A Comparison of Newer and Traditional Approaches to Diagnosing Vaginal Infections

Molecular diagnostic testing (eg, polymerase chain reaction [PCR]-based vaginitis testing) is widely used in clinical practice, although vaginitis experts have reservations about its use for vaginitis diagnosis. As with any new technology, cost to the health system is a large concern. Although clinical evaluation of signs and symptoms along with wet mount microscopy is traditionally used for vaginitis diagnosis, it is less accurate compared with molecular diagnostic testing. Here we review the benefits of adopting newer molecular diagnostics into routine gynecologic practice with some guidance from vaginitis experts that favor both traditional and more modern approaches. We argue that instead of trying to resist the oncoming tide of molecular diagnostics, we can embrace them and put them to appropriate use to effect rapid, accurate, and more flexible diagnosis of vaginitis conditions for our patients.

Cefazolin as the mainstay for antibiotic prophylaxis in patients with a penicillin allergy in obstetrics and gynecology

Cefazolin is the most common antibiotic used for prophylaxis in obstetrics and gynecology. Among those with a penicillin allergy, alternative antibiotics are often chosen for prophylaxis, given fears of cross-reactivity between penicillin and cefazolin. Alternative antibiotics in this setting are associated with adverse sequelae, including surgical site infection, induction of bacterial resistance, higher costs to the healthcare system, and possible Clostridium difficile infection. Given the difference in R1 side chains between penicillin and cefazolin, cefazolin use is safe and should be recommended for patients with a penicillin allergy, including those who experience Immunoglobulin E-mediated reactions such as anaphylaxis. Cefazolin should only be avoided in those who experience a history of a severe, life-threatening delayed hypersensitivity reaction manifested as severe cutaneous adverse reactions (Steven-Johnson Syndrome), hepatitis, nephritis, serum sickness, and hemolytic anemia in response to penicillin administration. In addition, >90% of those with a documented penicillin allergy do not have true allergies on skin testing. Increased referral for penicillin allergy testing should be incorporated into routine obstetric care and preoperative assessment to reduce suboptimal antibiotic prophylaxis use. More education is needed among providers surrounding penicillin allergy assessment and cross-reactivity among penicillins and cephalosporins to optimize antibiotic prophylaxis in obstetrics and gynecology.

Standard-Dose Azithromycin in Class III Obese Patients Undergoing Unscheduled Cesarean Delivery

OBJECTIVE

 Perioperative antibiotic prophylaxis reduces cesarean wound complications. This study investigates whether integration of standard-dose (500 mg) azithromycin prophylaxis reduced wound complications in patients with class III obesity (body mass index [BMI] ≥ 40 kg/m2) undergoing unscheduled cesarean delivery.

STUDY DESIGN

 Retrospective cohort study of patients with class III obesity undergoing unscheduled cesarean delivery in single hospital system from January 1, 2017, to January 1, 2020. A standard dose (500 mg) of azithromycin was integrated into system order sets in 2018. Medical history and postoperative wound outcomes were compared in pre- and postintegration cohorts. Wound complication was defined as composite of wound seroma, hematoma, superficial or deep infection.

RESULTS

 A total of 1,273 patients met inclusion criteria, 303 patients in the preorder set group, and 970 patients in the postorder set group. Demographics were similar between the pre- and postintegration cohorts, including BMI (median: 44.4 kg/m2, p = 0.84) and weight at delivery (mean: 121.2 ± 17.8 kg, p = 0.57). Patients in the postintegration cohort had lower rates of composite postpartum wound complication (7.9 vs. 13.9%, p = 0.002), superficial infection or deep infection/abscess (6.7 vs. 10.2%, p = 0.042), and postpartum readmission or unscheduled visits (18.7 vs. 24.4%, p < 0.029). Rates of chorioamnionitis and endometritis were similar between the pre- and postintegration groups (8.6 vs. 6.9%, p = 0.33, and 1.7 vs. 1.9%, p = 0.81, respectively). Patients in the postintegration cohort had lower risk of postoperative composite wound complication (unadjusted odds ratio [OR]: 0.54, confidence interval [CI]: 0.36-0.80, p = 0.002) and lower rates of wound infection (unadjusted OR: 0.63, 95% CI: 0.40-0.99, p = 0.044). When comparing patients who received azithromycin at delivery and patients who did not, standard-dose azithromycin reduced risk of postoperative wound complication (unadjusted OR: 0.67, 95% CI: 0.46-0.99, p = 0.043).

CONCLUSION

 A standard dose of azithromycin provides adequate perioperative prophylaxis in class III obese patients, decreasing rates of postcesarean wound complications and unscheduled postpartum outpatient visits.

KEY POINTS

· Class III obese patients undergoing unscheduled cesarean have high rates of wound complications.. · Standard-dose azithromycin reduces risk of postcesarean wound infection in class III obese patients.. · Standard-dose azithromycin reduces readmission, unscheduled visits in class III obese patients..

Microbiome and Vulvovaginitis

Vulvovaginitis occurs in mostly reproductive aged women. Recurrent vaginitis affects overall quality of life, with a large financial burden on the patient, family, and health system. This review discusses a clinician's approach to vulvovaginitis with specific attention to the 2021 updated Center for Disease Control and Prevention guidelines. The authors discuss the role of the microbiome in vaginitis and evidence-based approaches for diagnosis and treatment of vaginitis. This review also provides updates on new considerations, diagnosis, management, and treatment of vaginitis. Desquamative inflammatory vaginitis and genitourinary syndrome of menopause are discussed as differential diagnosis of vaginitis symptoms.

Oral Ibrexafungerp for Vulvovaginal Candidiasis Treatment: An Analysis of VANISH 303 and VANISH 306

Background: Ibrexafungerp is a novel antifungal treatment for acute vulvovaginal candidiasis (VVC). Using pooled data from two phase three studies (VANISH 303 and 306) in the treatment of acute VVC, this analysis sought to determine the effectiveness of ibrexafungerp in various patient subgroups that may impact outcomes. Materials and Methods: Data from VANISH 303 (NCT03734991) and VANISH 306 (NCT03987620) evaluating ibrexafungerp 300 mg twice daily (BID) for 1 day versus placebo, were pooled and analyzed to determine clinical cure rate, clinical improvement, and mycological cure at the test-of-cure visit (day 11 ± 3) and symptom resolution at the follow-up visit (day 25 ± 4) in the overall population. Patient subgroups analyzed included race, body mass index (BMI), baseline vulvovaginal signs and symptoms (VSS) score, and Candida species. Results: At the test-of-cure visit, patients receiving ibrexafungerp, compared with those who received placebo, had significantly higher rates of clinical cure (56.9% [214/376 patients] vs. 35.7% [65/182 patients]), clinical improvement (68.4% [257/376 patients] vs. 45.1% [82/182 patients]), and mycological cure (54.0% [203/376 patients] vs. 24.2% [44/182 patients]; all p < 0.0001). At the follow-up visit, patients receiving ibrexafungerp had sustained responses with higher symptom resolution rates (66.8% [251/376 patients]) versus placebo (48.4% [88/182 patients]; p < 0.0001). Race, BMI, baseline VSS score (including VSS severity score 13-18), and Candida species infection did not adversely affect clinical cure rates. Safety analysis results were consistent with the individual studies. Conclusions: Ibrexafungerp provides a safe and well-tolerated first-in-class fungicidal, 1-day oral treatment for patients with acute VVC, the first new therapy in >20 years. Clinical Trial Registration Number: NCT03734991.

Outcomes After Positive Syphilis Screening

BACKGROUND

Syphilis screening during pregnancy helps prevent congenital syphilis. The harms associated with false positive (FP) screens and whether screening leads to correct treatments has not been well determined.

METHODS

The population included mothers and infants from 75 056 pregnancies. Using laboratory-based criteria we classified initial positive syphilis screens as FP or true positive (TP) and calculated false discovery rates. For mothers and infants we determined treatments, clinical characteristics, and syphilis classifications.

RESULTS

There were 221 positive screens: 183 FP and 38 TP. The false discovery rate was 0.83 (95% confidence interval [CI], 0.78-0.88). False discovery rates were similar for traditional 0.83 [95% CI, 0.72-0.94] and reverse algorithms 0.83 (95% CI, 0.77-0.88), and for syphilis Immunoglobin (Ig) G 0.79 (95% CI, 0.71-0.86) and total 0.90 (95% CI, 0.82-0.97) assays. FP screens led to treatment in 2 women and 1 infant. Two high-risk women were not rescreened at delivery and were diagnosed after hospital discharge; 1 infant developed congenital syphilis. Among 15 TP women with new syphilis, the diagnosis was before the late third trimester in 14 (93%). In one-half of these women, there was concern for reinfection, treatment failure, inadequate treatment or follow-up care, or late treatment, and their infants did not achieve an optimal syphilis classification.

CONCLUSIONS

Syphilis screening identifies maternal syphilis, but limitations include FP screens, which occasionally lead to unnecessary treatment, inconsistent risk-based rescreening, and among TP mothers failure to optimize care to prevent birth of infants at higher risk for congenital syphilis.

Risk for postpartum depressive symptoms among pregnant women in a tertiary care setting with and without a positive COVID-19 test

OBJECTIVE

This study systematically examines risk for postpartum depressive symptoms based on COVID-19 positivity status during pregnancy.

METHODS

This is a retrospective matched cohort study of pregnant patients admitted to labor and delivery units from March through December 2020. Patients were administered three depression screening questions followed by the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

129 patients with positive COVID-19 tests (most with mild symptoms) were matched with 516 COVID-19 negative controls. We found no significant differences in rates of positive responses to screening questions (14/129, 10.9% vs. 72/516, 14.0%; p = .35) or EPDS scores >9 (6/97, 6.2% vs. 42/410, 10.2%; p = .22). Prior history of psychiatric illness was the only significant predictor of an EPDS score > 9 (adjOR 2.57, p = .002) or a positive brief screen for postpartum depressive symptoms (adjOR 2.93, p < .001).

CONCLUSIONS

No significant differences in the rates for postpartum depressive symptoms were observed among pregnant women with and without a positive COVID-19 test during pregnancy, suggesting that testing positive for COVID-19 during pregnancy was not associated with an increased risk for the development of depressive symptoms during the acute postpartum period. Overall rates of postpartum depression symptoms were low, perhaps owing to the higher socioeconomic status of the sample.

Preincision adjunctive prophylaxis for cesarean deliveries a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically review the relative effectiveness of preincision cefazolin with or without adjunctive prophylaxis (macrolides or metronidazole) vs cefazolin alone in decreasing the incidence of postcesarean delivery surgical site infections.

DATA SOURCES

We performed a systematic search on PubMed, Ovid EMBASE, Google Scholar, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from October 25, 2020, to November 25, 2020, to identify studies comparing cefazolin with adjunctive macrolides or metronidazole with cefazolin alone. The reference lists were reviewed, and a manual search of articles published after the last database search was performed.

STUDY ELIGIBILITY CRITERIA

Overall, 3 randomized controlled trials and 1 prospective observational study of reproductive-age women undergoing cesarean deliveries were included in the study. We excluded studies of women who were immunocompromised (eg, patients who were HIV positive) or women with a diagnosis of chorioamnionitis before cesarean delivery. All patients received first-line cefazolin (either cefazolin 1 g or 2 g). We compared preincision cefazolin alone with preincision cefazolin plus adjunctive therapy (500 mg, oral or intravenous formulations of azithromycin, metronidazole, or clarithromycin).

METHODS

A total of 6 review authors independently assessed the risk of bias for each study, using the Cochrane Risk of Bias criteria. Synthesis and further appraisal were done using the Grading of Recommendations, Assessment, Development, and Evaluation levels and the American College of Obstetricians and Gynecologists appraisal guidelines. Disagreements were resolved by discussion. Treatment effects were evaluated using meta-analysis, and pooled relative risks and 95% confidence intervals were generated using random-effects models using the Review Manager 5 software (version 5.4.1).

RESULTS

Overall, 3 randomized controlled trials and 1 prospective observational study representing 2613 women met the criteria for inclusion. Significant reductions in surgical site infections (relative risk, 0.46; 95% confidence interval, 0.34-0.63; 3 randomized controlled trials) and the duration of hospital stay (weighted mean difference, -1.46; 95% confidence interval, -2.21 to -0.71; 2 randomized controlled trials) were observed with preincision cefazolin and adjunctive prophylaxis compared with cefazolin alone. No significant difference was observed in maternal febrile morbidity (relative risk, 0.38; 95% confidence interval, 0.11-1.25; 2 randomized controlled trials).

CONCLUSION

Our findings have provided evidence for the use of preincision adjunctive extended-spectrum prophylaxis with cefazolin over cefazolin alone. However, future investigations are required to establish the relative efficacies of different adjunctive antibiotic options.

Newly diagnosed immune thrombocytopenia in a pregnant patient after coronavirus disease 2019 vaccination

Over 26 million cases of coronavirus disease 2019 (COVID‐19) have been reported in the United States with over 440 000 deaths. Despite COVID‐19 vaccine approval, pregnant women were excluded from clinical trials. We report a case of immune thrombocytopenia in the first trimester, which occurred 13 days after initiating the COVID‐19 vaccination series. Thorough evaluation, including hematology consultation, established the diagnosis. High‐dose oral corticosteroids were started, and she was discharged home with significant improvement in platelet count on her fourth day of hospitalization with no subsequent complications. We advocate that the benefits of COVID‐19 vaccination outweigh the risk of infection in pregnancy and that pregnant women should be included in clinical trials. Closer post‐vaccination surveillance may be warranted in the pregnant population pending further data.

Risks for Recurrent Vulvovaginal Candidiasis Caused by Non-Albicans Candida Versus Candida Albicans

Background: Vulvovaginal candidiasis (VVC) is the second most common vulvovaginitis (VV). About 20% of women will experience recurrent infections in their lifetime with non-albicans Candida (NAC) species being one of the causative agents. Although studies have looked at risk factors for recurrent VVC they are limited in scope. In this study, we explore whether risks of recurrent VVC are increased with NAC infections compared to Candida albicans infections. Methods: Through an institutional review board-approved retrospective chart review, we identified 174 women with positive yeast cultures and followed their charts to assess recurrent visits and treatments. We also assessed several baseline variables such as race, age, body mass index (BMI), obstetric history, probiotic use, contraceptive use, mycological therapy, steroid use, hormone replacement therapy, menopausal status, and medical comorbidities. Results: Women with NAC VV were more likely to have multiple visits for recurring infections compared to women who had C. albicans VV (66% vs. 34%). The women with multiple recurrences were younger, had a lower BMI, had lower parity, and endorsed higher use of probiotics. Conclusion: Women with positive NAC cultures were more likely to have multiple visits to their physicians for VV complaints. Identifying the causative species using vaginal fungal cultures can more accurately guide therapy and lead to better outcomes for these patients.

Optimizing mother-baby wellness during the 2019 coronavirus disease pandemic: A case for telemedicine

Background:

The 2019 coronavirus disease pandemic poses unique challenges to healthcare delivery. To limit the exposure of providers and patients to severe acute respiratory syndrome coronavirus 2, the Centers for Disease Control and Prevention encourages providers to use telehealth platforms whenever possible. Given the maternal mortality crisis in the United States and the compounding 2019 coronavirus disease public health emergency, continued access to quality preconception, prenatal, intrapartum, and postpartum care are essential to the health and well-being of mother and baby.

Objective:

This commentary explores unique opportunities to optimize virtual obstetric care for low-risk and high-risk mothers at each stage of pregnancy.

Methods:

In this review paper, we present evidence-based literature and tools from first-hand experience implementing telemedicine in obstetric care clinics during the pandemic.

Results:

Using the best evidence-based practices with telemedicine, health care providers can deliver care in the safest, most respectful, and appropriate way possible while providing the critical support necessary in pregnancy. In reviewing the literature, several studies endorse the implementation of specific tools outlined in this article, to facilitate the implementation of telemedicine. From a quality improvement standpoint, evidence-based telemedicine provides a solution for overburdened healthcare systems, greater confidentiality for obstetric services, and a personalized avenue for health care providers to meet maternal health needs in the pandemic.

Conclusion:

During the COVID-19 pandemic, continued access to quality prenatal, intrapartum, and postpartum care are essential to the health and well-being of mother and baby.

Impact of the COVID-19 Pandemic and Obstetrician and Gynecologist Workforce Distribution on Vaccine Deployment and Predicting Women's Healthcare Shortages

Background Obstetricians and gynecologists, who serve a vital role in providing women's healthcare in the United States, are at risk of COVID-19 exposure via asymptomatic patients and deliveries. This study analyzes state-level geographical distribution of COVID-19 cases and age distribution of Obstetricians and gynecologists (OB/GYNs) to project which US regions will experience a more significant COVID-19 patient burden and provides a guide for vaccine distribution in the OB/GYN workforce. Methods The Association of American Medical Colleges' state-level workforce data is combined with COVID-19 case data reported by Johns Hopkins University. All data and code are available at https://github.com/cxr244/covid-obgyn. Results Our findings illustrate that OB/GYNs in the Midwestern region of the US experience the highest number of COVID-19 patients per OB/GYN over 60 years of age: North Dakota, South Dakota, Iowa, Wisconsin, and Idaho have the highest burden of COVID-19 patients per OB/GYN, warranting vaccine distribution priority. Additionally, states with the highest proportion of OB/GYNs over the age of 60 like Florida (38%), New Mexico (37%), Alabama (36%), California (36%), and New Jersey (34%), should be strongly considered for priority vaccine allocation, to mitigate predicted OB/GYN workforce shortages.  Conclusion When planning and executing vaccine allocation, especially in the early stages of distribution, it is critical to evaluate which communities can benefit the greatest from the limited number of vaccines. A strategy of distribution of COVID-19 vaccines to older physicians with a more significant COVID-19 burden can minimize shortages of providers within these states and ensure adequate access to women's healthcare within the communities they serve.

Outcomes of Minimally Invasive Management of Tubo-ovarian Abscess: A Systematic Review

OBJECTIVE

To compare the success rate, complications, and hospital length-of-stay of 3 modalities of minimally invasive management of tubo-ovarian abscesses (TOAs): laparoscopy, ultrasound-guided drainage, and computed tomography-guided drainage.

DATA SOURCES

Electronic-based search in PubMed, EMBASE, Ovid MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, using the following Medical Subject Heading terms: "minimally invasive surgical procedures," "drainage," "abscess," "tubo-ovarian," "ovarian diseases," and "fallopian tube diseases."

METHODS OF STUDY SELECTION

Of the 831 articles in the initial results, 10 studies were eligible for inclusion in our systematic review.

TABULATION, INTEGRATION, AND RESULTS

A total of 975 patients were included in our study; 107 (11%) had laparoscopic drainage procedures, and 406 (42%) had image-guided (ultrasound or computed tomography) drainage of TOAs. Image-guided TOA drainage had higher success rates (90%-100%) than laparoscopic drainage (89%-96%) and the use of antibiotic treatment alone (65%-83%). Patients treated with image-guided drainage had no complications (for up to 6 months of follow-up) and shorter lengths of hospital stay (0-3 days on average) compared with laparoscopic drainage (5-12 days) or conservative management with antibiotics alone (7-9 days).

CONCLUSION

Although conservative management of TOAs with antibiotics alone remains first-line, our review indicates that better outcomes in the management of TOA were achieved by minimally invasive approach compared with conservative treatment with antibiotics only. Of the minimally invasive techniques, image-guided drainage of TOAs provided the highest success rates, the fewest complications, and the shortest hospital stays compared with laparoscopy. The low magnitude of evidence in the included studies calls for further randomized trials. This systematic review was registered in the International Prospective Register of Systematic Review (register, http://www.crd.york.ac.uk/PROSPERO;CRD 42020170345).

Risk of urinary tract infection following vaginal delivery: a comparison between intermittent and indwelling bladder catheterization

Objectives: The primary objective of the study was to determine the risk of postpartum urinary tract infection (UTI) in women exposed to intermittent versus indwelling catheterization in labor. The secondary objective was to identify risk factors for development of postpartum UTI.Methods: A case-control study was conducted between 1 January 2013 and 31 December 2016. Cases were defined as patients who were diagnosed with UTI and controls were not diagnosed with UTI. Obstetrical, infectious, and catheterization variables were collected. Univariate and multivariate analyses were performed.Results: A total of 26,517 full-term vaginal deliveries occurred during the study period with a rate of postpartum UTI of 0.7%. There were 166 cases and 695 controls included in the analysis. There was no significant difference in the rate of UTI between patients who underwent indwelling versus intermittent (reference) catheterization (OR 1.05, 95% CI: 0.67-1.64, p = .826). On multivariate analysis, significant risk factors for UTI included the relationship between use of catheterization and duration of labor (p = .026) and history of UTI during the pregnancy (p < .001).Conclusion: In this study, there was no difference in the rate of postpartum UTI based on catheterization method. Further studies are needed to determine the optimal method of catheterization during labor and to enable providers to implement quality improvement strategies aimed at decreasing the risk of infection.

2576. The Microbiome of Recurrent Bacterial Vaginosis Compared with Asymptomatic Controls

Background

Bacterial vaginosis (BV) affects nearly 1 in 3 women in the United States and is poorly understood. The study of the vaginal microbiome, using 16S rRNA-gene amplicon sequencing, has increased our knowledge of BV. We aimed to characterize the vaginal microbiome of women with recurrent BV firstly in comparison to controls, and secondly in comparison to a sub-population of our asymptomatic controls, positive for Gardnerella vaginalis via a vaginal pathogens DNA direct probe test (DNA probe).

Methods

Women aged 18–40 years, with recurrent BV, and asymptomatic controls were prospectively enrolled. Vaginal samples were collected from each participant. DNA was extracted, amplified using primers targeting the V3-V4 variable region of the 16S rRNA-gene, and then sequenced and processed through a hybrid Qiime MICCA bioinformatics pipeline. We also tested for G. vaginalis using the DNA probe.

Results

Seventeen recurrent BV patients and 46 controls were enrolled. Β diversity (P = 0.045), but not alpha diversity (P = 0.076) differed between groups. The genera Gardnerella and Prevotella were relatively more abundant, while Lactobacillus was relatively less abundant in recurrent BV vs. control groups. Of the patients for whom results of the DNA probe for Gardnerella vaginalis were available, 11 (69%) recurrent BV patients and 14 (35%) controls were positive. Control patients, negative by the DNA probe test, showed decreased alpha diversity (P = 0.0001) and significantly different β diversity (P = 0.001) compared with recurrent BV patients. Neither alpha (P = 0.31) nor β (P = 0.096) diversity differed between recurrent BV patients and controls that were G. vaginalis positive.

Conclusion

The microbiome of recurrent BV patients is distinct from that of asymptomatic controls; recurrent BV patients exhibit different β diversity, less Lactobacillus and more Gardnerella and Prevotella. Asymptomatic Gardnerella vaginalis-colonized controls demonstrate similar microbiome profiles to those of recurrent BV patients. These findings suggest that individual factors may influence whether or not a patient with a BV microbiomic profile experiences symptoms. Further investigation into these mechanisms could yield insights into the treatment of recurrent BV.

Disclosures

All authors: No reported disclosures.

2574. Temporal Changes in the Vaginal Microbiome During Treatment for Bacterial Vaginosis: Is Lactobacillus Iners an Important Player?

Background

Bacterial vaginosis (BV) is the most common vaginal condition affecting women of reproductive age and yet it remains poorly understood. Recurrent BV causes significant emotional and psychological distress and can prove difficult to resolve with currently available treatments. We aimed to investigate the microbiome of recurrent BV patients at various time points in relation to oral Metronidazole treatment.

Methods

Women aged 18–40 years, with recurrent BV, were prospectively enrolled. Vaginal samples (lavage) were collected at baseline (D0), at 7–10 days (D7) and 30–40 days (D30) after initiation of oral metronidazole treatment (500 mg BID, 7 days). DNA was extracted, amplified using primers targeting the V3-V4 region of the 16 srRNA, and then sequenced and processed through a hybrid Qiime MICCA bioinformatics pipeline.

Results

Seventeen recurrent BV patients were enrolled. Alpha diversity decreased (P = 0.0049) after the first week of treatment with oral metronidazole, but increased (P = 0.0062) to near baseline by D30. Lactobacillus iners, was the dominant Lactobacillus, with transient increase in this species corresponding with metronidazole treatment. There was also a decrease in Gardnerella vaginalis that re-normalized to baseline at 30 days. Of the 10 recurrent BV patients with data for all three time points, 4 relapsed by D30. Β diversity differed significantly between patients that relapsed and those that did not (p = 0.044). Alpha diversity did not differ between the groups (p = 0.07).

Conclusion

The dominant Lactobacillus pretreatment in this cohort was L.iners. Oral metronidazole was associated with a decrease in alpha diversity, decrease in G. vaginalis and increase in L. iners. Although L. iners increased after metronidazole treatment, this increase was not sustained by D30. Treatment with metronidazole, only temporarily altered the microbiome. Further studies are needed to clarify the role of L. iners in recurrent BV.

Disclosures

All authors: No reported disclosures.

371. Risk Factors for Non-Albicans Candidal Vulvovaginitis

Background

Every year millions of women experience vulvo-vaginal candida. While the majority of the women with vulvo-vaginal candida are infected with albicans, the distribution of non-albicans candida (NAC) species varies depending on geography, race and ethnicity, and past medical history. While there are studies that explore the relationship between these factors and the incidence of NAC many of these studies are outdated. In this study, we explore the clinical risk factors for development of NAC compared with the more common albicans candida infections.

Methods

We performed a retrospective cohort study. 174 women with a positive candida culture were identified via a database maintained by the Cleveland Clinic Microbiology department. Exclusion criteria were women with negative cultures, those under the age of 18, or with an initial encounter prior to 2004.

Results

The average age of women who presented with NAC was 41.5 [31.0, 53.0] and was not statistically significant from women with no NAC, 43.0 [42.0, 45.0] (P = 0.19). Among all initial positive yeast cultures 34.5% were C. glabrata followed by C. parapsilosis at 3.4%. Women who had a positive NAC culture were more likely to be post-menopausal than those with no NAC, 73.8 NAC vs. 26.2 no NAC (P ≤ 0.001). Additionally, women cultured with NAC were more likely to be on hormone replacement therapy, 77.8 NAC vs. 22.2 no NAC (P = 0.011). However, we found that recent antibiotic use, diabetes, and probiotic use had no impact.

Conclusion

This study shows that post-menopausal women and women who are hormone replacement therapy are more likely to be colonized by NAC indicating that these are risk factors.

Disclosures

All authors: No reported disclosures.

Vulvovaginitis: Find the cause to treat it

Vulvar and vaginal disorders are among the most common problems seen in ambulatory care. The cause is usually infectious, but noninfectious causes should also be considered, and differentiating them can be challenging. Accurate diagnosis based on patient history, physical examination, and laboratory testing is necessary so that effective therapy can be chosen.

A model to predict risk of postpartum infection after Caesarean delivery

PURPOSE

The purpose of this study is to build and validate a statistical model to predict infection after caesarean delivery (CD).

METHODS

Patient and surgical variables within 30 d of CD were collected on 2419 women. Postpartum infection included surgical site infection, urinary tract infection, endomyometritis and pneumonia. The data were split into model development and internal validation (1 January-31 August; N = 1641) and temporal validation subsets (1 September-31 December; N = 778). Logistic regression models were fit to the data with concordance index and calibration curves used to assess accuracy. Internal validation was performed with bootstrapping correcting for bias.

RESULTS

Postoperative infection occurred in 8% (95% CI 7.3-9.9), with 5% meeting CDC criteria for surgical site infections (SSI) (95% CI 4.1-5.8). Eight variables were predictive for infection: increasing BMI, higher number of prior Caesarean deliveries, emergent Caesarean delivery, Caesarean for failure to progress, skin closure using stainless steel staples, chorioamnionitis, maternal asthma and lower gestational age. The model discriminated between women with and without infection on internal validation (concordance index = 0.71 95% CI 0.67-0.76) and temporal validation (concordance index = 0.70, 95% CI 0.62, 0.78).

CONCLUSIONS

Our model accurately predicts risk of infection after CD. Identification of patients at risk for postoperative infection allows for individualized patient care and counseling.

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

PURPOSE

To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution.

METHODS

This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3-6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0-9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05-1.09; p = .02), asthma (OR 1.9; 95%CI 1.1-3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1-3.2; p = .02) were associated with increased SSI.

CONCLUSIONS

Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.