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Pasquale J, Gialdini C, Chamillard M, Diaz V, Rijken MJ, Browne JL, Seto MTY, Cheung KW, Bonet M. Clinical algorithms for the monitoring and management of spontaneous, uncomplicated labour and childbirth. BJOG 2024. [PMID: 38986678 DOI: 10.1111/1471-0528.17895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 05/31/2024] [Accepted: 06/10/2024] [Indexed: 07/12/2024]
Abstract
The aim of this manuscript is to develop evidence-based clinical algorithms for the assessment and management of spontaneous, uncomplicated labour and vaginal birth. The population is pregnant women at any stage of labour, with singleton, term pregnancies considered to be at low risk of developing complications in health facilities in low and middle income countries. We searched for relevant published algorithms, guidelines, systematic reviews and primary research studies on Cochrane Library, PubMed® and Google, using terms related to spontaneous, uncomplicated labour and childbirth up to 1 June 2023. Three case scenarios were developed to cover the assessment and management of spontaneous, uncomplicated first, second and third stages of labour. The algorithms provide pathways for definition, assessments, diagnosis and links to other algorithms in this series for the management of complications. We have developed three clinical algorithms to support evidence-based decision-making during spontaneous, uncomplicated labour and vaginal birth. These algorithms may help to guide healthcare staff to institute respectful care, with appropriate interventions where needed, and potentially will reduce the unnecessary use of interventions during labour and childbirth.
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Affiliation(s)
- Julia Pasquale
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Celina Gialdini
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
- Fundacio Blanquerna, Barcelona, Spain
| | | | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Marcus J Rijken
- Department of Global Public Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joyce L Browne
- Department of Global Public Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mimi Tin Yan Seto
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Mercedes Bonet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Program of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Shamim MA, Kumar J, Patil AN, Tiwari K, Sharma S, Anil A, Saravanan A, Sandeep M, Varthya SB, Singh S, Ahmed MI, Najmi A, Shamim MA, Gandhi A, Satapathy P, Sah R, Rustagi S, Gaidhane AM, Zahiruddin QS, Khatib MN, Padhi BK, Singh K, Dwivedi P. PeRinatal, neOnatal, and Maternal OuTcomEs with azithromycin prophylaxis in pregnancy and labour (PROMOTE-PROPHYLAXIS): systematic review and meta-analysis. EClinicalMedicine 2024; 73:102691. [PMID: 39022799 PMCID: PMC11253273 DOI: 10.1016/j.eclinm.2024.102691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/23/2024] [Accepted: 05/31/2024] [Indexed: 07/20/2024] Open
Abstract
Background Initial randomised controlled trials (RCTs) showed that prophylactic azithromycin in pregnant women improved maternal and neonatal outcomes; however, the recent evidence did not show any benefit to neonatal survival. There is conflicting evidence over the role of azithromycin prophylaxis in antenatal and intrapartum periods. We explored whether azithromycin prophylaxis in pregnant women improves maternal and neonatal outcomes. Methods For this systematic review and meta-analysis registered on PROSPERO [CRD42023411093], we searched seven databases (PubMed, Scopus, Embase, Cochrane Library, EBSCOHost, ProQuest, and Web of Science) and clinical trial registries until 04/23/2024, for RCTs evaluating antenatal/intrapartum azithromycin prophylaxis against placebo/routine care in pregnant women. The primary outcome was neonatal mortality. Intrapartum and antenatal administration were assessed separately. We used random-effects meta-analysis. The risk of bias was assessed using the Cochrane RoB 2 tool. The GRADE approach was used to evaluate the certainty of the evidence. Findings Screening 2161 records retrieved 20 RCTs (56,381 participants). Intrapartum azithromycin may make little or no difference to neonatal mortality [5 RCTs, 44,436 participants; Risk Ratio (RR): 1.02, 95% CI 0.86-1.20, I 2 = 0%, very low certainty], and maternal mortality [3 RCTs, 44,131 participants, RR: 1.26, 0.65-2.42, I 2 = 0%, low certainty]. Similarly, antenatal azithromycin may have little or no effect on neonatal mortality [3 RCTs; 5304 participants; RR: 0.74, 0.35-1.56, I 2 = 43%, very-low certainty] and maternal mortality [3 RCTs; 8167 participants RR: 1.62, 0.67-3.91, I 2 = 0%, low certainty]. There is no data on long-term adverse outcomes and antimicrobial resistance. Interpretation Low to very low certainty evidence suggests that intrapartum or antenatal azithromycin prophylaxis in pregnant women might not reduce maternal or neonatal mortality. Funding None.
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Affiliation(s)
- Muhammad Aaqib Shamim
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Jogender Kumar
- Neonatal Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Amol N. Patil
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Krishna Tiwari
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sakshi Sharma
- Department of Pediatrics, Government District Hospital, Pratapgarh, Rajasthan, India
| | - Abhishek Anil
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Aswini Saravanan
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | | | - Shoban Babu Varthya
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Molla Imaduddin Ahmed
- Pediatric Respiratory Medicine, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, Leicestershire, LE1 5WW, United Kingdom
| | - Ahmad Najmi
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Muhammad Aasim Shamim
- Department of Hospital Administration, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Gandhi
- Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, India
| | - Prakisini Satapathy
- Center for Global Health Research, Saveetha Medical College and Hospital, Chennai, India
- Medical Laboratories Techniques Department, AL-Mustaqbal University, Hillah, Babil, Iraq
| | - Ranjit Sah
- Department of Clinical Microbiology, D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
- Department of Public Health Dentistry, D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Sarvesh Rustagi
- School of Applied and Life Sciences, Uttaranchal University, Dehradun, Uttarakhand, India
| | - Abhay M. Gaidhane
- Global Health Academy, School of Epidemiology and Public Health, Datta Meghe Institute of Higher Education, Wardha, India
| | - Quazi Syed Zahiruddin
- Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India
| | - Mahalaqua Nazli Khatib
- Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India
| | - Bijaya Kumar Padhi
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuldeep Singh
- Centre of Excellence for Tribal Health, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pradeep Dwivedi
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
- Centre of Excellence for Tribal Health, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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McCoy JA, Peled T, Weiss A, Levine LD, Grisaru-Granovsky S, Rottenstreich M. Association between Group B Streptococcus and Clinical Chorioamnionitis by Gestational Week at Delivery-A Multicenter Cohort Study. Am J Perinatol 2024. [PMID: 38806156 DOI: 10.1055/a-2334-7088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
OBJECTIVE In the era of group B Streptococcus (GBS) screening and intrapartum antibiotic prophylaxis (IAP), GBS colonization has been associated with a lower risk of chorioamnionitis, possibly due to a protective effect of IAP. We sought to confirm this finding and assess whether this association varies by gestational week at delivery. STUDY DESIGN We performed a retrospective cohort study of term (37.0-42.6 weeks), singleton parturients with known GBS status who delivered from 2005 to 2021 at two academic medical centers in Israel. We excluded patients who underwent planned cesarean, out of hospital birth, or had a fetal demise. Patients received GBS screening and IAP for GBS positivity as routine clinical care. The primary outcome was a diagnosis of clinical chorioamnionitis as determined by the International Classification of Diseases 10th Revision code, compared between GBS-positive and -negative groups, and assessed by gestational week at delivery. RESULTS Of 292,126 deliveries, 155,255 met inclusion criteria. In total, 30.1% were GBS positive and 69.9% were negative. GBS-positive patients were 21% less likely to be diagnosed with clinical chorioamnionitis than GBS-negative patients, even after controlling for confounders (1.5 vs. 2.2%, adjusted odds ratio: 0.79, 95% confidence interval: 0.68-0.92). When assessed by gestational week at delivery, there was a significantly greater difference in rates of clinical chorioamnionitis between GBS-positive versus GBS-negative groups with advancing gestational age: 1.5-fold difference at 38 to 40 weeks, but a twofold difference at 42 weeks. The risk of clinical chorioamnionitis remained stable in the GBS-positive group, but increased significantly in the GBS-negative group at 41- and 42-week gestation (2.0 vs. 2.9%, p < 0.01 at 41 weeks; up to 3.9% at 42 weeks, p < 0.01). CONCLUSION In a large multicenter cohort with universal GBS screening and IAP, GBS positivity was associated with a lower risk of chorioamnionitis, driven by an increasing rate of chorioamnionitis among GBS-negative patients after 40 weeks. KEY POINTS · GBS positivity and IAP may be associated with lower risk of chorioamnionitis.. · GBS-positive patients were less likely to be diagnosed with chorioamnionitis.. · This difference increased with advancing gestational age after 40 weeks..
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Affiliation(s)
- Jennifer A McCoy
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
- Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
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Lewnard JA, Charani E, Gleason A, Hsu LY, Khan WA, Karkey A, Chandler CIR, Mashe T, Khan EA, Bulabula ANH, Donado-Godoy P, Laxminarayan R. Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: an evidence review and modelling analysis. Lancet 2024; 403:2439-2454. [PMID: 38797180 DOI: 10.1016/s0140-6736(24)00862-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/18/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024]
Abstract
National action plans enumerate many interventions as potential strategies to reduce the burden of bacterial antimicrobial resistance (AMR). However, knowledge of the benefits achievable by specific approaches is needed to inform policy making, especially in low-income and middle-income countries (LMICs) with substantial AMR burden and low health-care system capacity. In a modelling analysis, we estimated that improving infection prevention and control programmes in LMIC health-care settings could prevent at least 337 000 (95% CI 250 200-465 200) AMR-associated deaths annually. Ensuring universal access to high-quality water, sanitation, and hygiene services would prevent 247 800 (160 000-337 800) AMR-associated deaths and paediatric vaccines 181 500 (153 400-206 800) AMR-associated deaths, from both direct prevention of resistant infections and reductions in antibiotic consumption. These estimates translate to prevention of 7·8% (5·6-11·0) of all AMR-associated mortality in LMICs by infection prevention and control, 5·7% (3·7-8·0) by water, sanitation, and hygiene, and 4·2% (3·4-5·1) by vaccination interventions. Despite the continuing need for research and innovation to overcome limitations of existing approaches, our findings indicate that reducing global AMR burden by 10% by the year 2030 is achievable with existing interventions. Our results should guide investments in public health interventions with the greatest potential to reduce AMR burden.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
| | - Esmita Charani
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Alec Gleason
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Wasif Ali Khan
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Clare I R Chandler
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Tapfumanei Mashe
- One Health Office, Ministry of Health and Child Care, Harare, Zimbabwe; Health System Strengthening Unit, WHO, Harare, Zimbabwe
| | - Ejaz Ahmed Khan
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa International Hospital, Islamabad, Pakistan
| | - Andre N H Bulabula
- Division of Disease Control and Prevention, Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Pilar Donado-Godoy
- AMR Global Health Research Unit, Colombian Integrated Program of Antimicrobial Resistance Surveillance, Corporación Colombiana de Investigación Agropecuaria, Cundinamarca, Colombia
| | - Ramanan Laxminarayan
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA.
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Astete M, Lacassie HJ. Uterotonics, magnesium sulphate and antibiotics during childbirth and peripartum: Important obstetric drugs for the anaesthesiologist. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:412-420. [PMID: 38428678 DOI: 10.1016/j.redare.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/28/2023] [Indexed: 03/03/2024]
Abstract
The main causes of maternal mortality are comorbidities, hypertensive pregnancy syndrome, obstetric haemorrhage, and maternal sepsis. For this reason, uterotonics, magnesium sulphate, and antibiotics are essential tools in the management of obstetric patients during labour and in the peripartum period. These drugs are widely used by anaesthesiologists in all departments, and play a crucial role in treatment and patient safety. For the purpose of this narrative review, we performed a detailed search of medical databases and selected studies describing the use of these drugs in patients during pregnancy, delivery and the pospartum period. Uterotonics, above all oxytocin, play an important role in the prevention and treatment of pospartum haemorrhage, and various studies have shown that in obstetric procedures, such as scheduled and emergency caesarean section, they are effective at lower doses than those hitherto accepted. We also discuss the use of carbetocin as an effective alternative that has a therapeutic advantage in certain clinical circumstances. Magnesium sulphate is the gold standard in the prevention and treatment of eclampsia, and also plays a neuroprotective role in preterm infants. We describe the precautions to be taken during magnesium administration. Finally, we discuss the importance of understanding microbiology and the pharmacology of antibiotics in the management of obstetric infection and endometritis, and draw attention to the latest trends in antibiotic regimens in labour and caesarean section.
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Affiliation(s)
- M Astete
- Equipo de Anestesia, Hospital Clínico Dr. Lautaro Navarro Avaria, Punta Arenas, Chile
| | - H J Lacassie
- División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Crosara LF, Orsini PVB, Eskandar K, Khalil SM, Castilhos GSF, Strahl PAM, Milbradt TL, Philip CE. Single-dose oral azithromycin prophylaxis in planned vaginal delivery for sepsis prevention: A systematic review and meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2024; 165:107-116. [PMID: 37724021 DOI: 10.1002/ijgo.15124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/26/2023] [Accepted: 08/27/2023] [Indexed: 09/20/2023]
Abstract
INTRODUCTION The use of oral azithromycin (AZI) as a preventive measure against postpartum infections of planned vaginal births has garnered a lot of interest in recent years and has been the subject of many randomized controlled trials (RCTs). However, the results from these trials have not been consistent. Therefore, we aim to perform a systematic review and meta-analysis to determine whether the use of a single-dose of oral AZI is clinically significant. METHODS We systematically searched PubMed, Embase, and Cochrane Central for RCTs from May to June 2023, comparing a single dose of oral AZI with placebo in patients undergoing planned vaginal delivery at a minimum of 28 weeks of gestational age. The main outcomes were puerperal and neonatal sepsis. Statistical analyses were performed using Review Manager 5.4.1 (Cochrane Collaboration). Heterogeneity was assessed with I2 statistics. RESULTS Four RCTs were included (mothers, n = 42 235; newborns n = 42 492). Approximately 49.8% of mothers received a single dose of oral AZI for sepsis prophylaxis. Compared with placebo, AZI significantly reduced the incidence of puerperal sepsis (risk ratio [RR], 0.65 [95% confidence interval (CI), 0.55-0.77]; P < 0.001), mastitis or breast abscess (RR, 0.58 [95% CI, 0.42-0.79]; P < 0.001), endometritis (RR, 0.65 [95% CI, 0.54-0.77]; P < 0.001), wound infection (RR, 0.81 [95% CI, 0.69-0.96]; P = 0.013), infection rate (RR, 0.62 [95% CI, 0.51-0.76]; P < 0.001), and fever (RR, 0.50 [95% CI, 0.28-0.89]; P = 0.018) in mothers. No statistically significant differences were identified between groups regarding maternal all-cause mortality and the use of prescribed postpartum antibiotics. Similarly, no statistical differences were noted in the neonatal group regarding sepsis, infection rate, and all-cause mortality. CONCLUSION AZI appears to be an effective preventive measure against many postpartum infections in mothers but a substantial impact on neonatal outcomes has not yet been conclusively observed.
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Affiliation(s)
- L F Crosara
- Department of Medicine, Federal University of Santa Maria, Santa Maria, Brasil
| | - P V B Orsini
- Department of Medicine, Federal University of Santa Maria, Santa Maria, Brasil
| | - K Eskandar
- Department of Medicine, Pontifical Catholic University of Paraná, Curitiba, Brasil
| | - S M Khalil
- Department of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - G S F Castilhos
- Department of Medicine, Federal University of Santa Maria, Santa Maria, Brasil
| | - P A M Strahl
- Department of Medicine, Federal University of Santa Maria, Santa Maria, Brasil
| | - T L Milbradt
- Department of Medicine, Federal University of Santa Maria, Santa Maria, Brasil
| | - C E Philip
- Department of Gynaecology, Beaumont Hospital, Dublin, Ireland
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Ye H, Hu J, Li B, Yu X, Zheng X. Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials. BMC Pregnancy Childbirth 2024; 24:200. [PMID: 38486177 PMCID: PMC10938810 DOI: 10.1186/s12884-024-06390-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/04/2024] [Indexed: 03/18/2024] Open
Abstract
OBJECTIVE This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns. DATA SOURCES We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024. METHODS We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity. RESULTS The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I2, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I2, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I2, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I2, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I2, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears. CONCLUSION In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.
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Affiliation(s)
- Haiyan Ye
- Department of adult intensive care unite, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Jinlu Hu
- Department of adult intensive care unite, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Bo Li
- Department of adult intensive care unite, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China.
| | - Xia Yu
- Department of laboratory, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Xuemei Zheng
- Department of adult intensive care unite, School of Medicine, Chengdu Women's and Children's Central Hospital, University of Electronic Science and Technology of China, Chengdu, 611731, China
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8
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Oldenburg CE, Ouattara M, Bountogo M, Boudo V, Ouedraogo T, Compaoré G, Dah C, Zakane A, Coulibaly B, Bagagnan C, Hu H, O’Brien KS, Nyatigo F, Keenan JD, Doan T, Porco TC, Arnold BF, Lebas E, Sié A, Lietman TM. Mass Azithromycin Distribution to Prevent Child Mortality in Burkina Faso: The CHAT Randomized Clinical Trial. JAMA 2024; 331:482-490. [PMID: 38349371 PMCID: PMC10865159 DOI: 10.1001/jama.2023.27393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/14/2023] [Indexed: 02/15/2024]
Abstract
Importance Repeated mass distribution of azithromycin has been shown to reduce childhood mortality by 14% in sub-Saharan Africa. However, the estimated effect varied by location, suggesting that the intervention may not be effective in different geographical areas, time periods, or conditions. Objective To evaluate the efficacy of twice-yearly azithromycin to reduce mortality in children in the presence of seasonal malaria chemoprevention. Design, Setting, and Participants This cluster randomized placebo-controlled trial evaluating the efficacy of single-dose azithromycin for prevention of all-cause childhood mortality included 341 communities in the Nouna district in rural northwestern Burkina Faso. Participants were children aged 1 to 59 months living in the study communities. Interventions Communities were randomized in a 1:1 ratio to receive oral azithromycin or placebo distribution. Children aged 1 to 59 months were offered single-dose treatment twice yearly for 3 years (6 distributions) from August 2019 to February 2023. Main Outcomes and Measures The primary outcome was all-cause childhood mortality, measured during a twice-yearly enumerative census. Results A total of 34 399 children (mean [SD] age, 25.2 [18] months) in the azithromycin group and 33 847 children (mean [SD] age, 25.6 [18] months) in the placebo group were included. A mean (SD) of 90.1% (16.0%) of the censused children received the scheduled study drug in the azithromycin group and 89.8% (17.1%) received the scheduled study drug in the placebo group. In the azithromycin group, 498 deaths were recorded over 60 592 person-years (8.2 deaths/1000 person-years). In the placebo group, 588 deaths were recorded over 58 547 person-years (10.0 deaths/1000 person-years). The incidence rate ratio for mortality was 0.82 (95% CI, 0.67-1.02; P = .07) in the azithromycin group compared with the placebo group. The incidence rate ratio was 0.99 (95% CI, 0.72-1.36) in those aged 1 to 11 months, 0.92 (95% CI, 0.67-1.27) in those aged 12 to 23 months, and 0.73 (95% CI, 0.57-0.94) in those aged 24 to 59 months. Conclusions and Relevance Mortality in children (aged 1-59 months) was lower with biannual mass azithromycin distribution in a setting in which seasonal malaria chemoprevention was also being distributed, but the difference was not statistically significant. The study may have been underpowered to detect a clinically relevant difference. Trial Registration ClinicalTrials.gov Identifier: NCT03676764.
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Affiliation(s)
- Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
| | | | | | | | | | | | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | | | | | | | - Huiyu Hu
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Fanice Nyatigo
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Benjamin F. Arnold
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
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9
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Kuitunen I, Kekki M, Renko M. Intrapartum azithromycin to prevent maternal and neonatal sepsis and deaths: A systematic review with meta-analysis. BJOG 2024; 131:246-255. [PMID: 37691261 DOI: 10.1111/1471-0528.17655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/12/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES A systematic review with met-analysis was performed to summarise the evidence on the effect of intrapartum azithromycin on maternal and neonatal infections and deaths. SEARCH STRATEGY PubMed, Scopus and Web of Science databases were searched in March 2023. SELECTION CRITERIA Randomised controlled trials comparing intrapartum single-dose of azithromycin with placebo. DATA COLLECTION AND ANALYSIS Maternal infections, maternal mortality, neonatal sepsis, neonatal mortality. We used the random-effects Mantel-Haenszel method to calculate risk ratios (RR) with 95% confidence intervals (95% CI). We assessed risk of bias of the included studies and estimated the evidence certainty using the GRADE approach. MAIN RESULTS After screening 410 abstracts, five studies with 44 190 women and 44 565 neonates were included. The risk of bias was low in four and had some concerns in one of the studies. The risk of endometritis was 1.5% in the azithromycin group and 2.3% in the placebo group (RR 0.64, 95% CI 0.55-0.75), and the evidence certainty was high. The respective risk for chorioamnionitis was 0.05% and 0.1% (RR 0.50, 95% CI 0.22-1.18; evidence certainty moderate). The wound infection rate was lower in the azithromycin group (1.6%) than in the placebo group (2.5%), RR 0.52 (95% CI 0.30-0.89; moderate certainty evidence). The maternal sepsis rate was 1.1% in the azithromycin group and 1.7% in the placebo group (RR 0.66, 95% CI 0.56-0.77; evidence certainty high). Mortality rates did not show evidence of a difference (0.09% versus 0.08%; RR 1.26, 95% CI 0.65-2.42; moderate certainty evidence). The neonatal mortality rate was 0.7% in the azithromycin group and 0.8% in the placebo group (RR 0.94, 95% CI 0.76-1.16; moderate certainty evidence). The neonatal sepsis rate was 7.6% in the azithromycin group and 7.4% in the placebo group (RR 1.02, 95% CI 0.96-1.09; moderate certainty evidence). CONCLUSIONS Intrapartum administration of azithromycin to the mother reduces maternal postpartum infections, including sepsis. Impact on maternal mortality remains undecided. Azithromycin does not reduce neonatal sepsis or mortality rates.
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Affiliation(s)
- Ilari Kuitunen
- Department of Paediatrics, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Maiju Kekki
- Department of Obstetrics, Tampere University Hospital, Tampere, Finland
- Tampere Centre for Child and Maternal Health Research, Tampere University, Tampere, Finland
| | - Marjo Renko
- Department of Paediatrics, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland
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10
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Haraoui LP, Blaser MJ. The Microbiome and Infectious Diseases. Clin Infect Dis 2023; 77:S441-S446. [PMID: 38051971 DOI: 10.1093/cid/ciad577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Our perception of microbes has considerably changed since the recognition of their pathogenic potential in the 19th century. The discovery of antibiotics and their subsequent widespread adoption have substantially altered the landscape of medicine, providing us with treatment options for many infectious diseases and enabling the deployment of previously risky interventions (eg, surgical procedures and chemotherapy), while also leading to the rise of AMR. The latter is commonly viewed as the predominant downside of antibiotic use. However, with the increasing recognition that all metazoan organisms rely on a community of microbes (the microbiota) for normal development and for most physiologic processes, the negative impacts of antibiotic use now extend well beyond AMR. Using the iceberg as a metaphor, we argue that the effects of antibiotics on AMR represent the tip of the iceberg, with much greater repercussions stemming from their role in the rise of so-called noncommunicable diseases (including obesity, diabetes, allergic and autoimmune diseases, neurodevelopmental disorders, and certain cancers). We highlight some of the emerging science around the intersection of the microbiome, antibiotic use, and health (including biological costs and future therapeutic avenues), and we advocate a more nuanced approach in evaluating the impacts of proposed antibiotic use, especially in the setting of preexposure and postexposure prophylaxis.
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Affiliation(s)
- Louis-Patrick Haraoui
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche Charles-Le Moyne, Greenfield Park, Quebec, Canada
- Humans & the Microbiome Program, Canadian Institute for Advanced Research, Toronto, Ontario, Canada
| | - Martin J Blaser
- Humans & the Microbiome Program, Canadian Institute for Advanced Research, Toronto, Ontario, Canada
- Center for Advanced Biotechnology and Medicine, Rutgers University, Piscataway, New Jersey, USA
- Robert Wood Johnson School of Medicine, Departments of Medicine and Pathology & Laboratory Medicine, New Brunswick, New Jersey, USA
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11
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McCoy JA, Bromwich K, Gerson KD, Levine LD. Association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis among patients undergoing induction of labor at term. Am J Obstet Gynecol 2023; 229:672.e1-672.e8. [PMID: 37352908 PMCID: PMC10733553 DOI: 10.1016/j.ajog.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Rectovaginal colonization with Group B Streptococcus during pregnancy has historically been shown to be associated with an increased risk of clinical chorioamnionitis and peripartum infectious morbidity. OBJECTIVE Newer observational data in the era of intrapartum antibiotic prophylaxis suggest a possible reversal of this association; however, it is unclear if this is related to differences in labor management for those with and without Group B Streptococcus colonization. We therefore sought to assess the association between intrapartum antibiotic prophylaxis for Group B Streptococcus colonization and clinical chorioamnionitis within the context of a randomized induction of labor trial with a standardized labor protocol. STUDY DESIGN We performed an exploratory secondary analysis of a randomized trial of patients undergoing term induction at a tertiary care center. Patients received third trimester Group B Streptococcus screening and intrapartum antibiotic prophylaxis as routine care. Group B Streptococcus detection was performed using a carrot broth-enhanced subculture to Group B Streptococcus Detect approach (Hardy Diagnostics, Santa Maria, CA). Labor management was protocolized per the trial. Patients with unknown Group B Streptococcus status or who did not receive intrapartum antibiotic prophylaxis, if indicated, were excluded. The primary outcome was diagnosis of clinical chorioamnionitis, compared between patients who received intrapartum antibiotic prophylaxis for known Group B Streptococcus positive status (by culture, history, or Group B Streptococcus bacteriuria) and those who were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis. Secondary outcomes included postpartum endometritis, wound infection, a composite maternal peripartum infectious morbidity, and neonatal outcomes. RESULTS A total of 491 patients were enrolled in the trial. Of these, 466 had a known Group B Streptococcus status and received or did not receive intrapartum antibiotic prophylaxis accordingly and were included in this analysis: 292 (62.7%) were Group B Streptococcus negative and did not receive intrapartum antibiotic prophylaxis, and 174 (37.3%) were Group B Streptococcus positive and received intrapartum antibiotic prophylaxis. The majority of patients were Non-Hispanic Black (78.1%) and nulliparous (59.7%). There were no differences in demographic, clinical, induction or labor characteristics between groups. Patients who were Group B Streptococcus positive had a 49% lower rate of clinical chorioamnionitis (8.1% vs 14.7%, odds ratio, 0.51; P=.03) and a lower rate of peripartum infectious morbidity (8.1% vs 15.8%, odds ratio, 0.47; P=.02) compared to those who were Group B Streptococcus negative. Infants born to patients who were Group B Streptococcus positive were significantly less likely to be admitted to the neonatal intensive care unit (3.4% vs 15.1%, P<.001). CONCLUSION Although Group B Streptococcus colonization has historically been considered a risk factor for clinical chorioamnionitis, in the era of universal antibiotic prophylaxis for Group B Streptococcus positive patients, our findings support the point that intrapartum antibiotic prophylaxis for Group B Streptococcus positivity is associated with lower rates of clinical chorioamnionitis and peripartum infectious morbidity among patients undergoing induction with protocolized labor management. These findings demonstrate that intrapartum antibiotic prophylaxis for Group B Streptococcus may protect against perinatal infectious morbidity, a phenomenon that warrants further investigation.
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Affiliation(s)
- Jennifer A McCoy
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
| | - Kira Bromwich
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristin D Gerson
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa D Levine
- Maternal Fetal Medicine Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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12
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Evans C, Prendergast AJ. When and how to intervene to improve the health of children born HIV-free. J Int AIDS Soc 2023; 26 Suppl 4:e26157. [PMID: 37909224 PMCID: PMC10618881 DOI: 10.1002/jia2.26157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 08/21/2023] [Indexed: 11/02/2023] Open
Affiliation(s)
- Ceri Evans
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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13
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Duke T. Randomised controlled trials in child and adolescent health in 2023. Arch Dis Child 2023; 108:709-714. [PMID: 37474280 DOI: 10.1136/archdischild-2023-326046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
In the year July 2022 to June 2023 there were 501 publications from randomised controlled trials (RCTs) in child and adolescent health in developing countries identified through a standardised search strategy that has been going for 20 years. This year, trials addressed the widest range of diseases and conditions that affect the health, development and well-being of children, newborns, adolescents and mothers. RCTs reflected old, neglected and new problems, the changing epidemiology of child health, social and economic circumstances in many countries, local and global priorities of low-income and middle-income countries, environmental causes of poor child health, and inequities. The RCTs tested new and refined treatments, diagnostics, vaccines, holistic management, and prevention approaches, and explored many outcomes, including mortality, nutrition, psychosocial measures, and neurodevelopment. The studies were conducted in numerous hospitals and healthcare clinics, schools, and communities, including among some of the world's most disadvantaged populations in humanitarian and refugee emergencies. Some studies are of the highest quality, and others fall short. Many RCTs will influence guidelines, practice and policies for years to come.
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Affiliation(s)
- Trevor Duke
- Department of Paediatrics, University of Melbourne, and Intensive Care Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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14
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Tita ATN, Carlo WA, McClure EM. Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal Birth. Reply. N Engl J Med 2023; 389:283-284. [PMID: 37467509 DOI: 10.1056/nejmc2305875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
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15
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Eley V, Hasanin A, Landau R, Benhamou D, Mercier FJ, Bouvet L. Title: Antibiotic prophylaxis in obstetric care: is universal administration warranted? Anaesth Crit Care Pain Med 2023; 42:101235. [PMID: 37116865 DOI: 10.1016/j.accpm.2023.101235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Ahmed Hasanin
- Department of Anesthesia and Surgical Critical Care Medicine, Cairo University
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Dan Benhamou
- Service d'Anesthésie Réanimation Médecine Péri Opératoire, AP-HP. Université Paris Saclay Hôpital Bicêtre - 78, rue du Général Leclerc, France
| | - Frederic J Mercier
- Département d'Anesthésie, AP-HP. Université Paris-Saclay, Hôpital Antoine Béclère - 92140 Clamart, France
| | - Lionel Bouvet
- Service d'Anesthésie Réanimation, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, 59 boulevard Pinel, 69500 Bron, France
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16
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Sheffield JS. Prophylactic Antibiotics for Vaginal Delivery - Benefits and Possible Harms. N Engl J Med 2023; 388:1221-1223. [PMID: 36988599 DOI: 10.1056/nejme2300479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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