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who have experienced recent pregnancy in order to identify possible
interventions that may be delivered during prenatal care.
METHODS: We conducted a retrospective chart review of all
deceased women previously living with HIV (WLWH) who
received outpatient HIV care at our hospital-based clinic before
2017. We collected patient data regarding HIV status, most recent
pregnancy (if available), use of antiretroviral therapy (ART)
during pregnancy and before death, and cause of death. The
source of HIV infection was noted, when available, and included
perinatal infection, sexual exposure, drug use, and/or blood
transfusion. Outcomes of interest were compared among PHIV
women and non-PHIV women.
RESULTS: Seventy-nine WLWH were identified as deceased; 8 (10%)
had PHIV and 71 (90%) had non-PHIV. Almost all women were
non-Hispanic, black (68, 87%). These women died at a median age
of 46 (IQR 39-55) between the years 2005 to 2016. Twenty nine
(37%) had documented HIV drug resistance. Approximately half
of women (35, 49%) were taking ART at the time of death, but
forty-six (61%) had an AIDS-related cause of death. Compared to
non-PHIV women, PHIV women were more likely to have drug
resistant HIV (6/6, 100%, p¼0.17), die at a younger age (median
age 19 vs 49, p <0.0001) and have poorly controlled HIV (median
CD4 8 vs 100, p¼0.01). Of the 8 PHIV women, 2 (25%) had prior
pregnancies and both died within 3 years of delivery at ages 19 and
20. Both PHIV women had poorly controlled HIV infection due to
ART non-compliance and died of AIDS-related causes. In contrast,
2/46 (4%) of non-PHIV women died within 5 years of delivery at
ages 27 and 31 of cardiovascular disease and trauma.
CONCLUSIONS: Individuals living with PHIV account for 1-2% of all
people living with HIV infection in the US. Of the known WLWH
who received outpatient HIV treatment at our hospital before
death, approximately 10% had PHIV. PHIV women were more
likely to have drug resistant HIV and die at younger ages of AIDS-
related causes. Two women who had been pregnant within 5 years
of death died of AIDS-related causes due to ART non-compliance.
From these data, PHIV women are more likely to die of HIV
complications, which is a preventable cause of death. Studies of
larger sample sizes of women living with PHIV are needed to
determine if these data are generalizable. If so, providers should be
aware of the increased risk of death among PHIV following preg-
nancy and seek to develop strategies for ART adherence post-
partum.
19 A randomized controlled trial on the efficacy
and safety profile of single oral dose of fosfomycin
tromethamine versus cefuroxime axetil in the
treatment of asymptomatic bacteriuria among
pregnant women
F. Taladtad, S. Bravo
Philippine General Hospital, Manila, Philippines
OBJECTIVES: Urinary tract infections are one of the most common
illnesses among women during pregnancy. The pregnancy-induced
physiological and hormonal changes predispose them to develop
these kinds of infection. If left untreated, UTI in pregnancy may
lead to adverse fetal outcomes. The fosfomycin derivative, Fosfo-
mycin tromethamine, a broad-spectrum bactericidal antibiotic has
been approved as an oral single-dose treatment for acute uncom-
plicated cystitis.The objective of the study is to determine the ef-
ficacy and safety profile of a single 3-g dose of Fosfomycin
tromethamine versus Cefuroxime axetil in the treatment of
asymptomatic bacteriuria among pregnant patients. It aims to
IDSOG Abstracts
compare the effectiveness of Fosfomycin tromethamine and
Cefuroxime axetil in the treatment of asymptomatic bacteriuria in
terms of eradication rate of microorganisms isolated from urine
culture specimen among pregnant patients.
METHODS: Patients whose urine culture revealed significant growth
of an organism (more than 100,000 cfu/ml) and whose pathogen is
sensitive to both Fosfomycin and Cefuroxime were recruited to
enter the study. Informed consent was secured by the research
assistant. Each subject was randomized to either the group to be
given Cefuroxime or the group to be given Fosfomycin. Study
participants were assigned to one of two treatment groups by
pulling treatment indicator cards from shuffled sealed envelopes.
Patients in group one were given a single oral dose of 3grams of
Fosfomycin tromethamine dissolved in 150ml of water. Patients in
group two were given 500 mg Cefuroxime axetil capsules which
they took orally two times a day for seven days. Each patient was
given a sealed envelope (by the hired research assistant) with
assigned control number which contained the medications needed
for the whole treatment period. Patient’s follow-up consult was
scheduled three days post treatment to evaluate for any improve-
ment and/or worsening of clinical signs and symptoms and to
check for compliance to medications, by asking a series of open-
ended questions. Patients were asked regarding any side effects
experienced after intake of the medication. Clean-catch mid-
stream urine sample was collected again for post treatment urine
culture and sensitivity studies, seven days after the treatment. Pa-
tients were expected to have good compliance to the medications
they were given, follow-up three days into the treatment period
and to have the post-treatment urine culture studies done seven
days after treatment. Duration of involvement in this study was
approximately three weeks. The results of the pre-and post-treat-
ment urinary culture and sensitivity studies were compared to
check the efficacy of the assigned drug and the susceptibility of the
of the isolated uropathogens. A decrease in the number of colonies
of a single pathogen, or no growth in the repeat urine culture was
considered efficacious. Post-treatment cultures yielding the same
organism or an increase in colony counts will be recorded as
treatment failures. Patients who did not respond to the treatment
received were prescribed medications accordingly, depending on
the growth on the repeat urine culture. Effectiveness of treatment
is based on the bacterial eradication rate after the treatment of each
drug and as well as improvement in the clinical signs and symp-
toms of the patient after treatment. The microbial susceptibility to
the drug was also recorded. The safety profile was evaluated by
listing the side effects encountered during treatment. This is a
single-blinded study. The participants were instructed to avoid
disclosing the treatment they received with the other participants.
Urine specimen collected for the urine culture studies were
disposed as per hospital and laboratory protocol.
RESULTS: The most common isolated pathogen on the two groups
was Escherichia coli which was present in 64.29% of the urine
specimen of the participants involved. This was followed by
Klebsiella pneumoniae infection in 17.14% then by Enterococcus
faecalis in 10%. Both groups had almost the same isolated path-
ogens. There was no statistically significant difference in the bac-
terial growth count between the two groups. It should be noted
that for all isolated pathogens, there was a significant decrease in
the bacterial growth count after treatment with either of the two
medications given. This could be explained by the sensitivity of the
pathogens to the medications, since only those whose urine cul-
tures showed bacterial growth sensitive to both Cefuroxime and
DECEMBER 2017 American Journal of Obstetrics & Gynecology 729
IDSOG Abstracts
Fosfomycin are included in the study. Although still with signifi-
cant decrease, Escherichia coli growth count was highest among
the counts post-treatment with Cefuroxime. This could be attrib-
uted to the three participants who had unfavorable response to
treatment. Two of which had growth of a different pathogen
(Citrobacter koseri), while the other one still had growth of
Escherichia coli in the post-treatment urine culture.All the samples
included in the study were susceptible to both Cefuroxime and
Fosfomycin through in-vitro testing. However, despite appropriate
treatment, there was either persistence of bacterial growth or
growth of a new pathogen noted in three cases. This could be due
to a variety of factors. The more common cause discussed by Acar
et al., is the presence of drug resistant strains missed during the
conventional testing due to the heterogeneity of resistance (in vivo
resistance). The complex in vivo relationship of patient-infection-
antibiotic factors should be considered. Host factors apart from
spontaneous mutation and selection, as well as environmental
factors such as drug inactivation and bioconversion of antagonism
often as a result of the infection itself have been the focus of recent
studies. Resistance does not necessarily equate to treatment failure.
However, susceptibility testing in relation to existing pharmaco-
dynamics and pharmacokinetic properties are the only best at-
tempts to predict in vivo response and clinical outcome. One
hundred percent of those given Fosfomycin had resolution of their
urinary tract infection compared to 91.4% in the Cefuroxime
group. The difference, however, (p-value of 0.18), is not significant.
Twelve in the Fosfomycin group, and seven in the Cefuroxime
group had post-treatment urine culture results showing growth of
different organisms although the counts were not significant. The
relative risk of experiencing nausea associated with treatment is
around 14 times higher among women in the Fosfomycin group
than in the Cefuroxime group (1.99-100.77). Fosfomycin is a
powder preparation dissolved in 200cc of water and taken as a
single dose. This kind of preparation is not the usual preparation
of medications taken by patients. As for pregnant women, nausea
is also common. Nausea and vomiting, as well as abdominal pain
are among the anticipated side effects experienced by patients
given Fosfomycin. Both groups on the other hand, experienced
stomach upset and epigastric pain.
CONCLUSIONS: There was no statistically significant difference in
terms of eradication rates between Fosfomycin (100%) and
Cefuroxime (91.4%). However, since Cefuroxime is the standard
therapy being used for pregnant patients with asymptomatic
bacteriuria, some pathogens have already developed resistance to
the drug. Also, Fosfomycin is a single dose treatment which could
improve compliance, compared to Cefuroxime which is taken for
seven days. The most common pathogen sensitive to both Cefur-
oxime and Fosfomycin is Escherichia coli, which is present in
64.29% of the urine specimens included in the study. This was
followed by Klebsiella pneumoniae (17.14%) and Enterobacter
fecalis (10%). Almost all of the isolated pathogens were susceptible
to the drug given to the patients except for the three cases with
initial growth of Escherichia coli given Cefuroxime as treatment
but had bacterial growth in the post treatment urine culture per-
formed. Although with recurring infection noted in the three pa-
tients (7.14%) in the Cefuroxime group, with a p-value of 0.18,
this was statistically not significant. After being given Fosfomycin,
45.7% of patients in this group complained of nausea. Patients
treated with Fosfomycin have 14 times greater risk of experiencing
nausea compared to those given Cefuroxime.
730 American Journal of Obstetrics & Gynecology DECEMBER 2017
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20 Use of blood culture results and antibiotic
resistance patterns to inform choice of antibiotic for
peripartum fever
G. Wilkie1,2, S. Ona1,2, M. Prabhu2, S. R. Easter1, R. Tuomala1,2,
L. Riley2, K. Diouf1
1
Brigham and Women’s Hospital, Department of Obstetrics and Gynecology,
Boston, MA, 2Massachusetts General Hospital, Department of Obstetrics and
Genecology, Boston, MA
OBJECTIVES: We reviewed positive blood cultures and
antibiotic resistance patterns from febrile peripartum patients to
optimize our empiric antibiotic choice for obstetrical fever.
METHODS: We identified cases of obstetric bacteremia occurring
during pregnancy and up to 30 days after delivery at two tertiary
centers, where a standard protocol for evaluating fever 100.4 F
exists that includes blood cultures. Culture data was available from
2009-2013 at one center and from 2009-2017 at the other. Antibiotic
recommendations for antepartum fever include ampicillin and
gentamicin. Clindamycin is added in postpartum fever, with ampi-
cillin/sulbactam as an alternative. For suspicion of severe infection,
vancomycin and imipenem/cilastatin are recommended.
RESULTS: There were 144 blood cultures positive for pathogens. The
most commonly cultured species were Escherichia coli (22.2%,
n¼32), Bacteroides (11.1%, n¼16), Enterococcus (9.7%, n¼14),
Group B streptococcus (9.7%, n¼14), Viridans streptococci (7.6%,
n¼11) and Group A streptococcus (6.9%, n¼10). E. coli had high
rates of resistance to ampicillin (84% of isolates), but the majority
were sensitive to gentamicin (84% of isolates). Enterococcus and
Bacteroides were both pan-sensitive to ampicillin and gentamicin.
Streptococcal species were all ampicillin sensitive. There were low
rates of methicillin-resistant Staphylococcus aureus (MRSA) (1.4%,
n¼2).
CONCLUSIONS: E. coli is the most common cause of peripartum
bacteremia in our population. The rates of ampicillin-resistant E.
coli are concerning. However, the low frequency of gentamicin-
resistant E. coli supports our current initial antibiotic regimen for
antepartum fever. With high rates of ampicillin-resistant organisms
we discontinued ampicillin/sulbactam as a recommendation for
postpartum fever and changed initial therapy of severe infection to
piperacillin/tazobactam. The low rates of MRSA support not
empirically treating with vancomycin. Use of available culture data to
continually refine choices for empiric antibiotics may be important
for preventing morbidity in febrile obstetric patients. As changing
antibiotic resistance patterns is important, we plan to continue to
use our protocol to gather data and iteratively refine our antibiotic
recommendations.
21 ZIKV exposed pregnant women: testing
utilization and pregnancy outcomes
I. Goldfarb1, G. Lopez2, M. Naqvi3, L. Riley1
1
Massachusetts General Hospital, Harvard Medical School, 2Harvard
T.H.Chan School of Public Health, 3Mount Sinai School of Medicine
OBJECTIVES: The current Zika virus (ZIKV) outbreak and its po-
tential to cause Congenital Zika Syndrome have created a manage-
ment dilemma for obstetric patients and providers in light of
imperfect diagnostic studies. We sought to describe a cohort of
ZIKV-exposed pregnant women, utilization of current diagnostic
tests, risk factors for infection, and pregnancy outcomes.
METHODS: We prospectively collected demographic, exposure and
ZIKV diagnostic testing data in a cohort of pregnant women iden-
tified as ZIKV exposed over a 13 month period beginning January