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Afsari M, White A, Adhikari EH. Group B Streptococcus and Intraamniotic Inflammation and Infection. Clin Obstet Gynecol 2024; 67:576-588. [PMID: 39061126 DOI: 10.1097/grf.0000000000000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
Intraamniotic inflammation and infection complicate 2% to 5% of term deliveries. Group B Streptococcus (GBS) is a common cause of intraamniotic infection associated with invasive neonatal disease and maternal morbidity. Universal vaginal-rectal screening for GBS colonization is recommended between 36 and 37 weeks. Intrapartum antibiotic prophylaxis is recommended for individuals with positive GBS screens and other risk factors. Intravenous penicillin is the preferred antimicrobial agent. Individuals with penicillin allergies may receive cefazolin for low-risk allergies and either clindamycin or vancomycin for high-risk allergies, depending on their antimicrobial susceptibilities. Clinical trials are underway to evaluate the safety and immunogenicity of maternal anti-GBS vaccine candidates.
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Affiliation(s)
- Macy Afsari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center
| | - Alesha White
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center
- Department of Obstetrics and Gynecology, Parkland Health, Dallas, Texas
| | - Emily H Adhikari
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center
- Department of Obstetrics and Gynecology, Parkland Health, Dallas, Texas
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Saleem S, Yasmin H, Moore JL, Rahim A, Shakeel I, Lokangaka A, Tshefu A, Bauserman M, Mwenechanya M, Chomba E, Goudar SS, Kavi A, Derman RJ, Krebs NF, Figueroa L, Mazariegos M, Nyongesa P, Bucher S, Esamai F, Patel A, Waikar M, Shivkumar P, Hibberd PL, Petri WA, Billah SM, Haque R, Carlo WA, Tita A, Koso-Thomas M, Hemingway-Foday J, McClure EM, Goldenberg RL. Intrapartum and postpartum antibiotic use in seven low- and middle-income countries: Findings from the A-PLUS trial. BJOG 2024. [PMID: 39140197 DOI: 10.1111/1471-0528.17930] [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: 01/23/2024] [Revised: 07/24/2024] [Accepted: 08/01/2024] [Indexed: 08/15/2024]
Abstract
OBJECTIVE To describe the intrapartum and postpartum use of non-study antibiotics in low- and middle-income countries (LMICs) during the double-blinded NICHD Global Network Azithromycin in Labor (A-PLUS) trial. DESIGN The antibiotic use sub-study was a planned prospective, observational sub-study of the A-PLUS trial. SETTINGS The study was carried out in hospitals or health centres affiliated with eight sites of the Global Network for Women's and Children's Health Research (Global Network) in seven countries: Bangladesh, Pakistan, India (two sites), Kenya, Zambia, The Democratic Republic of the Congo (DRC) and Guatemala. POPULATION Totally, 29 278 pregnant women enrolled in the A-PLUS trial. METHODS We collected data on 29 278 pregnant women admitted to a facility for delivery related to non-study antibiotic use overall and during three time periods: (1) in the facility prior to delivery, (2) after delivery until facility discharge and (3) after discharge to 42 days post-partum. MAIN OUTCOME MEASURES Non-study antibiotic use overall and for treatment or prophylaxis by the site during the three time periods. RESULTS Of the 29 278 women in the study, 5020 (17.1%; 95% CI 16.7%-17.6%) received non-study antibiotics in the facility prior to delivery, 11 956 (40.8%; 95% CI 40.3%-41.4%) received non-study antibiotics in the facility after delivery, and 13 390 (47.6%; 95% CI 47.0%-48.2%) women received non-study antibiotics after delivery and after facility discharge. Antibiotics were prescribed more often among women in the Asian and Guatemalan sites than in the African sites. In the three time-periods, among those receiving antibiotics, prophylaxis was the indication in 82.3%, 97.7% and 90.7% of the cases, respectively. The type of antibiotics used varied substantially by time-period and site, but generally, penicillin-type drugs, cephalosporin-type drugs and metronidazole were used more frequently than other types. CONCLUSIONS Across the eight sites of the Global Network, in the facility before delivery, and in the post-partum periods before and after facility discharge, antibiotics were used frequently, but use was highly variable by site and time-period.
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Affiliation(s)
| | | | | | | | | | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Elwyn Chomba
- University of Zambia University Teaching Hospital, Lusaka, Zambia
| | - Shivaprasad S Goudar
- KLE Academy Higher Education and Research, J N Medical College Belagavi, Belagavi, Karnataka, India
| | - Avinash Kavi
- KLE Academy Higher Education and Research, J N Medical College Belagavi, Belagavi, Karnataka, India
| | | | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Lester Figueroa
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | - Manolo Mazariegos
- Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala
| | | | - Sherri Bucher
- Indiana School of Medicine, University of Indiana, Indianapolis, Indiana, USA
| | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, India
- Datta Meghe Institute of Higher Education and Research, Sawangi, India
| | | | | | | | | | - Sk Masum Billah
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
- University of Sydney, Sydney, New South Wales, Australia
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research (icddr,b), Dhaka, Bangladesh
| | | | - Alan Tita
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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Sinha T, Prins JR, Fernández-Pato A, Kruk M, Dierikx T, de Meij T, de Boer M, de Boer JF, Scherjon S, Kurilshikov A, Zhernakova A. Maternal antibiotic prophylaxis during cesarean section has a limited impact on the infant gut microbiome. Cell Host Microbe 2024; 32:1444-1454.e6. [PMID: 39146801 PMCID: PMC11335186 DOI: 10.1016/j.chom.2024.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 05/09/2024] [Accepted: 07/09/2024] [Indexed: 08/17/2024]
Abstract
Pregnant women undergoing a cesarean section (CS) typically receive antibiotics prior to skin incision to prevent infections. To investigate if the timing of antibiotics influences the infant gut microbiome, we conducted a randomized controlled trial (NCT06030713) in women delivering via a scheduled CS who received antibiotics either before skin incision or after umbilical cord clamping. We performed a longitudinal analysis on 172 samples from 28 infants at 8 post-birth time points and a cross-sectional analysis at 1 month in 79 infants from 3 cohorts. Although no significant associations with bacterial composition, metabolic pathways, short-chain fatty acids, and bile acids were found, we observed subtle differences between the groups at the bacterial strain level and in the load of antibiotic resistance genes. Rather, feeding mode was a predominant and defining factor impacting infant microbial composition. In conclusion, antibiotic administration during CS has only limited effects on the early-life gut microbiome.
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Affiliation(s)
- Trishla Sinha
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Asier Fernández-Pato
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marloes Kruk
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thomas Dierikx
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Tim de Meij
- Department of Paediatric Gastroenterology, Amsterdam UMC, Emma Children's Hospital, Amsterdam, the Netherlands
| | - Marjon de Boer
- Department of Obstetrics and Gynaecology, Reproduction and Development, Amsterdam UMC Locatie VUmc, Amsterdam, the Netherlands
| | - Jan Freark de Boer
- Department of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sicco Scherjon
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alexander Kurilshikov
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Alexandra Zhernakova
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Fixler JS. Surgical-site infection in multifetal cesarean delivery. Arch Gynecol Obstet 2024; 310:1049-1053. [PMID: 38448709 DOI: 10.1007/s00404-024-07384-7] [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: 12/03/2023] [Accepted: 01/07/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE The relationship between multifetal cesarean delivery and surgical-site infection (SSI) is unclear. If SSI is more common in multifetal cesareans, adjustment of practices such as antibiotic dosing could be warranted. The purpose of this study was to determine whether patients undergoing multifetal cesarean delivery are more likely to experience SSI than those undergoing singleton cesarean delivery. METHODS This was a retrospective cohort study including all cesarean deliveries at a tertiary hospital from 10/1/2009 to 12/28/2018. The primary outcome was rate of SSI in women after multifetal cesarean delivery as compared to those who underwent singleton cesarean delivery. Univariable analysis and multivariable logistic regression were used to assess independent clinical factors associated with SSI in multifetal cesarean deliveries. RESULTS 34,340 women underwent cesarean delivery during this period. 33,211 were singletons (96.7%), and 1,129 were multifetal (3.3%). There was no difference in the rate of SSI in multifetal gestations (15/1,129, 1.3%) as compared to singletons (493/33,211, 1.5%) (p = 0.670, OR 0.89 [95% CI 0.53, 1.50], aOR 1.06 [95% CI 0.61, 1.84]). Limiting analysis to multifetal deliveries, prolonged rupture of membranes (p < 0.004, OR 5.43 [95% CI 1.49, 19.88]), labor augmentation (p < 0.001, OR 15.84 [1.74, 144.53]), and chorioamnionitis (p < 0.001, OR 15.43 [95% CI 3.11, 76.62]) were more common in women with SSI. DISCUSSION SSI is not increased in multifetal cesarean delivery as compared to singleton cesarean delivery. In multifetal cesareans, chorioamnionitis, prolonged rupture of membranes, and labor augmentation were associated with increased odds of SSI.
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Affiliation(s)
- Joseph S Fixler
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
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Liabsuetrakul T, Meher S. Intrapartum care algorithms for liquor abnormalities: oligohydramnios, meconium, blood and purulent discharge. BJOG 2024; 131 Suppl 2:90-101. [PMID: 35415944 DOI: 10.1111/1471-0528.16728] [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: 07/06/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
AIM To construct evidence-based algorithms for the assessment and management of common amniotic fluid abnormalities detected during labour. POPULATION Low-risk singleton, term pregnant women in labour. SETTING Birth facilities in low- and middle-income countries. SEARCH STRATEGY We searched international guidelines published by the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetrics and Gynaecology (SOGC) and the World Health Organization (WHO). We also searched The Cochrane Library and MEDLINE up to 20 January 2020 using keywords for relevant systematic reviews and randomised trials. CASE SCENARIOS We developed evidence-based intrapartum care algorithms for four case scenarios: oligohydramnios; meconium-stained amniotic fluid; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These conditions may be associated with fetal and /or maternal morbidity. Differential diagnosis includes uteroplacental insufficiency, fetal growth restriction, fetal distress, abruption, placenta or vasa praevia, uterine rupture and intra-amniotic infection, respectively. Algorithms include how to assess for, diagnose and manage these conditions. CONCLUSIONS Four algorithms are presented, to provide a systematic approach and guidance on the clinical management for the following amniotic fluid abnormalities: oligohydramnios; meconium-stained liquor; bloody amniotic fluid or vaginal bleeding; and purulent amniotic fluid or discharge. These algorithms may be beneficial in supporting clinical decision making, particularly in low-resource settings. TWEETABLE ABSTRACT Evidence based algorithms for management of common amniotic fluid abnormalities seen during labour.
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Affiliation(s)
- T Liabsuetrakul
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - S Meher
- The Fetal Medicine Centre, Birmingham Women's and Children's Foundation Trust, Edgbaston, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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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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Tamir Yaniv R, Farladansky-Gershnabel S, Gluska H, Daykan Y, Shechter Maor G, Schonman R, Biron-Shental T. Cesarean Delivery Complicated by Peripartum Infection and Risk of Uterine Rupture During Subsequent Trial of Labor. J Womens Health (Larchmt) 2024; 33:986-990. [PMID: 38502835 DOI: 10.1089/jwh.2023.0727] [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] [Indexed: 03/21/2024] Open
Abstract
Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery.
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Affiliation(s)
- Rina Tamir Yaniv
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | | | - Hadar Gluska
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Yair Daykan
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Gil Shechter Maor
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Ron Schonman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Tal Biron-Shental
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
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Duffy CR, Oberhardt M, Ross N, Ewing J, Messina M, Fitzgerald K, Saiman L, Goffman D. Perioperative Antibiotics and Other Factors Associated with Postcesarean Infections: A Case-Control Study. Am J Perinatol 2024; 41:e520-e527. [PMID: 35858646 DOI: 10.1055/a-1904-9583] [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] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our objective was to determine modifiable risk factors associated with surgical site infection (SSI) and postpartum endometritis. We hypothesized that inappropriate surgical antibiotic prophylaxis would be a risk factor for both types of infections. STUDY DESIGN This was a single-center case-control study of SSI and endometritis after cesarean delivery over a 2-year period from 2016 to 2017. Cases were identified by International Classification of Diseases, 10th Revision diagnosis codes, infection control surveillance, and electronic medical records search and were subsequently confirmed by chart review. Three controls were randomly selected for each case from all cesareans ± 48 hours from case delivery. Demographic, pregnancy, and delivery characteristics were abstracted. Separate multivariable logistic regression models were used to assess factors associated with SSI and endometritis. Postpartum outcomes, including length of stay and readmission, were also compared. RESULTS We identified 141 cases of SSI and endometritis with an overall postpartum infection rate of 4.0% among all cesarean deliveries. In adjusted analysis, factors associated with both SSI and endometritis were intrapartum delivery, classical or other (non-low-transverse) uterine incision, and blood transfusion. Factors associated with SSI only included inadequate antibiotic prophylaxis, public insurance, hypertensive disorder of pregnancy, and nonchlorhexidine abdominal preparation; factors only associated with endometritis included β-lactam allergy, anticoagulation therapy, and chorioamnionitis. Among cases, 34% of those with SSI and 25% of those with endometritis did not receive adequate antibiotic prophylaxis, compared with 12.9 and 13.5% in control groups, respectively. Failure to receive appropriate antibiotic prophylaxis was associated with an increased risk of SSI (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 1.3-15.6) but not endometritis (aOR 0.9, 95% CI 0.4-2.0). CONCLUSION Inadequate surgical antibiotic prophylaxis was associated with an increased risk of SSI but not postpartum endometritis, highlighting the different mechanisms of these infections and the importance of prioritizing adequate surgical prophylaxis. Additional potentially modifiable factors which emerged included blood transfusion and chlorhexidine skin preparation. KEY POINTS · Inadequate antibiotic prophylaxis is associated with a four-fold risk in surgical site infections.. · The most common cause for failure to achieve adequate surgical prophylaxis was inappropriate timing of antibiotics at or after skin incision.. · Blood transfusions are strongly associated (>10-fold risk) with both SSI and endometritis..
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Matthew Oberhardt
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- NewYork-Presbyterian Value Institute, New York, New York
| | - Naima Ross
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Julie Ewing
- NewYork-Presbyterian Value Institute, New York, New York
| | - Maria Messina
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
- Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Kelly Fitzgerald
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
- Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
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9
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Roberts AW, Hotra J, Soto E, Pedroza C, Sibai BM, Blackwell SC, Chauhan SP. Indicated vs universal third-trimester ultrasound examination in low-risk pregnancies: a pre-post-intervention study. Am J Obstet Gynecol MFM 2024; 6:101373. [PMID: 38583714 DOI: 10.1016/j.ajogmf.2024.101373] [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: 02/29/2024] [Revised: 03/13/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND In low-risk pregnancies, a third-trimester ultrasound examination is indicated if fundal height measurement and gestational age discrepancy are observed. Despite potential improvement in the detection of ultrasound abnormality, prior trials to date on universal third-trimester ultrasound examination in low-risk pregnancies, compared with indicated ultrasound examination, have not demonstrated improvement in neonatal or maternal adverse outcomes. OBJECTIVE The primary objective was to determine if universal third-trimester ultrasound examination in low-risk pregnancies could attenuate composite neonatal adverse outcomes. The secondary objectives were to compare changes in composite maternal adverse outcomes and detection of abnormalities of fetal growth (fetal growth restriction or large for gestational age) or amniotic fluid (oligohydramnios or polyhydramnios). STUDY DESIGN Our pre-post intervention study at 9 locations included low-risk pregnancies, those without indication for ultrasound examination in the third trimester. Compared with indicated ultrasound in the preimplementation period, in the postimplementation period, all patients were scheduled for ultrasound examination at 36.0-37.6 weeks. In both periods, clinicians intervened on the basis of abnormalities identified. Composite neonatal adverse outcomes included any of: Apgar score ≤5 at 5 minutes, cord pH <7.00, birth trauma (bone fracture or brachial plexus palsy), intubation for >24 hours, hypoxic-ischemic encephalopathy, seizure, sepsis (bacteremia proven with blood culture), meconium aspiration syndrome, intraventricular hemorrhage grade III or IV, periventricular leukomalacia, necrotizing enterocolitis, stillbirth after 36 weeks, or neonatal death within 28 days of birth. Composite maternal adverse outcomes included any of the following: chorioamnionitis, wound infection, estimated blood loss >1000 mL, blood transfusion, deep venous thrombus or pulmonary embolism, admission to intensive care unit, or death. Using Bayesian statistics, we calculated a sample size of 600 individuals in each arm to detect >75% probability of any reduction in primary outcome (80% power; 50% hypothesized risk reduction). RESULTS During the preintervention phase, 747 individuals were identified during the initial ultrasound examination, and among them, 568 (76.0%) met the inclusion criteria at 36.0-37.6 weeks; during the postintervention period, the corresponding numbers were 770 and 661 (85.8%). The rate of identified abnormalities of fetal growth or amniotic fluid increased from between the pre-post intervention period (7.1% vs 22.2%; P<.0001; number needed to diagnose, 7; 95% confidence interval, 5-9). The primary outcome occurred in 15 of 568 (2.6%) individuals in the preintervention and 12 of 661 (1.8%) in the postintervention group (83% probability of risk reduction; posterior relative risk, 0.69 [95% credible interval, 0.34-1.42]). The composite maternal adverse outcomes occurred in 8.6% in the preintervention and 6.5% in the postintervention group (90% probability of risk; posterior relative risk, 0.74 [95% credible interval, 0.49-1.15]). The number needed to treat to reduce composite neonatal adverse outcomes was 121 (95% confidence interval, 40-200). In addition, the number to reduce composite maternal adverse outcomes was 46 (95% confidence interval, 19-74), whereas the number to prevent cesarean delivery was 18 (95% confidence interval, 9-31). CONCLUSION Among low-risk pregnancies, compared with routine care with indicated ultrasound examination, implementation of a universal third-trimester ultrasound examination at 36.0-37.6 weeks attenuated composite neonatal and maternal adverse outcomes.
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Affiliation(s)
- Aaron W Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan).
| | - John Hotra
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Eleazar Soto
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, Department of Pediatrics, The University of Texas Health Science Center at Houston, Houston, TX (Dr Pedroza)
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX (Dr Roberts, Mr Hotra, Drs Soto, Sibai, Blackwell, and Chauhan)
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10
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Kominiarek MA, Espinal M, Cassimatis IR, Peace JM, Premkumar A, Toledo P, Shramuk M, Wafford EQ. Peripartum interventions for people with class III obesity: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101354. [PMID: 38494155 DOI: 10.1016/j.ajogmf.2024.101354] [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: 11/17/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE This study aimed to identify evidence-based peripartum interventions for people with a body mass index ≥40 kg/m2. DATA SOURCES PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions. STUDY ELIGIBILITY CRITERIA Cohort and randomized controlled trials that implemented an intervention and evaluated peripartum outcomes of people with a body mass index ≥40 kg/m2 were included. The primary outcome depended on the intervention but was commonly related to wound morbidity after cesarean delivery (ie, infection, separation, hematoma). METHODS Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios with 95% confidence intervals and heterogeneity (I2 statistics) were reported. RESULTS Of 20,301 studies screened, 30 studies (17 cohort and 13 randomized controlled trials) encompassing 10 types of interventions were included. The interventions included delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, 6 types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared with planned vaginal delivery did not improve outcomes according to 3 cohort studies. One cohort study compared 3 g with 2 g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 randomized controlled trials, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort and 6 randomized controlled trials) met the inclusion criteria for the meta-analysis. Two randomized controlled trials compared subcuticular closure with suture vs staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; risk ratio, 1.09; 95% confidence interval, 0.75-1.59; I2=9%). Prophylactic negative-pressure wound therapy was compared with standard dressing in 4 cohort and 4 randomized controlled trials, which found no differences in wound morbidity (cohort n=2200; risk ratio, 1.19; 95% confidence interval, 0.88-1.63; I2=66.1%) or surgical site infections (randomized controlled trial n=1262; risk ratio, 0.90; 95% confidence interval, 0.63-1.29; I2=0). CONCLUSION Few studies address interventions in people with a body mass index ≥40 kg/m2, and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic negative-pressure wound therapy after cesarean delivery for people with a body mass index ≥40 kg/m2.
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Affiliation(s)
- Michelle A Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Kominiarek and Espinal).
| | - Mariana Espinal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL (Drs Kominiarek and Espinal)
| | - Irina R Cassimatis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR (Dr Cassimatis)
| | - Jack M Peace
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (Dr Peace)
| | - Ashish Premkumar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL (Dr Premkumar)
| | - Paloma Toledo
- Department of Anesthesiology, University of Miami, Miami, FL (Dr Toledo)
| | - Maxwell Shramuk
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (Mr Shramuk)
| | - Eileen Q Wafford
- Galter Health Sciences Library & Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL (Ms Wafford)
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11
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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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12
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Kehl S. Obesity at term: What to consider? How to deliver? Arch Gynecol Obstet 2024; 309:1725-1733. [PMID: 38326633 DOI: 10.1007/s00404-023-07354-5] [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: 11/03/2023] [Accepted: 12/17/2023] [Indexed: 02/09/2024]
Abstract
Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.
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Affiliation(s)
- Sven Kehl
- Department of Obstetrics and Gynaecology, Erlangen University Hospital, Universitätsstr. 21-23, 91054, Erlangen, Germany.
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13
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Mackeen AD, Sullivan MV, Berghella V. Evidence-based cesarean delivery: preoperative management (part 7). Am J Obstet Gynecol MFM 2024; 6:101362. [PMID: 38574855 DOI: 10.1016/j.ajogmf.2024.101362] [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: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.
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Affiliation(s)
- A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan).
| | - Maranda V Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan)
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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14
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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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15
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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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Jung E, Romero R, Suksai M, Gotsch F, Chaemsaithong P, Erez O, Conde-Agudelo A, Gomez-Lopez N, Berry SM, Meyyazhagan A, Yoon BH. Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment. Am J Obstet Gynecol 2024; 230:S807-S840. [PMID: 38233317 PMCID: PMC11288098 DOI: 10.1016/j.ajog.2023.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 04/05/2023]
Abstract
Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The condition is suspected when intrapartum fever is associated with two other maternal and fetal signs of local or systemic inflammation (eg, maternal tachycardia, uterine tenderness, maternal leukocytosis, malodorous vaginal discharge or amniotic fluid, and fetal tachycardia). Clinical chorioamnionitis is a syndrome caused by intraamniotic infection, sterile intraamniotic inflammation (inflammation without bacteria), or systemic maternal inflammation induced by epidural analgesia. In cases of uncertainty, a definitive diagnosis can be made by analyzing amniotic fluid with methods to detect bacteria (Gram stain, culture, or microbial nucleic acid) and inflammation (white blood cell count, glucose concentration, interleukin-6, interleukin-8, matrix metalloproteinase-8). The most common microorganisms are Ureaplasma species, and polymicrobial infections occur in 70% of cases. The fetal attack rate is low, and the rate of positive neonatal blood cultures ranges between 0.2% and 4%. Intrapartum antibiotic administration is the standard treatment to reduce neonatal sepsis. Treatment with ampicillin and gentamicin have been recommended by professional societies, although other antibiotic regimens, eg, cephalosporins, have been used. Given the importance of Ureaplasma species as a cause of intraamniotic infection, consideration needs to be given to the administration of antimicrobial agents effective against these microorganisms such as azithromycin or clarithromycin. We have used the combination of ceftriaxone, clarithromycin, and metronidazole, which has been shown to eradicate intraamniotic infection with microbiologic studies. Routine testing of neonates born to affected mothers for genital mycoplasmas could improve the detection of neonatal sepsis. Clinical chorioamnionitis is associated with decreased uterine activity, failure to progress in labor, and postpartum hemorrhage; however, clinical chorioamnionitis by itself is not an indication for cesarean delivery. Oxytocin is often administered for labor augmentation, and it is prudent to have uterotonic agents at hand to manage postpartum hemorrhage. Infants born to mothers with clinical chorioamnionitis near term are at risk for early-onset neonatal sepsis and for long-term disability such as cerebral palsy. A frontier is the noninvasive assessment of amniotic fluid to diagnose intraamniotic inflammation with a transcervical amniotic fluid collector and a rapid bedside test for IL-8 for patients with ruptured membranes. This approach promises to improve diagnostic accuracy and to provide a basis for antimicrobial administration.
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Affiliation(s)
- Eunjung Jung
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.
| | - Manaphat Suksai
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Francesca Gotsch
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Piya Chaemsaithong
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Mahidol University, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Offer Erez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Agustin Conde-Agudelo
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Nardhy Gomez-Lopez
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
| | - Stanley M Berry
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arun Meyyazhagan
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Centre of Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Bo Hyun Yoon
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
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17
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Cozzi GD, Ye Y, Mbah R, Mbunwe DM, Pekwarake S, Yui Bunwi E, Fondzeyuf A, Ngong MG, Dionne JA, Harper LM, Jauk VC, Carlo WA, Halle-Ekane G, Tih PM, Szychowski JM, Tita AT, Subramaniam A. Predicting peripartum infection in laboring patients at high risk in Cameroon, Africa. Eur J Obstet Gynecol Reprod Biol 2024; 293:9-14. [PMID: 38096705 DOI: 10.1016/j.ejogrb.2023.12.003] [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: 05/19/2023] [Revised: 11/07/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To develop a predictive model for peripartum infection among high risk laboring patients in Cameroon, Africa. STUDY DESIGN We conducted a secondary analysis of the Cameroon Antibiotic Prophylaxis Trial (NCT03248297), a multicenter 3-arm double-blind randomized controlled trial of oral azithromycin ± amoxicillin among term pregnancies with prolonged labor or rupture of membranes in Cameroon 1/2018-5/2020. Patients with chorioamnionitis prior to randomization, study drug contraindications, or planned cesarean were excluded. The outcome of interest was a composite of maternal peripartum infection (chorioamnionitis, endometritis, sepsis by World Health Organization criteria, wound infection/abscess) diagnosed up to 6 weeks postpartum. Potential predictors were compared between patients with and without the composite outcome, and evaluated at a 0.05 alpha level. Statistically significant exposures were analyzed using multivariable regression (to generate adjusted odds ratios and 95 % confidence intervals) with backwards selection to generate a parsimonious model. Receiver operating characteristic curves with associated area under the curve assessed the model's predictive ability. A nomogram based on the final best fit multivariable model was constructed. RESULTS Of 756 patients in the parent trial, 652 were analyzed: 45 (7 %) had peripartum infection. Those with infection were more likely to be nulliparous, lower education level, higher gestational age, receive antibiotics per hospital protocols, and undergo cesarean. In our best-fit multivariable model, none/primary education (vs university), cesarean birth, and antibiotic receipt per physician discretion (vs for cesarean prophylaxis) were significantly associated with increased infection risk. This model was moderately predictive (AUC = 0.75, 95 % CI 0.67-0.82). When using this 3 factor model, for a patient with a cesarean birth, receipt of antibiotics per physician discretion, and university education, the probability of peripartum infection was 35 % (95 % CI 0.11-0.73). CONCLUSIONS While several variables such as parity are associated with infectious morbidity within 6 weeks among high risk laboring patients in Cameroon, only education level, antibiotic indication, and cesarean birth were independently associated, and a model including these 3 factors was moderately predictive. Validation of our findings in a larger population is warranted.
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Affiliation(s)
- Gabriella D Cozzi
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Yuanfan Ye
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rahel Mbah
- Cameroon Baptist Convention Health Services, Cameroon, Africa
| | - Doreen M Mbunwe
- Cameroon Baptist Convention Health Services, Cameroon, Africa
| | | | - Edwan Yui Bunwi
- Cameroon Baptist Convention Health Services, Cameroon, Africa
| | | | - Mary G Ngong
- Cameroon Baptist Convention Health Services, Cameroon, Africa
| | - Jodie A Dionne
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lorie M Harper
- Department of Women's Health, Division of Maternal Fetal Medicine, University of Texas at Austin, Dell School of Medicine, Austin, TX, USA
| | - Victoria C Jauk
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory Halle-Ekane
- Cameroon Baptist Convention Health Services, Cameroon, Africa; University of Buea, Cameroon, Africa
| | - Pius M Tih
- Cameroon Baptist Convention Health Services, Cameroon, Africa
| | - Jeff M Szychowski
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alan T Tita
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akila Subramaniam
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
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18
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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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19
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Basany K, Chaudhuri S, Shailaja P. L, Agiwal V, Angaali N, A. Y. N, D. S, Haggerty C, Reddy PS. Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India. PLoS One 2024; 19:e0286165. [PMID: 38271389 PMCID: PMC10810521 DOI: 10.1371/journal.pone.0286165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 12/21/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates. MAIN OBJECTIVES To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India. METHODS A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity. RESULTS The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%). CONCLUSION The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.
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Affiliation(s)
- Kalpana Basany
- Department of Obstetrics and Gynecology, Society for Health Allied Research and Education, INDIA MediCiti Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sirshendu Chaudhuri
- Department of Epidemiology, Indian Institute of Public Health, Hyderabad, Telangana, India
| | - Lakshmi Shailaja P.
- Department of Obstetrics and Gynecology, Fernandez Hospital, Hyderabad, Telangana, India
| | - Varun Agiwal
- Department of Epidemiology, Indian Institute of Public Health, Hyderabad, Telangana, India
| | - Neelima Angaali
- Department of Microbiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Nirupama A. Y.
- Department of Epidemiology, Indian Institute of Public Health, Hyderabad, Telangana, India
| | - Shailendra D.
- Department of Pharmacology, SHARE INDIA, MediCiti Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Catherine Haggerty
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - P. S. Reddy
- Department of Obstetrics and Gynecology, Society for Health Allied Research and Education, INDIA MediCiti Institute of Medical Sciences, Hyderabad, Telangana, India
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
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20
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Shah NM, Charani E, Ming D, Cheah FC, Johnson MR. Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis. JOURNAL OF INTENSIVE MEDICINE 2024; 4:46-61. [PMID: 38263965 PMCID: PMC10800776 DOI: 10.1016/j.jointm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 01/25/2024]
Abstract
Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.
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Affiliation(s)
- Nishel M Shah
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Damien Ming
- Department of Infectious Diseases, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
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21
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Boureka E, Krasias D, Tsakiridis I, Karathanasi AM, Mamopoulos A, Athanasiadis A, Dagklis T. Prevention of Early-Onset Neonatal Group B Streptococcal Disease: A Comprehensive Review of Major Guidelines. Obstet Gynecol Surv 2023; 78:766-774. [PMID: 38134342 DOI: 10.1097/ogx.0000000000001223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Importance Group B Streptococcus (GBS) colonization during pregnancy is associated with significant neonatal morbidity and mortality and represents a major public health concern, often associated with poor screening and management. Objective The aim of this study was to review and compare the most recently published influential guidelines on the screening and management of this clinical entity during antenatal and intrapartum periods. Evidence Acquisition A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, and the Society of Obstetricians and Gynecologists of Canada on the prevention of early-onset neonatal group B streptococcal disease was carried out. Results There is a consensus among the reviewed guidelines regarding the optimal screening specimen type, indications for intrapartum antibiotic administration such as bacteriuria during pregnancy, clinical signs of chorioamnionitis or maternal pyrexia, and history of GBS-related neonatal disease. There is also agreement on several conditions where no intervention is recommended, that is, antepartum treatment of GBS and GBS-positive women with planned cesarean delivery and intact membranes. Controversy exists regarding the optimal screening time, with the Royal College of Obstetricians and Gynecologists stating against routine screening and on management strategies related to preterm labor and preterm prelabor rupture of membranes. Conclusions The development of consistent international practice protocols for the timely screening of GBS and effective management of this clinical entity both during pregnancy and the intrapartum period seems of paramount importance to safely guide clinical practice and subsequently improve neonatal outcomes.
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Affiliation(s)
| | | | | | | | - Apostolos Mamopoulos
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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22
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Ledgerwood C, Angelides M, Idler J, Smith B, DuMont T, Cheema T, Barker B. Fetal and Maternal Monitoring. Crit Care Nurs Q 2023; 46:391-397. [PMID: 37684734 DOI: 10.1097/cnq.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Fetal monitoring in the intrapartum and peripartum periods is important for the well-being of both baby and mother. Electronic fetal monitoring was first designed over 50 years ago in an attempt to improve perinatal outcomes. Its purpose is to assess fetal oxygenation and acid-base status during the antepartum course when indicated and during labor. Maternal assessment begins early in gestation with blood pressure monitoring and urine protein excretion to diagnose potential complications, such as severe hypertension and preeclampsia/eclampsia.
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Affiliation(s)
- Chelsea Ledgerwood
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network Medicine Institute, Pittsburgh, Pennsylvania (Drs Ledgerwood, DuMont, Cheema, and Barker and Ms Smith); Allegheny Health Network Women's Institute, Pittsburgh, Pennsylvania (Dr Angelides); and Division of Maternal Fetal Medicine, Allegheny Health Network Women's Institute, Pittsburgh, Pennsylvania (Dr Idler)
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23
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Nunes I, Nicholson W, Theron G. FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery. Int J Gynaecol Obstet 2023; 163 Suppl 2:21-33. [PMID: 37807585 DOI: 10.1002/ijgo.15117] [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] [Indexed: 10/10/2023]
Abstract
FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.
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Affiliation(s)
- Inês Nunes
- Centro Hospitalar Vila Nova de Gaia/Espinho, Department of Obstetrics and Gynaecology, CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Wanda Nicholson
- George Washington University Milken School of Public Health, Washington, District of Columbia, USA
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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24
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Alhousseini A, Farr C, Ogunyemi D, Wharton K, Fawaz A, Bazzi N, Andrews-Johnson T, Bahado-Singh R. Delivery of a Fetus with a Non-Reassuring Status Is Associated with Significant Maternal Morbidity. Gynecol Obstet Invest 2023; 88:359-365. [PMID: 37751727 DOI: 10.1159/000534189] [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: 11/16/2022] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVES When a labor process is complicated by non-reassuring fetal status (NRFS), obstetricians focus on delivery to optimize neonatal status. We explored maternal morbidity in the setting of NRFS. Our hypothesis is that delivery of a live newborn with NRFS is associated with significant maternal morbidity. Design, Participants, Setting, and Methods: A large retrospective cohort study of 27,886 women who delivered between January 2013 and December 2016 in a single health system was studied. Inclusion criteria included (1) women over the age of 18 at the time of admission; (2) singleton pregnancy; (3) live birth; and (4) gestational age greater than or equal to 37 weeks at the time of admission. NRFS was defined as umbilical cord pH less than or equal to 7.00, fetal bradycardia, late decelerations, and/or umbilical artery base excess ≤-12. Univariate and multivariate logistic regression and propensity score analyses were performed, and propensity score adjusted odds ratios (AORPS) were derived. p values <0.05 were considered statistically significant. Primary outcomes are maternal blood transfusion, maternal readmission, maternal intensive care unit (ICU) admission, and cesarean delivery in relation to umbilical artery pH, fetal bradycardia, and late decelerations. RESULTS Umbilical artery pH less than or equal to 7 was associated with maternal blood transfusion (AORPS 6.83 [95% CI 2.22-21.0, p < 0.001]), maternal readmission (AORPS 12.6 [95% CI 2.26-69.8, p = 0.0039]), and cesarean delivery (AORPS 5.76 [95% CI 3.63-9.15, p < 0.0001]). Fetal bradycardia was associated with transfusion (AORPS 2.13 [95% CI 1.26-3.59, p < 0.005]) and maternal ICU admission (AORPS 3.22 [95% CI 1.23-8.46, p < 0.017]). Late decelerations were associated with cesarean delivery (AORPS 1.65 [95% CI 1.55-1.76, p < 0.0001]), clinical chorioamnionitis (AORPS 2.88 [95% CI 2.46-3.37, p < 0.0001]), and maternal need for antibiotics (AORPS 1.89 [95% CI 1.66-2.15, p < 0.0001]). Umbilical artery base excess less than or equal to -12 was associated with readmission (AORPS 6.71 [95% CI 2.22-20.3, p = 0.0007]), clinical chorioamnionitis (AORPS 1.89 [95% CI 1.24-2.89, p = 0.0031]), and maternal need for antibiotics (AORPS 1.53 [95% CI 1.03-2.26, p = 0.0344]). LIMITATIONS The retrospective design contributes to potential bias compared to the prospective design. However, by utilizing multivariate logistic regression analysis with a propensity score method, specifically inverse probability of treatment weighting, we attempted to minimize the impact of confounding variables. Additionally, only a portion of the data set had quantitative blood losses recorded, while the remainder had estimated blood losses. CONCLUSION NRFS is associated with significant maternal complications, in the form of increased need for blood transfusions, ICU admissions, and increased infection and readmission rates. Strategies for minimizing maternal complications need to be proactively considered in the management of NRFS.
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Affiliation(s)
- Ali Alhousseini
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
- Department of Obstetrics and Gynecology, Corewell William Beaumont Hospital, Royal Oak, Michigan, USA
- Department of Obstetrics and Gynecology, Michigan State University, Lansing, Michigan, USA
| | - Carly Farr
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Dotun Ogunyemi
- Department of Obstetrics and Gynecology, Corewell William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Kurt Wharton
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
- Department of Obstetrics and Gynecology, Corewell William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Aya Fawaz
- Department of Obstetrics and Gynecology, Michigan State University, Lansing, Michigan, USA
| | - Nagham Bazzi
- Department of Obstetrics and Gynecology, Corewell William Beaumont Hospital, Royal Oak, Michigan, USA
- Department of Surgery, Lebanese University, Beirut, Lebanon
| | - Tonyie Andrews-Johnson
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
- Department of Obstetrics and Gynecology, Corewell William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Ray Bahado-Singh
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
- Department of Obstetrics and Gynecology, Corewell William Beaumont Hospital, Royal Oak, Michigan, USA
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25
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Andzane D, Miskova A, Krone A, Rezeberga D. Impact of Intraoperative Factors on the Development of Postpartum Septic Complications. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1637. [PMID: 37763756 PMCID: PMC10536124 DOI: 10.3390/medicina59091637] [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: 08/05/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Triclosan-coated sutures (antibacterial sutures) can reduce the risk of postoperative surgical site infection. This study aimed to investigate the effect of intraoperative factors, including antibacterial sutures, on the risk of postpartum septic complications. Materials and Methods: The prospective study included patients who underwent caesarean section. The exclusion criterion was chorioamnionitis. The investigation group patient's (n = 67) uterus and fascial sheath of the abdominal wall were sutured with triclosan-coated polyglactin 910 sutures during surgery. The control group consisted of 98 patients using uncoated polyglactin 910 sutures only. The patients were contacted by phone after the 30th postoperative day. Results: No significant difference was found between the investigation group and the control group in the development of postpartum endometritis (11.7% in the investigation group vs. 8.4% in the control group, p = 0.401), wound infection (6.3% vs. 3.6%, p = 0.444) or patients experienced any septic complication (15.9% vs. 12%, p = 0.506). Postpartum endometritis was more common in patients who underwent instrumental uterine examination during the surgery (23.8% vs. 18%, p = 0.043). A moderately strong correlation was found for haemoglobin level on the third-fourth postoperative day with the development of postpartum septic complications, p < 0.001, Pearson coefficient -0.319. Post-caesarean delivery septic complications were not statistically more common in patients with blood loss greater than 1 L. The incidence of post-caesarean endometritis was 13.4%, and wound infection was 4.8% in this study's hospital, having five to six thousand deliveries per year. Conclusions: Using antibacterial sutures during caesarean section does not affect the incidence of postpartum septic complications. Instrumental uterine examination during caesarean section increases the risk of post-caesarean endometritis and is, therefore, not recommended. Haemoglobin level on the 3rd-4th postoperative day, rather than the estimated blood loss during surgery, affects the development of postpartum septic complications.
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Affiliation(s)
- Diana Andzane
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
- Gynaecology Clinic, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, Miera Street 45, LV-1013 Riga, Latvia
- Department of Clinical Skills and Medical Technologies, Rīga Stradiņš University, Anninmuizas Bulvaris 26a, LV-1067 Riga, Latvia
| | - Anna Miskova
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, Miera Street 45, LV-1013 Riga, Latvia
- Department of Clinical Skills and Medical Technologies, Rīga Stradiņš University, Anninmuizas Bulvaris 26a, LV-1067 Riga, Latvia
| | - Antra Krone
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
| | - Dace Rezeberga
- Riga Maternity Hospital, Miera Street 45, LV-1013 Riga, Latvia; (A.M.); (A.K.); (D.R.)
- Gynaecology Clinic, Riga East Clinical University Hospital, Hipokrata Street 2, LV-1079 Riga, Latvia
- Department of Obstetrics and Gynaecology, Rīga Stradiņš University, Miera Street 45, LV-1013 Riga, Latvia
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26
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Gameiro I, Botelho T, Martins AI, Henriques R, Lapa P. Morganella morganii: A Rare Cause of Early-Onset Neonatal Sepsis. Cureus 2023; 15:e45600. [PMID: 37868540 PMCID: PMC10588523 DOI: 10.7759/cureus.45600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 10/24/2023] Open
Abstract
Morganella morganii is an opportunistic Gram-negative bacillus commonly found in the human gastrointestinal tract and the environment. In adults, it is often associated with nosocomial infections, primarily surgical wound infections, urinary tract infections, and hepatobiliary infections. It is a rare cause of early-onset neonatal sepsis, with fewer than 15 reported cases in the literature. The authors aim to present a case of a low birth weight preterm born at 28 weeks' gestation, who developed early-onset neonatal sepsis due to M. morganii. We successfully treated the infection using a combination of third-generation cephalosporin and aminoglycoside, and in this report, we explain the rationale behind employing this antibiotic therapy.
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Affiliation(s)
- Inês Gameiro
- Neonatology Department, Maternidade Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Teresa Botelho
- Neonatology Department, Maternidade Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Ana Isabel Martins
- Neonatology Department, Maternidade Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Raquel Henriques
- Neonatology Department, Maternidade Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Patrícia Lapa
- Neonatology Department, Maternidade Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
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27
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Chen X, Shi Y. Determinants of microbial colonization in the premature gut. Mol Med 2023; 29:90. [PMID: 37407941 DOI: 10.1186/s10020-023-00689-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/20/2023] [Indexed: 07/07/2023] Open
Abstract
Abnormal microbial colonization in the gut at an early stage of life affects growth, development, and health, resulting in short- and long-term adverse effects. Microbial colonization patterns of preterm infants differ from those of full-term infants in that preterm babies and their mothers have more complicated prenatal and postnatal medical conditions. Maternal complications, antibiotic exposure, delivery mode, feeding type, and the use of probiotics may significantly shape the gut microbiota of preterm infants at an early stage of life; however, these influences subside with age. Although some factors and processes are difficult to intervene in or avoid, understanding the potential factors and determinants will help in developing timely strategies for a healthy gut microbiota in preterm infants. This review discusses potential determinants of gut microbial colonization in preterm infants and their underlying mechanisms.
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Affiliation(s)
- Xiaoyu Chen
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, 110000, China
| | - Yongyan Shi
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, 110000, China.
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28
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Sidell MA, Getahun D, Tartof SY, Xiang AH, Sharma AJ, Mukhopadhyay S, Puopolo KM, Schrag SJ, Kunani P, Koebnick C. Higher body mass index after intrapartum antibiotic exposure in children persists over 10-years. Pediatr Obes 2023; 18:e13035. [PMID: 37026509 PMCID: PMC11299422 DOI: 10.1111/ijpo.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/01/2023] [Accepted: 03/10/2023] [Indexed: 04/08/2023]
Abstract
Exposure to intrapartum antibiotic prophylaxis to reduce perinatal group B streptococcal disease was associated with increased childhood body mass index (BMI) persisting to age 10 years compared to no exposure (Δ BMI at 10 years: vaginal delivery 0.14 kg/m2 , caesarean 0.40 kg/m2 ).
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Affiliation(s)
- Margo A Sidell
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Darios Getahun
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
- Department of Health Systems Science Kaiser Permanente Bernard J. Tyson School of Medicine
| | - Anny H Xiang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Andrea J Sharma
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sagori Mukhopadhyay
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, PA, USA
| | - Karen M Puopolo
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, PA, USA
| | | | - Poornima Kunani
- Department of Pediatrics, Kaiser Permanente Manhattan Beach Medical Office, Manhattan Beach, CA
| | - Corinna Koebnick
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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29
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Cuna A, Nsumu M, Menden HL, Chavez-Bueno S, Sampath V. The Detrimental Effects of Peripartum Antibiotics on Gut Proliferation and Formula Feeding Injury in Neonatal Mice Are Alleviated with Lactobacillus rhamnosus GG. Microorganisms 2023; 11:1482. [PMID: 37374984 DOI: 10.3390/microorganisms11061482] [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: 05/17/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Peripartum antibiotics can negatively impact the developing gut microbiome and are associated with necrotizing enterocolitis (NEC). The mechanisms by which peripartum antibiotics increase the risk of NEC and strategies that can help mitigate this risk remain poorly understood. In this study, we determined mechanisms by which peripartum antibiotics increase neonatal gut injury and evaluated whether probiotics protect against gut injury potentiated by peripartum antibiotics. To accomplish this objective, we administered broad-spectrum antibiotics or sterile water to pregnant C57BL6 mice and induced neonatal gut injury to their pups with formula feeding. We found that pups exposed to antibiotics had reduced villus height, crypt depth, and intestinal olfactomedin 4 and proliferating cell nuclear antigen compared to the controls, indicating that peripartum antibiotics impaired intestinal proliferation. When formula feeding was used to induce NEC-like injury, more severe intestinal injury and apoptosis were observed in the pups exposed to antibiotics compared to the controls. Supplementation with the probiotic Lactobacillus rhamnosus GG (LGG) reduced the severity of formula-induced gut injury potentiated by antibiotics. Increased intestinal proliferating cell nuclear antigen and activation of the Gpr81-Wnt pathway were noted in the pups supplemented with LGG, suggesting partial restoration of intestinal proliferation by probiotics. We conclude that peripartum antibiotics potentiate neonatal gut injury by inhibiting intestinal proliferation. LGG supplementation decreases gut injury by activating the Gpr81-Wnt pathway and restoring intestinal proliferation impaired by peripartum antibiotics. Our results suggest that postnatal probiotics may be effective in mitigating the increased risk of NEC associated with peripartum antibiotic exposure in preterm infants.
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Affiliation(s)
- Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marianne Nsumu
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Heather L Menden
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Susana Chavez-Bueno
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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30
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Barinov SV, Di Renzo GC, Tsibizova VI, Shifman EМ, Leont'eva NN, Arbuzov AB. Detoxification treatment in Gynecology using a modified molded sorbent. Best Pract Res Clin Obstet Gynaecol 2023:102346. [PMID: 37225639 DOI: 10.1016/j.bpobgyn.2023.102346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/26/2023]
Abstract
Postpartum endometritis is a common complication of cesarean section, the progression of which often leads to the loss of the uterus and the patient's fertility. We evaluated a detoxification therapy for treating patients with postpartum endometritis using an intrauterine application of a modified molded sorbent containing polyvinylpyrrolidone. A retrospective, controlled study included 124 patients with postpartum endometritis. The study group, n = 63, was composed of puerperae with postpartum endometritis after cesarean section, receiving antibacterial therapy in combination with the intrauterine application of a molded modified sorbent containing polyvinylpyrrolidone (FSMP) for 24 h daily for 5 days. The control group, n = 61, was composed of puerperae with postpartum endometritis after cesarean section, receiving antibacterial treatment only. The uterine cavity was infected by coccal flora (Enterococcus faecalis (26.6%), Staphylococcus spp. (21.3%), E. faecium (14.3%), and Gram-negative Escherichia coli (9.6%). A combination of these microorganisms was present in 40.5% of crops. Antibiotic resistance was detected in 53.6%-68.3% of the cases. In the study group, we observed: a faster and higher decrease in neutrophils (p < 0.05); a lower uterine concentration of pro-inflammatory cytokines: interleukin-1 beta (IL-1β) and tumor necrosis factor α (TNFα) - 4.0 and 3.2 times, respectively, compared with the control group (p < 0.05); and a significant decrease in the uterus volume and cavity (M-echo). Using a newly modified sorbent associated with antibiotic treatment in patients with postpartum endometritis, compared with antibiotics alone, we showed a sharp reduction of inflammatory parameters, residual microorganism growth, and faster uterine volume involution. Moreover, the frequency of hysterectomy decreased by 14.4 times.
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Affiliation(s)
- S V Barinov
- Federal State Budget Institution of Higher Education, "Omsk State Medical University" of the Russian Ministry of Health, Omsk, Russian Federation.
| | - G C Di Renzo
- Centre for Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy; Wayne State University Medical School and Perinatal Research Branch, NIH-NICHD, Detroit, MI, 48201, USA; PREIS International and European School of Perinatal, Neonatal and Reproductive Medicine, Florence, Italy; Department of Obstetrics, Gynecology and Perinatal Medicine of the Clinical Institute of Children's Health Named After N.F. Filatov, I.M. Sechenov First State Medical University Under Ministry of Health of the Russian Federation, Moscow, Russian Federation.
| | - V I Tsibizova
- Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, Saint-Petersburg, Russian Federation; PREIS International and European School of Perinatal, Neonatal and Reproductive Medicine, Florence, Italy.
| | - E М Shifman
- Department of Anesthesiology and Сritical Care of Moscow Regional M.V. Vladimirsky Moscow`s Regional Research Clinical Institute, Moscow, Russian Federation.
| | - N N Leont'eva
- Center of New Chemical Technologies Boreskov Institute of Catalysis, Omsk, Russian Federation.
| | - A B Arbuzov
- Center of New Chemical Technologies Boreskov Institute of Catalysis, Omsk, Russian Federation.
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31
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Liu BD, Starkey M, Virani A, Pichette SL, Fass S, Song G. Review article: Functional dyspepsia and pregnancy-Effects and management in a special population. Aliment Pharmacol Ther 2023; 57:1375-1396. [PMID: 37129241 DOI: 10.1111/apt.17534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/23/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy. AIMS AND METHODS To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions. RESULTS Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD. CONCLUSIONS Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.
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Affiliation(s)
- Benjamin D Liu
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Morgan Starkey
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Aleena Virani
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Sandra L Pichette
- Department of Obstetrics and Gynecology, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA
| | - Shira Fass
- Department of Psychiatry, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Gengqing Song
- Division of Gastroenterology and Hepatology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio, USA
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32
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Mei JY, Silverman NS. Group B Streptococcus in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:375-387. [PMID: 37149317 DOI: 10.1016/j.ogc.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
To decrease risk of early-onset neonatal sepsis from group B streptococcus (GBS), pregnant patients should undergo screening between 36 0/7 and 37 6/7 weeks' gestation. Patients with a positive vaginal-rectal culture, GBS bacteriuria , or history of newborn with GBS disease should receive intrapartum antibiotic prophylaxis (IAP) with an agent targeting GBS. If GBS status is unknown at time of labor, IAP should be administered in cases of preterm birth, rupture of membranes for >18 hours, or intrapartum fever. The antibiotic of choice is intravenous penicillin; alternatives should be considered in cases of penicillin allergy depending on allergy severity.
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Affiliation(s)
- Jenny Y Mei
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 430, Los Angeles, CA 90095-1740, USA
| | - Neil S Silverman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Suite 430, Los Angeles, CA 90095-1740, USA.
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33
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Hamel MS, Tuuli M. Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery. Obstet Gynecol Clin North Am 2023; 50:327-338. [PMID: 37149313 DOI: 10.1016/j.ogc.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.
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Black M, Kothari A, Chawla G, Pelecanos A, Zahumensky A, McDermott L, O'Connor H, Kalma B, Eley V. Attitudes and awareness of Australian women regarding peripartum antibiotic use: A multicentre survey. Aust N Z J Obstet Gynaecol 2023; 63:171-177. [PMID: 35856134 DOI: 10.1111/ajo.13587] [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: 04/04/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peripartum antibiotics are commonly administered. Little is known of the attitudes of pregnant women toward peripartum antibiotics. AIM We aimed to assess the awareness of and attitudes toward peripartum antibiotic use in Australian women. MATERIALS AND METHODS We surveyed post-partum women at three hospitals over six months. Women reported if they received antibiotics 48 h either side of delivery and responded to statements assessing attitudes to peripartum antibiotic use. Administered antibiotics were recorded. We reported the proportion receiving antibiotics and the proportion aware of receiving them. Participants responded on five-point Likert scales and selected side effects of concern. RESULTS Participants responding were 248 of 299 (83%, Royal Brisbane and Women's Hospital), 56 of 106 (53%, Caboolture Hospital) and 17 (Redcliffe Hospital, denominator not recorded). Of 183 (57%) receiving antibiotics, 134 (73%) received them pre-delivery only, 18 (10%) post-delivery only and 31 (17%) pre- and post-delivery. Pre-delivery, the most common indication was pre-incisional prophylaxis for caesarean delivery (93 of 160 responses, 58%). Seventy-nine (51%, 156 responses) of those receiving pre-delivery antibiotics were aware. Of 49 women receiving post-delivery antibiotics, 36 (73%) were aware. Most agreed they were worried that pre-delivery antibiotics would affect their baby (198, 62%) and 160 (50%) were concerned about effects on their own microbiome. Most (204, 65%) agreed they would rather not take antibiotics while breastfeeding. CONCLUSION Many women were unaware of receiving pre-delivery antibiotics. Most had concerns about side effects. Improved communication regarding peripartum antibiotic use would improve patient-centred care.
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Affiliation(s)
- Matthew Black
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Alka Kothari
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Obstetrics and Gynaecology, Redcliffe Hospital, Moreton Bay Region, Queensland, Australia
| | - Gunjan Chawla
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Anaesthesia, Caboolture Hospital, Moreton Bay Region, Queensland, Australia
| | - Anita Pelecanos
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Amanda Zahumensky
- Department of Anaesthesia, Caboolture Hospital, Moreton Bay Region, Queensland, Australia
| | - Laura McDermott
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Hannah O'Connor
- Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Benjamin Kalma
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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35
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Tita ATN, Carlo WA, McClure EM, Mwenechanya M, Chomba E, Hemingway-Foday JJ, Kavi A, Metgud MC, Goudar SS, Derman R, Lokangaka A, Tshefu A, Bauserman M, Bose C, Shivkumar P, Waikar M, Patel A, Hibberd PL, Nyongesa P, Esamai F, Ekhaguere OA, Bucher S, Jessani S, Tikmani SS, Saleem S, Goldenberg RL, Billah SM, Lennox R, Haque R, Petri W, Figueroa L, Mazariegos M, Krebs NF, Moore JL, Nolen TL, Koso-Thomas M. Azithromycin to Prevent Sepsis or Death in Women Planning a Vaginal Birth. N Engl J Med 2023; 388:1161-1170. [PMID: 36757318 PMCID: PMC10627427 DOI: 10.1056/nejmoa2212111] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The use of azithromycin reduces maternal infection in women during unplanned cesarean delivery, but its effect on those with planned vaginal delivery is unknown. Data are needed on whether an intrapartum oral dose of azithromycin would reduce maternal and offspring sepsis or death. METHODS In this multicountry, placebo-controlled, randomized trial, we assigned women who were in labor at 28 weeks' gestation or more and who were planning a vaginal delivery to receive a single 2-g oral dose of azithromycin or placebo. The two primary outcomes were a composite of maternal sepsis or death and a composite of stillbirth or neonatal death or sepsis. During an interim analysis, the data and safety monitoring committee recommended stopping the trial for maternal benefit. RESULTS A total of 29,278 women underwent randomization. The incidence of maternal sepsis or death was lower in the azithromycin group than in the placebo group (1.6% vs. 2.4%), with a relative risk of 0.67 (95% confidence interval [CI], 0.56 to 0.79; P<0.001), but the incidence of stillbirth or neonatal death or sepsis was similar (10.5% vs. 10.3%), with a relative risk of 1.02 (95% CI, 0.95 to 1.09; P = 0.56). The difference in the maternal primary outcome appeared to be driven mainly by the incidence of sepsis (1.5% in the azithromycin group and 2.3% in the placebo group), with a relative risk of 0.65 (95% CI, 0.55 to 0.77); the incidence of death from any cause was 0.1% in the two groups (relative risk, 1.23; 95% CI, 0.51 to 2.97). Neonatal sepsis occurred in 9.8% and 9.6% of the infants, respectively (relative risk, 1.03; 95% CI, 0.96 to 1.10). The incidence of stillbirth was 0.4% in the two groups (relative risk, 1.06; 95% CI, 0.74 to 1.53); neonatal death within 4 weeks after birth occurred in 1.5% in both groups (relative risk, 1.03; 95% CI, 0.86 to 1.24). Azithromycin was not associated with a higher incidence in adverse events. CONCLUSIONS Among women planning a vaginal delivery, a single oral dose of azithromycin resulted in a significantly lower risk of maternal sepsis or death than placebo but had little effect on newborn sepsis or death. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; A-PLUS ClinicalTrials.gov number, NCT03871491.).
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Affiliation(s)
- Alan T N Tita
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Waldemar A Carlo
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Elizabeth M McClure
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Musaku Mwenechanya
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Elwyn Chomba
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Jennifer J Hemingway-Foday
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Avinash Kavi
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Mrityunjay C Metgud
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Shivaprasad S Goudar
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Richard Derman
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Adrien Lokangaka
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Antoinette Tshefu
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Melissa Bauserman
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Carl Bose
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Poonam Shivkumar
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Manju Waikar
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Archana Patel
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Patricia L Hibberd
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Paul Nyongesa
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Fabian Esamai
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Osayame A Ekhaguere
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Sherri Bucher
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Saleem Jessani
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Shiyam S Tikmani
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Sarah Saleem
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Robert L Goldenberg
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Sk M Billah
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Ruth Lennox
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Rashidul Haque
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - William Petri
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Lester Figueroa
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Manolo Mazariegos
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Nancy F Krebs
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Janet L Moore
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Tracy L Nolen
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
| | - Marion Koso-Thomas
- From the University of Alabama at Birmingham, Birmingham (A.T.N.T., W.A.C.); RTI International, Durham (E.M.M., J.J.H.-F., J.L.M., T.L.N.), and the University of North Carolina at Chapel Hill, Chapel Hill (M.B., C.B.) - both in North Carolina; University Teaching Hospital, Lusaka, Zambia (M. Mwenechanya, E.C.); Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi (A.K., M.C.M., S.S.G.), Mahatma Gandhi Institute of Medical Sciences, Sewagram (P.S.), Government Medical College (M.W.) and Lata Medical Research Foundation (A.P.), Nagpur, and Datta Meghe Institute of Medical Sciences, Wardha (A.P.) - all in India; Thomas Jefferson University, Philadelphia (R.D.); Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo (A.L., A.T.); Boston University School of Public Health, Boston (P.L.H.); Moi University School of Medicine, Eldoret, Kenya (P.N., F.E.); Indiana School of Medicine, University of Indiana, Indianapolis (O.A.E., S.B.); Aga Khan University, Karachi, Pakistan (S.J., S.S.T., S.S.); Columbia University School of Medicine, New York (R.L.G.); the International Center for Diarrheal Disease Research, Dhaka (S.M.B., R.H.), and LAMB Hospital, Parbattipur (R.L.) - both in Bangladesh; the University of Sydney, Sydney (S.M.B.); the University of Virginia, Charlottesville (W.P.); Instituto de Nutrición de Centroamérica y Panamá, Guatemala City, Guatemala (L.F., M. Mazariegos); the University of Colorado-Anschutz Medical Campus, Denver (N.F.K.); and Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (M.K.-T.)
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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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Izewski JM, Bell BZ, Haas DM. Antibiotics in Labor and Delivery. Obstet Gynecol Clin North Am 2023; 50:137-150. [PMID: 36822699 DOI: 10.1016/j.ogc.2022.10.011] [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] [Indexed: 02/23/2023]
Abstract
Infections are common in obstetric care and often require specific antibiotics, depending on the infection site and prevailing organisms. Summaries of antibiotic recommendations and treatment algorithms are provided for the following conditions: routine labor, group B streptococcus prophylaxis, preterm prelabor rupture of membranes, operative vaginal delivery, cesarean delivery, obstetric anal sphincter lacerations, chorioamnionitis, postpartum endometritis, infections of the urinary tract, and bacterial endocarditis prophylaxis.
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Kuder MM, Baird R, Hopkins M, Lang DM. Anaphylaxis in Pregnancy. Immunol Allergy Clin North Am 2023; 43:103-116. [PMID: 36410997 DOI: 10.1016/j.iac.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anaphylaxis in pregnancy is a rare event, but has important implications for the pregnant patient and fetus. The epidemiology, pathophysiology, diagnosis, and treatment all carry important considerations unique to the pregnant patient. Common culprits of anaphylaxis are primarily medications, particularly antibiotics and anesthetic agents. Diagnosis can be difficult given the relative lack of cutaneous symptoms, and normal physiologic changes in pregnancy such as low blood pressure and tachycardia. Apart from patient positioning, treatment is similar to that of the general population, with a focus on prompt epinephrine administration.
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Affiliation(s)
- Margaret M Kuder
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation.
| | - Rachael Baird
- Women's Health Institute, Cleveland Clinic Foundation
| | - Maeve Hopkins
- Women's Health Institute, Cleveland Clinic Foundation
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Foundation
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Maher JY, Gomez-Lobo V, Merke DP. The management of congenital adrenal hyperplasia during preconception, pregnancy, and postpartum. Rev Endocr Metab Disord 2023; 24:71-83. [PMID: 36399318 PMCID: PMC9884653 DOI: 10.1007/s11154-022-09770-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/21/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders of steroidogenesis of the adrenal cortex, most commonly due to 21-hydroxylase deficiency caused by mutations in the CYP21A2 gene. Although women with CAH have decreased fecundity, they are able to conceive; thus, if pregnancy is not desired, contraception options should be offered. If fertility is desired, women with classic CAH should first optimize glucocorticoid treatment, followed by ovulation induction medications and gonadotropins if needed. Due to the possible pregnancy complications and implications on the offspring, preconception genetic testing and counseling with a high-risk obstetrics specialist is recommended. For couples trying to avoid having a child with CAH, care with a reproductive endocrinology and infertility specialist to utilize in vitro fertilization can be offered, with or without preimplantation genetic testing for monogenic disorders. Prenatal screening and diagnosis options during pregnancy include maternal serum cell free-DNA for sex of the baby, and chorionic villus sampling and amniocentesis for diagnosis of CAH. Pregnant women with classic CAH need glucocorticoids to be adjusted during the pregnancy, at the time of delivery, and postpartum, and should be monitored for adrenal crisis. Maternal and fetal risks may include chorioamnionitis, maternal hypertension, gestational diabetes, cesarean section, and small for gestational age infants. This review on CAH due to 21-hydroxylase deficiency highlights reproductive health including genetic transmission, contraception options, glucocorticoid management, fertility treatments, as well as testing, antenatal monitoring, and management during pregnancy, delivery, and postpartum.
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Affiliation(s)
- Jacqueline Yano Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Staff Clinician, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Veronica Gomez-Lobo
- Director of Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 8N248, Bethesda, MD, 20892, USA
| | - Deborah P Merke
- National Institutes of Health Clinical Center and Eunice Kennedy Shriver National Institute of Child Health and Human Development, 10 Central Drive, Room 1-2740, Bethesda, MD, 20892, USA.
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Freret TS, James K, Kaimal AJ. Antibiotic administration and wound complications after obstetric anal sphincter injuries. Am J Obstet Gynecol MFM 2023; 5:100883. [PMID: 36736824 DOI: 10.1016/j.ajogmf.2023.100883] [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: 10/12/2022] [Revised: 01/19/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Obstetric anal sphincter injuries are associated with both short-term and long-term maternal morbidity. Antibiotic administration has been shown to decrease wound complications after obstetric anal sphincter injuries. However, the rate of antibiotic administration in a contemporary obstetrical population is not known. OBJECTIVE This study aimed to describe the rate of antibiotic administration for obstetric anal sphincter injuries, to characterize factors associated with antibiotic administration on the day of delivery among women with obstetric anal sphincter injuries, and to determine if there was an association between antibiotic administration and reduced wound complications. STUDY DESIGN This was a retrospective cohort study of women with a singleton vaginal birth complicated by obstetric anal sphincter injuries between 2016 and 2021 in a single healthcare system. Information about any antibiotic administration on the day of delivery was collected. Information on wound complications (determined by International Classification of Disease, 10th Revision, codes) that occurred within the first 6 months postpartum were available for patients who delivered at tertiary-care centers. Multivariable logistic regression analysis was used to identify factors associated with antibiotic administration and the association between antibiotics and wound complications. RESULTS During the study period, 1550 women met the inclusion criteria of whom 855 (55.2%) received antibiotics. Antibiotic administration was higher at tertiary-care hospitals than at community-based hospitals (68.7 vs 26.8%; P<.001). In the adjusted analysis, antibiotic administration was higher among women with a fourth-degree laceration (adjusted odds ratio, 2.72; 95% confidence interval, 1.69-4.37) and lower among women of Asian or Pacific Islander heritage (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.97). At tertiary-care hospitals, 43 women (4.1%) had a wound complication, and more than 80% of those presented within the first 2 weeks postpartum. Antibiotic use was associated with reduced rates of wound complications (adjusted odds ratio, 0.34; 95% confidence interval, 0.13-0.91). All patients received a regimen with gram-positive bacterial coverage; there was no association between type of antibiotic regimen administered and wound complications. CONCLUSION Any antibiotic administration on the day of delivery was associated with a decreased rate of wound complications after obstetric anal sphincter injuries. However, only about half of the women with obstetric anal sphincter injuries received antibiotics. Optimizing antibiotic administration may help to reduce the risk of complications in this population.
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Affiliation(s)
- Taylor S Freret
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Drs Freret and James).
| | - Kaitlyn James
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Drs Freret and James)
| | - Anjali J Kaimal
- Department of Obstetrics, Gynecology, and Reproductive Biology, University of South Florida, Tampa, FL (Dr Kaimal)
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Gardemeister S, Skogberg K, Saisto T, Salonen A, de Vos WM, Korpela K, Kolho KL. Cross-sectional study of the proportion of antibiotic use during childbirth in full-term deliveries in Finland. BMC Pregnancy Childbirth 2023; 23:50. [PMID: 36681812 PMCID: PMC9862572 DOI: 10.1186/s12884-023-05368-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023] Open
Abstract
PURPOSE In developed countries, data on the frequency of antibiotics given to mothers during childbirth are limited beyond the overall effect of all various prophylactic indications. Also, data on the impact of such antibiotics to the well-being of term babies are scarce. We aimed to characterize the frequency of antibiotic use during childbirth of term pregnancy. Secondly, we assessed whether the use of antibiotics was associated with any symptoms in infants. METHODS This was a cross-sectional study of 1019 term deliveries of women participating in the prospective Health and Early Life Microbiota (HELMi) birth cohort study between March 2016 and March 2018 in the capital region of Finland. The data on antibiotic use were collected from the hospital records. RESULTS In total, 37% of the mothers received antibiotics during childbirth and 100% in Caesarean Sects. (17% of the deliveries). Less than 5% of antibiotics were non-prophylactic. In vaginal deliveries, the most common indication (18%) was prophylaxis for Group B Streptococcus. The most frequently used antibiotics were cefuroxime (22%) and benzylpenicillin (15%), and 56% received only one dose. In infants exposed to antibiotics during delivery, defecation frequency was higher during the first months (p-value < 0.0001- 0.0145), and weight gain was higher at the age of three months (p-value 0.0371). CONCLUSION More than every third new-born in a developed country is exposed to antibiotics during birth. Our findings support the hypothesis that maternal antibiotics given during birth have an impact on the well-being of the infants. These findings should inform current policies for prophylactic antibiotics in childbirth.
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Affiliation(s)
- Susanna Gardemeister
- grid.7737.40000 0004 0410 2071Children’s Hospital, University of Helsinki, Stenbäckinkatu 11, FI-00029 HUS Helsinki, Finland
| | - Kirsi Skogberg
- grid.7737.40000 0004 0410 2071Division of Infectious Diseases, Inflammation Centre, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Terhi Saisto
- grid.7737.40000 0004 0410 2071Department of Obstetrics and Gynaecology, Helsinki University Hospital, HUS, and University of Helsinki, Helsinki, Finland
| | - Anne Salonen
- grid.7737.40000 0004 0410 2071Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Willem M. de Vos
- grid.7737.40000 0004 0410 2071Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland ,grid.4818.50000 0001 0791 5666Laboratory of Microbiology, Wageningen University, Wageningen, The Netherlands
| | - Katri Korpela
- grid.7737.40000 0004 0410 2071Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Kaija-Leena Kolho
- grid.7737.40000 0004 0410 2071Children’s Hospital, University of Helsinki, Stenbäckinkatu 11, FI-00029 HUS Helsinki, Finland ,grid.7737.40000 0004 0410 2071Human Microbiome Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland ,grid.502801.e0000 0001 2314 6254Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Thao V, Sharpe EE, Dholakia R, Ahn HH, Moriarty JP, Borah BJ, Gill MC, Theiler RN. Evaluating the cost-effectiveness of testing pregnant women for penicillin allergy. PLoS One 2023; 18:e0280151. [PMID: 36662778 PMCID: PMC9858404 DOI: 10.1371/journal.pone.0280151] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/20/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION True penicillin allergy is rare and is commonly incorrectly reported. In fact, less than five percent of patients who report a penicillin allergy will have a currently active clinically-significant IgE- or T-cell-mediated hypersensitivity when appropriately tested. Penicillin is the agent of choice for intrapartum antibiotic prophylaxis to reduce the risk of group B streptococcus early-onset disease in the newborn. Inaccurate penicillin allergy status may lead to inappropriate antibiotic use, as most alternative drugs are more expensive and broader spectrum than penicillin. Penicillin allergy testing has been found to be safe in pregnancy and cost-effective in other patient populations. OBJECTIVE To evaluate the cost-effectiveness of penicillin allergy testing and appropriate antibiotic treatment (test then treat strategy) compared to usual care among pregnant women. METHODS We developed a decision tree to evaluate the cost of providing appropriate care via a test then treat strategy for pregnant women who report a penicillin allergy, compared to usual care. RESULTS Using the test then treat strategy the additional cost to ensure appropriate care for all pregnant women who report a penicillin allergy, was $1122.38 per person. Adopting a test then treat strategy increased the number of appropriate antibiotic use from 7,843/10,000 to 10,000/10,000 simulations. CONCLUSION Our results show that a test then treat strategy for pregnant women who report a penicillin allergy is a good-value intervention.
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Affiliation(s)
- Viengneesee Thao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Emily E. Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ruchita Dholakia
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Hannah H. Ahn
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - James P. Moriarty
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Bijan J. Borah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Margaret C. Gill
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Regan N. Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America
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Cate JJM, Burn M, Kwah J, Liao J, Illuzzi J, Reddy U, Son M. Survey of Obstetric Providers to Assess the Knowledge and Management of a Reported Penicillin Allergy in Pregnant Women. Am J Perinatol 2023; 40:1-8. [PMID: 35709740 DOI: 10.1055/a-1877-9970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Penicillin allergy is the most commonly reported drug allergy in the United States; however, less than 10% of individuals labeled with a penicillin allergy are truly allergic. A reported penicillin allergy in pregnancy is associated with adverse maternal and perinatal outcomes. Despite recommendations for penicillin allergy testing in pregnancy, limited literature regarding obstetric providers' comfort and knowledge in addressing penicillin allergy and referral patterns exists. The objective of this study is to survey obstetric providers to assess their clinical practice patterns and baseline penicillin allergy knowledge, identify potential knowledge gaps in the management of pregnant patients with reported penicillin allergy, and measure the impact of an educational intervention on provider knowledge and practice patterns. STUDY DESIGN An anonymous, electronic 23-question survey administered to all obstetric providers at a single academic medical center assessed obstetric provider characteristics, self-reported antibiotic practice patterns, and antibiotic allergy knowledge before (June 19, 2020) and after (September 16, 2020) a penicillin allergy educational intervention, which consisted of multiple small-group educational sessions and a culminating departmental educational session. Discrete knowledge comparison by provider type and experience level of pre- and postintervention was performed using chi-square tests. RESULTS Of 277 obstetric providers invited, 124 (45%) responded preintervention and 62 (22%) postintervention. In total, 27% correctly identified the percentage of patients labeled penicillin allergic who would tolerate penicillins, 45% identified cephalosporin cross-reactivity, 59% understood penicillin allergies can wane, and 54% identified penicillin skin testing (PST) as a valid allergy verification tool. Among 48 respondents who attended educational sessions and responded postintervention, their knowledge of penicillin allergy waning (79% preeducation vs. 98% posteducation, p < 0.01) and PST as a valid tool for penicillin allergy verification (50% preeducation vs. 83% posteducation, p < 0.01) improved. CONCLUSION Knowledge gaps related to penicillin allergy exist among obstetric providers. Educational initiatives may improve provider knowledge, help in the identification of patients requiring penicillin allergy evaluation, and reduce referral barriers. KEY POINTS · Obstetric providers lack adequate knowledge of penicillin allergy.. · Educational interventions can improve discrete knowledge.. · Limited knowledge is a barrier to allergy referral for penicillin allergy delabeling..
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Affiliation(s)
- Jennifer J M Cate
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Martina Burn
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Jason Kwah
- Section of Rheumatology, Allergy, and Immunology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jane Liao
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jessica Illuzzi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Uma Reddy
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Section of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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Yagur Y, Ribak R, Ben Ezry E, Cohen I, Or Madar L, Kovo M, Biron-Shental T. Do maternal albumin levels affect post-operative complications after cesarean delivery? BMC Pregnancy Childbirth 2022; 22:909. [PMID: 36474218 PMCID: PMC9727901 DOI: 10.1186/s12884-022-05215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND This study explored the correlation between maternal serum albumin levels prior to elective cesarean delivery (CD) and postoperative complications. METHODS This retrospective cohort study included women admitted for elective CD at term to our tertiary referral center, during the years 2016-2018. Blood samples were collected during the preoperative admission. Information collected included maternal demographics, pregnancy and postoperative complications. Data between patients with preoperative serum albumin levels < 3.3 g/dL or ≥ 3.3 g/dL were compared. RESULTS Among 796 women admitted for an elective CD, 537 met the inclusion criteria. There were 250 (46.6%) women in the low albumin level group (< 3.3 g/dL) and 287 (53.4%) with serum albumin level ≥ 3.3 g/dL. Patients with serum albumin ≥ 3.3 g/dL had increased rates of surgical site infection (SSI) (5.6% vs. 1.6% respectively; p = 0.02), need for antibiotics during the post-partum period (10.8% vs 3.2%, respectively; p = 0.001), surgical intervention (2.1% vs. 0%, respectively; p = 0.03) and higher rate of rehospitalization (5.2% vs. 0.4%, respectively; p = 0.001). Multivariant analysis showed that albumin level ≥ 3.3 g/dL was independently associated with composite postoperative adverse maternal outcome. CONCLUSIONS High serum albumin levels among women undergoing CD, might be associated with abnormal postoperative outcomes. Larger prospective studies, with a heterogenous population are needed to validate these observations.
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Affiliation(s)
- Yael Yagur
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Ribak
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emili Ben Ezry
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Cohen
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Libby Or Madar
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Kovo
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Biron-Shental
- grid.12136.370000 0004 1937 0546Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel Affiliated With Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Group B Streptococcus and Pregnancy: Critical Concepts and Management Nuances. Obstet Gynecol Surv 2022; 77:753-762. [PMID: 36477387 DOI: 10.1097/ogx.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Group B Streptococcus (GBS) is a common pathogen with an effective treatment. However, it remains a significant cause of neonatal sepsis, morbidity, and mortality. The screening and management of this infection are some of the first concepts learned during medical training in obstetrics. However, effective screening and evidence-based management of GBS are nuanced with many critical caveats. Objective The objectives of this review are to discuss the essential aspects of GBS screening and management and to highlight recent changes to recommendations and guidelines. Evidence Acquisition Original research articles, review articles, and guidelines on GBS were reviewed. Results The following recommendations are based on review of the evidence and professional society guidelines. Screening for GBS should occur between 36 weeks and the end of the 37th week. The culture swab should go 2 cm into the vagina and 1 cm into the anus. Patients can perform their own swabs as well. Penicillin allergy testing has been shown to be safe in pregnancy. Patients with GBS in the urine should be treated at term with antibiotic prophylaxis, independent of the colony count of the culture. Patients who are GBS-positive with preterm and prelabor rupture of membranes after 34 weeks are not candidates for expectant management, as this population has higher rates of neonatal infectious complications. Patients with a history of GBS colonization in prior pregnancy who are GBS-unknown in this current pregnancy and present with labor should receive intrapartum prophylaxis. Work on the GBS vaccine continues. Conclusions Although all of the efforts and focus on neonatal early-onset GBS infection have led to lower rates of disease, GBS still remains a major cause of neonatal morbidity and mortality requiring continued vigilance from obstetric providers.
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Lian Q, Zheng T, Huo X, Zhang J, Zhang L. Prophylactic antibiotic use during labor and delivery in China: a nationwide, multicenter, hospital-based, cross-sectional study. BMC Med 2022; 20:391. [PMID: 36320077 PMCID: PMC9628083 DOI: 10.1186/s12916-022-02577-w] [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: 07/14/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Prophylactic antibiotic use during delivery is common in routine obstetric practice to prevent infection globally, especially in low- and middle-income countries. In China, however, little is currently known about the national estimates for prophylactic antibiotic use during delivery. Therefore, we aimed to describe the prevalence of prophylactic antibiotic use and guideline adherence using national data in China. METHODS This cross-sectional study analyzed a national dataset from the China Labor and Delivery Survey in 2015-2016. The primary outcomes were prophylactic antibiotic use and clinician adherence to WHO recommendations for the prevention and treatment of maternal peripartum infections. We estimated the weighted prevalence of the outcomes with Taylor series linearization and investigated the associated factors of the outcomes with logistic regression. RESULTS Of the 72,519 deliveries, the prevalence of antibiotic prophylaxis was 52.0%, varying from 92.8% in Shanxi to 17.3% in Hainan. The prevalence of clinician adherence to the WHO guideline was 79.9%, ranging from 93.4% in Shandong to 50.0% in Shanxi. Prophylactic antibiotic use was associated with cesarean delivery (AOR, 55.77; 95%CI, 25.74-120.86), operative vaginal delivery (AOR, 4.00; 95%CI, 1.64-9.78), preterm (AOR, 1.96; 95%CI, 1.60-2.41), premature rupture of membranes (PROM) (AOR, 2.80; 95%CI, 1.87-4.18), and meconium-stained amniotic fluid (AOR, 1.91; 95%CI, 1.30-2.81) in all deliveries and also episiotomy (AOR, 1.48; 95%CI, 1.02-2.16) in vaginal deliveries. Clinician adherence was positively associated with cesarean delivery (AOR, 5.72; 95%CI, 2.74-11.93) while negatively associated with operative vaginal delivery (AOR, 0.26; 95%CI, 0.11-0.61), PROM (AOR, 0.50; 95%CI, 0.35-0.70), and meconium-stained amniotic fluid (AOR, 0.66; 95%CI, 0.48-0.91) in all deliveries. In vaginal deliveries, clinician adherence was negatively associated with episiotomy (AOR, 0.67; 95%CI, 0.46-0.96) and severe perineal trauma (AOR, 0.09; 95%CI, 0.02-0.44). Besides, clinicians in general hospitals prescribed prophylactic antibiotics more likely (AOR, 2.79; 95%CI, 1.50-5.19) and had a lower adherence (AOR, 0.38; 95%CI, 0.20-0.71) than their peers in maternity hospitals. CONCLUSIONS We observed that about half of all deliveries in China received antibiotics for prophylaxis, and most deliveries were prescribed according to the WHO guideline. Furthermore, the two prevalence rates for prophylactic antibiotic use and clinician adherence varied widely across provinces of China.
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Affiliation(s)
- Qiguo Lian
- NHC Key Lab of Reproduction Regulation (Shanghai Institute for Biomedical and Pharmaceutical Technologies), Fudan University, Shanghai, 200237, China
| | - Tao Zheng
- Department of Obstetrics, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Xiaona Huo
- Department of Obstetrics, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Jun Zhang
- MOE-Shanghai Key Lab of Children's Environmental Health, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200092, China
| | - Lin Zhang
- Department of Obstetrics, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China. .,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, 200030, China.
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Dunk SA, Owen J, Lu MY, Kim DJ, Szychowski JM, Subramaniam A. Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity. Am J Obstet Gynecol MFM 2022; 4:100705. [PMID: 35931367 DOI: 10.1016/j.ajogmf.2022.100705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND A recent study from the United Kingdom suggested that a single dosage of adjunctive amoxicillin/clavulanic acid with operative vaginal delivery reduces maternal infectious morbidity by 40% (from 19% to 11%). However, 89% of their study population received an episiotomy. OBJECTIVE This study aimed to evaluate whether operative vaginal delivery is an independent risk factor for composite maternal postpartum infectious morbidity in a population with a low episiotomy rate. STUDY DESIGN This was a retrospective cohort study of patients with viable singleton vaginal deliveries after ≥34 weeks gestation at a single perinatal center (2013-2018). The patients were categorized by the mode of delivery: spontaneous vaginal delivery or operative vaginal delivery (forceps or vacuum-assisted). The primary outcome was a composite of maternal infectious morbidity up to 6 weeks after delivery, defined as (1) endometritis, (2) perineal wound morbidity (infection, breakdown, or dehiscence), or (3) culture-proven urinary tract infection. The patient characteristics and outcomes were compared between the groups using appropriate tests. Multivariable models were used to estimate the association between operative vaginal delivery and study outcomes compared with spontaneous vaginal delivery, with adjustment for selected confounders. RESULTS Of 14,647 deliveries meeting the inclusion criteria, 732 (5.0%) were operative vaginal deliveries: 354 (48%) forceps and 378 (52%) vacuums. Overall, 210 (1.4%) patients developed the morbidity composite. Patients having an operative vaginal delivery were more likely to be nulliparous, have labor inductions, develop intrapartum chorioamnionitis, receive an episiotomy, and sustain a third- or fourth-degree laceration. After adjusting for confounding factors, no significant association was observed between operative vaginal delivery and composite morbidity (adjusted odds ratio, 1.4 [0.8-2.4]) or any of its individual components. Administration of postpartum antibiotics and documented fever were also similar between groups. There was also no significant association between instrument (forceps vs vacuum) and the maternal infection composite. CONCLUSION In this single-center US cohort, operative vaginal delivery was not an independent risk factor for maternal composite postpartum infectious morbidity.
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Affiliation(s)
- Sarah A Dunk
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam).
| | - John Owen
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Michelle Y Lu
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Dhong-Jin Kim
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Jeff M Szychowski
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Biostatistics, The University of Alabama at Birmingham, Birmingham, AL (Dr Szychowski)
| | - Akila Subramaniam
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam); Departments of Obstetrics and Gynecology (Drs Dunk, Owen, and Lu, Mr Kim, and Drs Szychowski and Subramaniam)
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Feduniw S, Gaca Z, Malinowska O, Brunets W, Zgliczyńska M, Włodarczyk M, Wójcikiewicz A, Ciebiera M. The Management of Pregnancy Complicated with the Previable Preterm and Preterm Premature Rupture of the Membranes: What about a Limit of Neonatal Viability?-A Review. Diagnostics (Basel) 2022; 12:2025. [PMID: 36010375 PMCID: PMC9407094 DOI: 10.3390/diagnostics12082025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022] Open
Abstract
Preterm premature rupture of the membranes (PPROM) at the limit of viability is associated with low neonatal survival rates and a high rate of neonatal complications in survivors. It carries a major risk of maternal morbidity and mortality. The limit of viability can be defined as the earliest stage of fetal maturity when a fetus has a reasonable chance, although not a high likelihood, for extra-uterine survival. The study reviews available data on preventing preterm delivery caused by the previable PPROM, pregnancy latency, therapeutic options including the use of antibiotics and steroids, neonatal outcomes, and future directions and opportunities.
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Affiliation(s)
- Stepan Feduniw
- Department of Reproductive Health, Centre of Postgraduate Medical Education, 01-004 Warsaw, Poland
| | | | - Olga Malinowska
- Faculty of Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland
| | | | - Magdalena Zgliczyńska
- Department of Obstetrics, Perinatology and Neonatology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Marta Włodarczyk
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, 02-097 Warsaw, Poland
- Centre for Preclinical Research, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Anna Wójcikiewicz
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, 01-809 Warsaw, Poland
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Karaca SY, Adıyeke M, İleri A, İleri H, Vural T, Özmüş DN, Şimşek E, Özeren M. Identifying the Risk Factors Associated with Surgical Site Infection Following Cesarean Section in Adolescent Mothers. J Pediatr Adolesc Gynecol 2022; 35:472-477. [PMID: 35031447 DOI: 10.1016/j.jpag.2021.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/17/2021] [Accepted: 12/31/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE This study aimed to determine the modifiable risk factors associated with surgical site infection (SSI) after cesarean section in adolescent pregnant patients. DESIGN Retrospective case-control study SETTING: Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey PARTICIPANTS: Pregnant adolescents (≤ 19 years) who underwent cesarean section at our institution between January 2014 and March 2021 INTERVENTIONS AND MAIN OUTCOME MEASURES: To determine the modifiable and nonmodifiable risk factors associated with SSI following cesarean section in adolescents. The diagnosis of SSI was made according to the criteria defined by the Centers for Disease Control and Prevention (CDC). RESULTS SSI was diagnosed in 62 (2.9%) of 2105 adolescent mothers who underwent cesarean section. Univariate and multivariate analyses confirmed that body mass index (BMI) (OR = 2.35; 95% CI, 1.3-4.78), induction of labor (OR = 1.9; 95% CI, 1.2-3.71), and preoperative hemoglobin values less than 10 g/dl (OR = 2.1; 95% CI, 1.2-4.46) were risk factors for SSI in adolescent mothers. Patient- and operation-related risk factors did not reach the level of statistical significance. CONCLUSIONS BMI, labor induction, and antenatal anemia were independent risk factors for SSI in adolescents. Among these, BMI and anemia were modifiable patient-related risk factors. Addressing obesity in adolescents and treating prenatal anemia could be the first steps toward preventing SSI.
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Affiliation(s)
- Suna Yıldırım Karaca
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey; Ege University, Institute of Health Sciences, Department of Stem Cell, Izmir, Turkey
| | - Mehmet Adıyeke
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Alper İleri
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Hande İleri
- Alsancak State Hospital, Department of Family Medicine, Izmir, Turkey.
| | - Tayfun Vural
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Doğay Nurtaç Özmüş
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Ecem Şimşek
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
| | - Mehmet Özeren
- Health Sciences University Tepecik Education and Research Hospital, Department of Obstetrics and Gynaecology, Izmir, Turkey
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Fadlalmola HA, Al-Sayaghi KM, Al-Hebshi AA, Alshengeti AM, Almohammadi NH, Alawfi AD, Aljohani MM, Elhaddad NF. Vaginal preparation with different antiseptic solutions before cesarean section for preventing postoperative infections: A systematic review and network meta-analysis. J Obstet Gynaecol Res 2022; 48:2659-2676. [PMID: 35904080 DOI: 10.1111/jog.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/20/2022] [Accepted: 07/14/2022] [Indexed: 11/26/2022]
Abstract
AIMS We aimed to investigate the effect of various vaginal wash solutions on reducing risks of post-cesarean endometritis, wound infections, fever, and hospital stay duration. METHODS Scopus, Web of Science, PubMed, and Cochrane Library were searched for randomized clinical trials that compared different vaginal wash solutions to each other or to "no vaginal cleaning"; without restriction on the age of parturients or site where trials were conducted. We analyzed this frequentist network meta-analysis using the netmeta package in R software version 4.1.2; synthesized data as mean difference or risk ratio with their 95% confidence intervals. RESULTS Our network meta-analysis included 29 RCTs with a total sample size of 9311 women undergoing CS. Regarding post-cesarean endometritis, we found that povidone-iodine had the highest significant risk reduction compared to "no vaginal cleaning" (RR = 0.08, 95% CI [0.01, 0.69]). While regarding post-cesarean reduction of wound infection, fever, and hospital stay duration, we found that chlorhexidine 4% (RR = 0.17, 95% CI [0.05, 0.65]), saline 0.9% (RR = 0.12, 95% CI [0.03; 0.48]), and saline 0.9% (MD = -1.29, 95% CI [-2.18; -0.39]), respectively, had the highest significant risk reduction compared to "no vaginal cleaning." CONCLUSION Vaginal wash solutions were associated with a significant reduction of post-cesarean endometritis, wound infection, fever, and hospital stay duration. Since povidone-iodine had the highest significant reduction of post-cesarean endometritis, we recommend setting povidone-iodine as the standard practice as pre cesarean vaginal wash solution; consistent practice guidelines of Enhanced Recovery After Surgery (ERAS).
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Affiliation(s)
- Hammad Ali Fadlalmola
- Nursing College, Department of Community Health Nursing, Taibah University, Medina, Saudi Arabia
| | - Khaled Mohammed Al-Sayaghi
- Nursing College, Department of Medical Surgical Nursing, Taibah University, Medina, Saudi Arabia.,Nursing Division, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
| | - Abdulqader Abdlah Al-Hebshi
- Department of Pediatrics, Prince Mohammed Bin AbdulAziz Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Amer Mohammad Alshengeti
- Department of Pediatrics, College of Medicine, Taibah University, Almadinah, Saudi Arabia.,Infection Prevention and Control Department, Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, Almadinah, Saudi Arabia
| | - Nawal H Almohammadi
- Faculty of Medicine, Department of Pathology, Taibah University, Medina, Saudi Arabia
| | | | - Maher M Aljohani
- Department of Pathology, College of Medicine, Taibah University, Medina, Saudi Arabia.,Department of Pathology and Laboratory Medicine, Prince Mohammed Bin Abdulaziz Hospital, Medina, Saudi Arabia
| | - Nourhan F Elhaddad
- Obstetrics and Gynecology Department, Prince Mohammed Bin Abdul Aziz Hospital, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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