on day 1, 14 times on day 2 (pretreatment, 8 times before mock embryo transfer, 3 times after mock embryo transfer, and 2 times post infusion), and on Day 5.

With both medications, the frequency of uterine contractions remained stable during the first 2 days after retrieval, followed by a significant decrease noted in both treatment groups that lasted for about 3 hours.

“These medications are quite short acting, so they need to be administered an hour or two before transfer just to get the uterus settled to facilitate implantation,” explained Dr. Pierson, who is also a consultant for Ferring.

Without the control medication the frequency of uterine contractions can be as high as 6 or 7 per minute after embryo transfer, he said, adding that the ideal is somewhere around 1 to 1.5 contractions per minute.

“This is a very new approach to improving implantation and quite different,” he explained. While atosiban is already used to treat preterm labor, barusiban was specifically developed to treat uterine contractions in IVF, and another similar medication is being developed by the company.

“Both barusiban and atosiban are very well tolerated drugs; however, toxicology tests are still needed before we can use these drugs in patients undergoing embryo transfer rather than donors,” Dr. Blockeel said. Optimal dosing also needs further investigation.

AMSTERDAM — Two drugs that inhibit uterine contractions might provide a novel approach to improving implantation rates in patients undergoing IVF, according to early research reported at the annual meeting of the European Society of Human Reproduction and Embryology.

“Contractions of the uterus are more frequent in IVF cycles compared to normal menstrual cycles, and a higher frequency of contractions around the time of embryo transfer is associated with a more negative impact on pregnancy outcomes,” reported Dr. Christophe Blockeel of the center for reproductive medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium.

“We've learned that uterine contractions are actually in many cases expelling somewhere between 15% to 50% of embryos after transfer,” commented Roger Pierson, Ph.D., a collaborator in the study, and professor of obstetrics, gynecology, and reproductive sciences at the University of Saskatchewan (Sask).

“Regardless of which catheter you use, or whether or not you use ultrasound, you are still irritating the uterus and it doesn't matter how gentle you are, some women are going to respond with advanced uterine contractions,” he said in an interview.

The study, which was conducted in oocyte donors and was funded by Ferring Pharmaceuticals, examined the effect of the selective oxytocin antagonist barusiban and the mixed oxytocin/vasopressin antagonist atosiban versus placebo on luteal phase uterine contractions.

The study participants were 125 oocyte donors who had undergone controlled ovarian stimulation, oocyte retrieval, and luteal phase supplementation with progeste progesterone. Women were randomized to either barusiban (41 women, IV bolus 9 mg, IV infusion 2.16 mg/h); atosiban (42 women, IV bolus 6.75 mg, IV infusion 18 mg/h); or placebo on day 2 after oocyte retrieval.

Transvaginal ultrasounds lasting at least 5 minutes were obtained after retrieval on day 1, 14 times on day 2 (pretreatment, 8 times before mock embryo transfer, 3 times after mock embryo transfer, and 2 times post infusion), and on Day 5.

With both medications, the frequency of uterine contractions remained stable during the first 2 days after retrieval, followed by a significant decrease noted in both treatment groups that lasted for about 3 hours.

“These medications are quite short acting, so they need to be administered an hour or two before transfer just to get the uterus settled to facilitate implantation,” explained Dr. Pierson, who is also a consultant for Ferring.

Without the control medication the frequency of uterine contractions can be as high as 6 or 7 per minute after embryo transfer, he said, adding that the ideal is somewhere around 1 to 1.5 contractions per minute.

“This is a very new approach to improving implantation and quite different,” he explained. While atosiban is already used to treat preterm labor, barusiban was specifically developed to treat uterine contractions in IVF, and another similar medication is being developed by the company.

“Both barusiban and atosiban are very well tolerated drugs; however, toxicology tests are still needed before we can use these drugs in patients undergoing embryo transfer rather than donors,” Dr. Blockeel said. Optimal dosing also needs further investigation.

AMSTERDAM — Vitrified ovarian tissue yields a greater number of viable oocytes after thaw and transplant, compared with tissue that is frozen using conventional techniques, according to data presented at the European Society of Human Reproduction and Embryology.

“Both ischemic loss from cortical transplantation and oocyte loss from freezing can be prevented with ultrathin grafts and vitrification,” said Dr. Sherman Silber, director of the Infertility Center of St. Louis.

In fact, oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants, he said.

In one study, Dr. Silber compared oocyte viability in 14 young cancer patients who had received ovarian tissue transplants after either vitrification (n = 8) or conventional freezing (n = 6). He compared his results with those of nine patients who had received fresh ovarian tissue transplanted from their identical twins.

Oocyte viability was similar in the twin patients who had received fresh tissue and cancer patients who had received vitrified tissue, but was significantly decreased in cancer patients who had received conventionally frozen tissue, he reported.

“We found that 91.9% of the fresh oocytes were viable, compared with 88.9% of those vitrified. However, slow freezing resulted in a 56% loss of viability,” he said.

Ovarian function returned in all patients regardless of whether they had received fresh tissue or tissue frozen by either method, emphasized Dr. Silber. All patients regained a normal ovarian cycle 4-5 months after transplant.

Dr. Silber's data point to the superiority of vitrification over conventional freezing, in terms of oocyte viability. However, another paper presented at the meeting suggests vitrification may result in abnormal expression of a gene known as GAPDH (glyceraldehyde 3-phosphate dehydrogenase). In an in vitro study of human ovarian tissue, “we detected drastically reduced levels of GAPDH-gene expression in ovarian tissue after vitrification, compared with conventional freezing,” reported Vladimir Isachenko, Ph.D., of the University of Ulm (Germany).

“This is a housekeeping gene,” he explained in an interview. “If there is no expression of this gene, or expression is decreased, it will eventually result in cell death,” he said.

Studies to date show no indication of abnormalities in children conceived from vitrified ovarian tissue or oocytes, commented Dr. Silber.

But abnormal gene expression could have very subtle effects that might also not become evident until adulthood, Dr. Isachenko explained. He suggested that the mechanism by which vitrification might alter gene expression might be the direct contact of tissue with liquid nitrogen. Based on his findings, his laboratory no longer uses vitrification.

Oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants.

Source Dr. Silber

AMSTERDAM — Vitrified ovarian tissue yields a greater number of viable oocytes after thaw and transplant, compared with tissue that is frozen using conventional techniques, according to data presented at the European Society of Human Reproduction and Embryology.

“Both ischemic loss from cortical transplantation and oocyte loss from freezing can be prevented with ultrathin grafts and vitrification,” said Dr. Sherman Silber, director of the Infertility Center of St. Louis.

In fact, oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants, he said.

In one study, Dr. Silber compared oocyte viability in 14 young cancer patients who had received ovarian tissue transplants after either vitrification (n = 8) or conventional freezing (n = 6). He compared his results with those of nine patients who had received fresh ovarian tissue transplanted from their identical twins.

Oocyte viability was similar in the twin patients who had received fresh tissue and cancer patients who had received vitrified tissue, but was significantly decreased in cancer patients who had received conventionally frozen tissue, he reported.

“We found that 91.9% of the fresh oocytes were viable, compared with 88.9% of those vitrified. However, slow freezing resulted in a 56% loss of viability,” he said.

Ovarian function returned in all patients regardless of whether they had received fresh tissue or tissue frozen by either method, emphasized Dr. Silber. All patients regained a normal ovarian cycle 4-5 months after transplant.

Dr. Silber's data point to the superiority of vitrification over conventional freezing, in terms of oocyte viability. However, another paper presented at the meeting suggests vitrification may result in abnormal expression of a gene known as GAPDH (glyceraldehyde 3-phosphate dehydrogenase). In an in vitro study of human ovarian tissue, “we detected drastically reduced levels of GAPDH-gene expression in ovarian tissue after vitrification, compared with conventional freezing,” reported Vladimir Isachenko, Ph.D., of the University of Ulm (Germany).

“This is a housekeeping gene,” he explained in an interview. “If there is no expression of this gene, or expression is decreased, it will eventually result in cell death,” he said.

Studies to date show no indication of abnormalities in children conceived from vitrified ovarian tissue or oocytes, commented Dr. Silber.

But abnormal gene expression could have very subtle effects that might also not become evident until adulthood, Dr. Isachenko explained. He suggested that the mechanism by which vitrification might alter gene expression might be the direct contact of tissue with liquid nitrogen. Based on his findings, his laboratory no longer uses vitrification.

Oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants.

Source Dr. Silber

AMSTERDAM — Vitrified ovarian tissue yields a greater number of viable oocytes after thaw and transplant, compared with tissue that is frozen using conventional techniques, according to data presented at the European Society of Human Reproduction and Embryology.

“Both ischemic loss from cortical transplantation and oocyte loss from freezing can be prevented with ultrathin grafts and vitrification,” said Dr. Sherman Silber, director of the Infertility Center of St. Louis.

In fact, oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants, he said.

In one study, Dr. Silber compared oocyte viability in 14 young cancer patients who had received ovarian tissue transplants after either vitrification (n = 8) or conventional freezing (n = 6). He compared his results with those of nine patients who had received fresh ovarian tissue transplanted from their identical twins.

Oocyte viability was similar in the twin patients who had received fresh tissue and cancer patients who had received vitrified tissue, but was significantly decreased in cancer patients who had received conventionally frozen tissue, he reported.

“We found that 91.9% of the fresh oocytes were viable, compared with 88.9% of those vitrified. However, slow freezing resulted in a 56% loss of viability,” he said.

Ovarian function returned in all patients regardless of whether they had received fresh tissue or tissue frozen by either method, emphasized Dr. Silber. All patients regained a normal ovarian cycle 4-5 months after transplant.

Dr. Silber's data point to the superiority of vitrification over conventional freezing, in terms of oocyte viability. However, another paper presented at the meeting suggests vitrification may result in abnormal expression of a gene known as GAPDH (glyceraldehyde 3-phosphate dehydrogenase). In an in vitro study of human ovarian tissue, “we detected drastically reduced levels of GAPDH-gene expression in ovarian tissue after vitrification, compared with conventional freezing,” reported Vladimir Isachenko, Ph.D., of the University of Ulm (Germany).

“This is a housekeeping gene,” he explained in an interview. “If there is no expression of this gene, or expression is decreased, it will eventually result in cell death,” he said.

Studies to date show no indication of abnormalities in children conceived from vitrified ovarian tissue or oocytes, commented Dr. Silber.

But abnormal gene expression could have very subtle effects that might also not become evident until adulthood, Dr. Isachenko explained. He suggested that the mechanism by which vitrification might alter gene expression might be the direct contact of tissue with liquid nitrogen. Based on his findings, his laboratory no longer uses vitrification.

Oocyte viability from transplanted vitrified ovarian tissue is similar to that of fresh transplants.

Source Dr. Silber

MONTREAL — Mycoplasma genitalium is likely an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings implicating the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women. M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” Dr. Wiesenfeld said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” Dr. Wiesenfeld said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

In order to rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said. Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” Dr. Wiesenfeld said.

MONTREAL — Mycoplasma genitalium is likely an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings implicating the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women. M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” Dr. Wiesenfeld said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” Dr. Wiesenfeld said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

In order to rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said. Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” Dr. Wiesenfeld said.

MONTREAL — Mycoplasma genitalium is likely an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings implicating the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women. M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” Dr. Wiesenfeld said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” Dr. Wiesenfeld said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

In order to rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said. Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” Dr. Wiesenfeld said.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment, or write a prescription for their patients' partners without requiring the partners to come into the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

Using estimates of disease prevalence, treatment failure, costs, and quality-adjusted life years, EPT would have resulted in 984 fewer cases of chlamydia (rather than the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (rather than the actual 56,585 cases). This reduction in disease would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years.

Currently, in the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But there are 21 states where the laws are “somewhat murky. Either there are no laws, which means that presumably you can go ahead and provide this treatment” or there's nothing prohibiting treatment. She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to the implementation of EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDS or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

However, she said that both legal and clinical concerns are barriers to EPT. “Research studies have shown that there are few risks to partners who receive EPT and there are significant benefits. I think if the legal status of EPT was clarified, it would be much easier to educate physicians about its benefits,” she said, noting that the logical places to prescribe EPT are health departments, which are usually state administered.

Dr. Villers noted that her study probably underestimates the benefits of EPT because it is based on the assumption that the infected patient was female, and was confined to the 3-month period following her treatment. Also we did not take into account multiple sexual partners, and we only looked at direct medical costs, not indirect costs, such as time off from work.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment, or write a prescription for their patients' partners without requiring the partners to come into the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

Using estimates of disease prevalence, treatment failure, costs, and quality-adjusted life years, EPT would have resulted in 984 fewer cases of chlamydia (rather than the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (rather than the actual 56,585 cases). This reduction in disease would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years.

Currently, in the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But there are 21 states where the laws are “somewhat murky. Either there are no laws, which means that presumably you can go ahead and provide this treatment” or there's nothing prohibiting treatment. She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to the implementation of EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDS or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

However, she said that both legal and clinical concerns are barriers to EPT. “Research studies have shown that there are few risks to partners who receive EPT and there are significant benefits. I think if the legal status of EPT was clarified, it would be much easier to educate physicians about its benefits,” she said, noting that the logical places to prescribe EPT are health departments, which are usually state administered.

Dr. Villers noted that her study probably underestimates the benefits of EPT because it is based on the assumption that the infected patient was female, and was confined to the 3-month period following her treatment. Also we did not take into account multiple sexual partners, and we only looked at direct medical costs, not indirect costs, such as time off from work.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment, or write a prescription for their patients' partners without requiring the partners to come into the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

Using estimates of disease prevalence, treatment failure, costs, and quality-adjusted life years, EPT would have resulted in 984 fewer cases of chlamydia (rather than the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (rather than the actual 56,585 cases). This reduction in disease would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years.

Currently, in the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But there are 21 states where the laws are “somewhat murky. Either there are no laws, which means that presumably you can go ahead and provide this treatment” or there's nothing prohibiting treatment. She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to the implementation of EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDS or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

However, she said that both legal and clinical concerns are barriers to EPT. “Research studies have shown that there are few risks to partners who receive EPT and there are significant benefits. I think if the legal status of EPT was clarified, it would be much easier to educate physicians about its benefits,” she said, noting that the logical places to prescribe EPT are health departments, which are usually state administered.

Dr. Villers noted that her study probably underestimates the benefits of EPT because it is based on the assumption that the infected patient was female, and was confined to the 3-month period following her treatment. Also we did not take into account multiple sexual partners, and we only looked at direct medical costs, not indirect costs, such as time off from work.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Women who have not yet established prenatal care have a significantly higher rate of acute pyelonephritis before 12 weeks of gestation compared with women who already have an obstetric provider by 12 weeks, based on results of a retrospective study.

“Many providers do not see patients early in the first trimester, because they often like to ensure there is an established pregnancy. But we would encourage them to have patients present as early as possible, at least for labs and urine screening,” said Dr. Mollie Ann McDonnold, who presented her findings at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (IDSOG).

Her retrospective study examined 254 consecutive hospital admissions for acute pyelonephritis in pregnancy between January 2004 and June 2007. Overall, there were 29 cases (11%) occurring before 12 weeks' gestation, and 60 cases (24%) before 16 weeks' gestation.

Among women who had already established prenatal care (219), most infections occurred later in pregnancy, with only 5% of cases occurring before 12 weeks, and 16% occurring prior to 16 weeks of gestation. However, among women without prenatal care (35), 51% of cases presented prior to 12 weeks and 74% occurred prior to 16 weeks of gestation.

“These results were expected as it is not common to establish prenatal care prior to 12 weeks,” said Dr. McDonnold of Brown University, Providence, R.I.

There were no differences in age, ethnicity, parity, length of hospital stay, presence or degree of fever, or heart rate at admission between women with or without established prenatal care.

However, there was a statistically significant difference in insurance between the groups. While 57% of women with no prenatal care had no insurance, only 1.6% of women with prenatal care were in this situation. And 24% of women with prenatal care had private insurance, compared with just 2.4% of women without prenatal care.

“I think this is an extremely important observation,” commented Dr. Michael Gravett, president of IDSOG and professor of obstetrics and gynecology at the University of Washington in Seattle.

“The trend in prenatal care is that since we now do a lot of prenatal diagnosis, we frequently defer initiation of care and labs until about 12 or 13 weeks. This is a reminder that common things occur more commonly and we tend to overlook them. This is a caution to see women earlier at least for urinalysis,” the physician said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — Although bacteriuria in early pregnancy has been associated with pyelonephritis and preterm delivery, the same is not true for polymicrobial urine cultures or “mixed flora,” said Dr. Amber Naresh of Magee-Women's Hospital, Pittsburgh.

“Urine cultures with polymicrobial growth in the first half of pregnancy are essentially the same as negative cultures as far as these pregnancy outcomes are concerned,” Dr. Naresh said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Her retrospective cohort study, carried out between 2004 and 2007, compared 449 women with polymicrobial urine cultures and 375 women with negative urine cultures, all at less than 20 weeks' gestation. Polymicrobial growth was defined as mixed flora of more than 100,000 colony forming units per milliliter.

Admissions for pyelonephritis were identified by ICD-9 codes, and gestational age at delivery was determined from a research registry.

The rates of pyelonephritis were the same in the women with polymicrobial growth and those with a negative urine culture (0.22% and 0%). Similarly, preterm delivery at less than 37 weeks' gestation occurred in 18% of women with polymicrobial growth and 16% of those with negative urine cultures, and delivery at less than 34 weeks occurred in 6% and 5%, respectively, Dr. Naresh reported.

There were no differences between the groups in maternal age, race, socioeconomic status, and tobacco use, but women with polymicrobial growth had higher rates of group B streptococcal (GBS) infection (41% vs. 32%). “Put another way, women with GBS were more likely to have polymicrobial growth than women who were GBS negative,” she said, adding that those with vaginal GBS may “have a higher bacterial load in the vagina and are therefore more prone to having contamination of their urine specimen.”

Women with polymicrobial growth also were more likely to have had a previous preterm birth (8.7%), compared with women with negative urine cultures (1.3%). “Unfortunately, I don't have an explanation for this, especially since there is no association between polymicrobial growth and preterm delivery in the current pregnancy,” she said.

The mean date of collection of urine was 12.3 weeks of gestation in the polymicrobial group and 11.6 weeks in those with negative cultures. “It's questionable whether this has any clinical significance, although it clearly has statistical significance.”

Practices vary among obstetric providers regarding the management of polymicrobial growth in urine cultures. “Some practitioners routinely repeat the culture—at least that's a very common practice at my institution. They feel that that the polymicrobes may themselves be pathogenic, or may be covering up a monomicrobial infection. Others regard it essentially as a negative result, and still others might treat with antibiotics,” Dr. Naresh said.

“I believe these cultures likely represent contamination, and I feel I can safely recommend that they do not have to be repeated,” she said.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, said study presenter Margaret Kennedy.

Ms. Kennedy is a student at the University of Pittsburgh School of Medicine.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

Multivariate analysis of the data revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened.

On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld.

“Some providers don't think HIV is relevant to their population because they have an affluent population. It mirrors chlamydia screening. They don't think their patients are at risk,” the physician related.

A comparison of medical records with subjects' responses revealed some recall bias.

Two percent of those who reported having been tested had actually declined testing.

Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined).

In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” Ms. Kennedy said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he opined.

The investigators said they had no conflicts of interest.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, said study presenter Margaret Kennedy.

Ms. Kennedy is a student at the University of Pittsburgh School of Medicine.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

Multivariate analysis of the data revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened.

On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld.

“Some providers don't think HIV is relevant to their population because they have an affluent population. It mirrors chlamydia screening. They don't think their patients are at risk,” the physician related.

A comparison of medical records with subjects' responses revealed some recall bias.

Two percent of those who reported having been tested had actually declined testing.

Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined).

In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” Ms. Kennedy said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he opined.

The investigators said they had no conflicts of interest.

MONTREAL — HIV screening of pregnant women falls well short of national guidelines, particularly among patients seen in private practice, according to a study presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“We have to really reinforce with all providers the importance of universal screening,” said Dr. Harold Wiesenfeld, senior investigator of the study, which found that patients were 17.5 times less likely to undergo screening in private practice than were those in a clinic setting.

The study of 300 women revealed that 61% had no HIV screening results in their medical record at the time of parturition.

Guidelines adopted in 1999 by the Institute of Medicine, the Centers for Disease Control, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend routine, universal HIV screening in pregnancy to avoid vertical transmission, said study presenter Margaret Kennedy.

Ms. Kennedy is a student at the University of Pittsburgh School of Medicine.

But among the study's subjects, all of whom were questioned up to 72 hours before delivery, only 65% reported undergoing HIV screening during pregnancy, while 25% reported no screening, and 10% were not sure if they had been tested.

Multivariate analysis of the data revealed that being white and married were each independently associated with a threefold greater risk of not being screened.

The provider's influence was the most important factor in screening, said Ms. Kennedy.

Women whose provider did not consider screening important were14 times more likely to be unscreened; those whose providers considered screening optional were 2.9 times more likely to be unscreened.

On the other hand, women whose providers encouraged screening were 3.7 times more likely to have undergone screening.

“My personal opinion is the importance of HIV screening is not stressed in many patient/provider encounters,” said Dr. Wiesenfeld.

“Some providers don't think HIV is relevant to their population because they have an affluent population. It mirrors chlamydia screening. They don't think their patients are at risk,” the physician related.

A comparison of medical records with subjects' responses revealed some recall bias.

Two percent of those who reported having been tested had actually declined testing.

Of those who reporting no screening, 11% had actually been screened (35% said they had not been offered screening, and 65% said they had declined).

In addition, 17% of those who were unsure had been screened.

“Universal offering of HIV screening as an opt-out, in conjunction with encouragement from providers, may greatly increase prenatal HIV screening rates,” Ms. Kennedy said.

“Universal HIV screening is not at the rates we would like across the country,” concluded Dr. Wiesenfeld.

“The take-home message is that it's low—but what's more important is who is not being screened. Women who are white, and affluent, and in a private practice center … are less likely to be screened, as are those who don't feel their provider is encouraging it,” he opined.

The investigators said they had no conflicts of interest.

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment or write a prescription for their patients' partners without requiring the partners to come in to the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

The model suggested that EPT would have resulted in 984 fewer cases of chlamydia (out of the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (out of the actual 56,585 cases). This would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years, she said.

In the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But the laws are “somewhat murky” in 21 states.

She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDs or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

Dr. Villers noted that her study probably underestimates the benefits of EPT by assuming that the infected patient is female, and by considering only the 3-month period following her treatment. In addition, “we did not take into account multiple sexual partners, and we also only looked at direct medical costs.”

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment or write a prescription for their patients' partners without requiring the partners to come in to the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

The model suggested that EPT would have resulted in 984 fewer cases of chlamydia (out of the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (out of the actual 56,585 cases). This would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years, she said.

In the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But the laws are “somewhat murky” in 21 states.

She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDs or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

Dr. Villers noted that her study probably underestimates the benefits of EPT by assuming that the infected patient is female, and by considering only the 3-month period following her treatment. In addition, “we did not take into account multiple sexual partners, and we also only looked at direct medical costs.”

MONTREAL — Expedited partner treatment, also known as patient-delivered partner therapy, could substantially reduce costs and morbidity from sexually transmitted diseases if it were allowed in all states, according to Dr. Margaret Villers.

The practice allows physicians who are treating patients with sexually transmitted diseases to either provide treatment or write a prescription for their patients' partners without requiring the partners to come in to the office.

Although the Centers for Disease Control and Prevention has encouraged expedited partner treatment (EPT) since 2006, it is explicitly legal in only 19 states, and “in multiple states and localities, there are legal barriers which may prevent universal implementation,” Dr. Villers said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology (For a map showing the legal status of EPT in each state, visit www.cdc.gov/std/ept/legal/default.htm

“The South Carolina statute very much mirrors the other states where it's prohibited in the sense that if you do not see a patient—if you've never met them, if you have not examined them, and if you do not have an ongoing relationship with them—then you are not allowed to prescribe a medication for them,” explained Dr. Villers of the Medical University of South Carolina, Charleston.

In a cost-utility model examining the potential impact of EPT in 11 states where it was illegal in 2007 (one state, North Dakota, has since made the practice legal), she estimated there would be a cost savings of almost $6 million and the prevention of more than 2,000 cases of Chlamydia trachomatis and Neisseria gonorrhoeae annually.

The model suggested that EPT would have resulted in 984 fewer cases of chlamydia (out of the actual 196,819 cases) and 1,280 fewer cases of gonorrhea (out of the actual 56,585 cases). This would have resulted in a net savings of $1,671,387 for chlamydia and $4,163,534 for gonorrhea, and a combined gain of 453 quality-adjusted life years, she said.

In the 19 U.S. states where EPT is explicitly legal, “there are state statutes that either allow for the provision of a prescription in general or specifically for the treatment of STDs only,” she said. But the laws are “somewhat murky” in 21 states.

She said that approximately 1 year ago the American Bar Association sent an open letter to all members encouraging states and localities to pass statutes that might decrease barriers to EPT.

“Improved clarification of the legal status of EPT, whether it is a state law which only allows the prescription of medications for STDs or whether it is a broader general law, might actually make this type of treatment more acceptable to physicians,” she said in an interview.

Dr. Villers noted that her study probably underestimates the benefits of EPT by assuming that the infected patient is female, and by considering only the 3-month period following her treatment. In addition, “we did not take into account multiple sexual partners, and we also only looked at direct medical costs.”

MONTREAL — Community-acquired strains are the most common source of methicillin-resistant Staphylococcus aureus colonization and infection in babies in the neonatal intensive care unit, even though they have never left the hospital, researchers found.

Findings in a 5-year retrospective study of 50 MRSA-colonized neonates in the NICU were presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

"There are higher rates of community-acquired MRSA infection in our neonates than in our general adult and pediatric patient population," said lead investigator Dr. Gweneth Lazenby of the Medical University of South Carolina in Charleston said. "This is a call for people to help us really detail the sources of such early colonization, how we can prevent it, and how we can prevent subsequent infection."

Theories on how neonates are exposed to MRSA in the NICU include maternal transmission, transmission from other family or hospital workers, contaminated equipment, and a recently reported possible transmission through breast milk, she said. "We have some concern about family members and maternal transmission to neonates and so we would like to consider interrupting transmission by possibly culturing the individuals the babies are exposed to."

In the current study, there was a mean of 21 days between birth and colonization of the 50 infants. However, 30% tested positive within 7 days of birth, she said.

"The 30% of infants who acquired early MRSA colonization, within the first week, were 2.5 times more likely to go on to develop infection," she explained. No other risk factors for infection could be identified, although there was a nonsignificant trend toward a higher risk with lower birth weight.

In total, 16 of the 50 colonized infants (32%) eventually developed MRSA infections, which included 8 blood stream infections, 6 skin and soft tissue infections, and 2 ventilator-associated pneumonias. One of the bloodstream infections was fatal and was identified as a community-acquired MRSA strain (USA 300).

Pulse field gel electrophoresis identified USA 300 in 36% of 14 colonizing strains and 56% of 9 infection strains, she said. "This is considerably higher than what is seen in the rest of our hospital's pediatric and adult patient population, where we see a 4%-6% colonization rate and a 19% infection rate, with one-quarter of those infections being community-acquired."

Dr. Lazenby said decolonization is not currently attempted in neonates.

The current management is isolation and contact precautions to prevent spreading the infection, she said.

Dr. Lazenby said she had no disclosures to declare.

MONTREAL — Community-acquired strains are the most common source of methicillin-resistant Staphylococcus aureus colonization and infection in babies in the neonatal intensive care unit, even though they have never left the hospital, researchers found.

Findings in a 5-year retrospective study of 50 MRSA-colonized neonates in the NICU were presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

"There are higher rates of community-acquired MRSA infection in our neonates than in our general adult and pediatric patient population," said lead investigator Dr. Gweneth Lazenby of the Medical University of South Carolina in Charleston said. "This is a call for people to help us really detail the sources of such early colonization, how we can prevent it, and how we can prevent subsequent infection."

Theories on how neonates are exposed to MRSA in the NICU include maternal transmission, transmission from other family or hospital workers, contaminated equipment, and a recently reported possible transmission through breast milk, she said. "We have some concern about family members and maternal transmission to neonates and so we would like to consider interrupting transmission by possibly culturing the individuals the babies are exposed to."

In the current study, there was a mean of 21 days between birth and colonization of the 50 infants. However, 30% tested positive within 7 days of birth, she said.

"The 30% of infants who acquired early MRSA colonization, within the first week, were 2.5 times more likely to go on to develop infection," she explained. No other risk factors for infection could be identified, although there was a nonsignificant trend toward a higher risk with lower birth weight.

In total, 16 of the 50 colonized infants (32%) eventually developed MRSA infections, which included 8 blood stream infections, 6 skin and soft tissue infections, and 2 ventilator-associated pneumonias. One of the bloodstream infections was fatal and was identified as a community-acquired MRSA strain (USA 300).

Pulse field gel electrophoresis identified USA 300 in 36% of 14 colonizing strains and 56% of 9 infection strains, she said. "This is considerably higher than what is seen in the rest of our hospital's pediatric and adult patient population, where we see a 4%-6% colonization rate and a 19% infection rate, with one-quarter of those infections being community-acquired."

Dr. Lazenby said decolonization is not currently attempted in neonates.

The current management is isolation and contact precautions to prevent spreading the infection, she said.

Dr. Lazenby said she had no disclosures to declare.

MONTREAL — Community-acquired strains are the most common source of methicillin-resistant Staphylococcus aureus colonization and infection in babies in the neonatal intensive care unit, even though they have never left the hospital, researchers found.

Findings in a 5-year retrospective study of 50 MRSA-colonized neonates in the NICU were presented at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

"There are higher rates of community-acquired MRSA infection in our neonates than in our general adult and pediatric patient population," said lead investigator Dr. Gweneth Lazenby of the Medical University of South Carolina in Charleston said. "This is a call for people to help us really detail the sources of such early colonization, how we can prevent it, and how we can prevent subsequent infection."

Theories on how neonates are exposed to MRSA in the NICU include maternal transmission, transmission from other family or hospital workers, contaminated equipment, and a recently reported possible transmission through breast milk, she said. "We have some concern about family members and maternal transmission to neonates and so we would like to consider interrupting transmission by possibly culturing the individuals the babies are exposed to."

In the current study, there was a mean of 21 days between birth and colonization of the 50 infants. However, 30% tested positive within 7 days of birth, she said.

"The 30% of infants who acquired early MRSA colonization, within the first week, were 2.5 times more likely to go on to develop infection," she explained. No other risk factors for infection could be identified, although there was a nonsignificant trend toward a higher risk with lower birth weight.

In total, 16 of the 50 colonized infants (32%) eventually developed MRSA infections, which included 8 blood stream infections, 6 skin and soft tissue infections, and 2 ventilator-associated pneumonias. One of the bloodstream infections was fatal and was identified as a community-acquired MRSA strain (USA 300).

Pulse field gel electrophoresis identified USA 300 in 36% of 14 colonizing strains and 56% of 9 infection strains, she said. "This is considerably higher than what is seen in the rest of our hospital's pediatric and adult patient population, where we see a 4%-6% colonization rate and a 19% infection rate, with one-quarter of those infections being community-acquired."

Dr. Lazenby said decolonization is not currently attempted in neonates.

The current management is isolation and contact precautions to prevent spreading the infection, she said.

Dr. Lazenby said she had no disclosures to declare.

MONTREAL — Mycoplasma genitalium is probably an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings that implicate the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women.

M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” he said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” he said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

To rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said.

Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium, Dr. Wiesenfeld said.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” he said.

MONTREAL — Mycoplasma genitalium is probably an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings that implicate the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women.

M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” he said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” he said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

To rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said.

Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium, Dr. Wiesenfeld said.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” he said.

MONTREAL — Mycoplasma genitalium is probably an underrecognized cause of some cases of cervicitis, but the role of the physician in screening for and treating this organism remains unclear, according to Dr. Harold Wiesenfeld of Magee-Womens Hospital and the University of Pittsburgh.

Dr. Wiesenfeld outlined his work showing a link between M. genitalium and subclinical pelvic inflammatory disease, as well as more recent findings that implicate the organism in cervicitis, at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

“Many cases, perhaps most cases, of cervicitis occur in women who are negative for the traditional pathogens known to cause cervicitis, such as Neisseria gonorrhoeae and Chlamydia trachomatis,” he said in an interview. “Our findings may explain the etiology of cervicitis in some women.”

His study of 524 women at risk for lower genital tract infection and undergoing testing for sexually transmitted disease found elevated polymorphonuclear leukocytes (PMNs), a microscopic marker for cervical inflammation, in 22% of the women.

M. genitalium was identified in 8% of the overall cohort, but occurred more frequently among those with elevated PMNs compared with those without (37% vs. 21%). In fact, among all women with elevated PMNs, M. genitalium was the most common pathogen “eclipsing the more traditionally recognized cervicitis organisms,” he said.

In contrast, only 32% of those with elevated PMNs had C. trachomatis, 22% had N. gonorrhoeae, 22% had bacterial vaginosis, and 21% had Trichomonas vaginalis.

After logistic regression, infection with M. genitalium was independently associated with elevated PMNs, with an odds ratio of 2.5, he said.

“As there is an independent association between M. genitalium and cervical inflammation, it is likely that M. genitalium is the cause of a true cervical infection rather than just a colonizing organism,” he said. “I would not expect a colonizing organism to cause a cervical inflammatory response.”

To rule out confounding STDs, the analysis was then restricted to 345 women who had tested negative for gonorrhea, chlamydia, and Trichomonas species. Eight percent of this cohort tested positive for M. genitalium, and 46% of this group had elevated PMNs compared with the 18 women who had no STD infections.

“After controlling for age, M. genitalium infection was independently associated with elevated PMNs with an odds ratio of 4.7,” he said.

Only a minority of women had clinical signs of cervicitis, and there were no clinical differences between those who tested positive or negative for M. genitalium, Dr. Wiesenfeld said.

The findings shed new light on the contributions of M. genitalium to cervicitis, but “at this point I do not think that these findings will change the routine management of cervicitis,” he said.