MRC ORACLE Children Study. Long term outcomes following prescription of antibiotics to pregnant women with either spontaneous preterm labour or preterm rupture of the membranes

Adverse events in people taking macrolide antibiotics versus placebo for any indication

BACKGROUND

Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases.

OBJECTIVES

To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides.

SELECTION CRITERIA

We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event.

MAIN RESULTS

We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials.

AUTHORS' CONCLUSIONS

The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.

[Antibiotic prophylaxis in preterm premature rupture of membranes: CNGOF preterm premature rupture of membranes guidelines]

OBJECTIVE

To analyse benefits and risks of antibiotic prophylaxis in the management of preterm premature rupture of membranes.

METHODS

PubMed and Cochrane Central databases search.

RESULTS

Streptoccoccus agalactiae (group B streptococcus) and Escherichia coli are the two main bacteria identified in early neonatal sepsis (EL3). Antibiotic prophylaxis at admission is associated with significant prolongation of pregnancy (EL2), reduction in neonatal morbidity (EL1) without impact on neonatal mortality (EL2). Co-amoxiclav could be associated with an increased risk for neonatal necrotising enterocolitis (EL2). Antibiotic prophylaxis at admission in women with preterm premature rupture of the membranes is recommended (Grade A). Monotherapy with amoxicillin, third generation cephalosporin and erythromycin can be used as well as combination of erythromycin and amoxicillin (Professional consensus) for 7 days (GradeC). Shorter treatment is possible when initial vaginal culture is negative (Professional consensus). Co-amxiclav, aminoglycosides, glycopeptides, first and second generation cephalosporin, clindamycin and metronidazole are not recommended (Professional consensus).

CONCLUSIONS

Antibiotic prophylaxis against Streptoccoccus agalactiae (group B streptococcus) and E. coli is recommended in women with preterm premature of the membranes (Grade A). Monotherapy with amoxicillin, third generation cephalosporin or erythromycin, as well as combination of erythromycin and amoxicillin are recommended (Professional consensus).

Neurodevelopmental considerations in surgical necrotizing enterocolitis

The majority of surviving infants with surgical necrotizing enterocolitis (NEC) will have some degree of neurodevelopmental impairment. The impact of specific medial and surgical treatments for infants with severe NEC remains largely unknown but is being actively investigated. It is incumbent upon all providers caring for these infants to continue to focus on long term neurodevelopmental outcomes and to develop more widespread methods of neurodevelopmental assessment.

Antecedents of cerebral palsy according to severity of motor impairment

INTRODUCTION

The purpose of this study was to determine whether antecedents and neuroimaging patterns vary according to the severity of motor impairment in children with cerebral palsy.

MATERIAL AND METHODS

A population-based study in which all 309 term-born children with spastic and dyskinetic cerebral palsy born between 1983 and 1994 and 618 matched controls were studied. Antecedents were retrieved from obstetric records. Information on neuroimaging was retrieved from the cerebral palsy Register of Western Sweden. Cases were grouped by severity of motor impairment: mild (walks without aids), moderate (walks with aids) or severe (dependent on wheelchair). Binary logistic regression, the Cochran-Armitage test for trends, interaction analyses and interrelationship analyses were performed.

RESULTS

Antecedents associated with mild motor impairment were antepartum (placental weight, maternal weight and antibiotic therapy) or intrapartum and postpartum adverse events (meconium-stained amniotic fluid, low Apgar score, admission to neonatal intensive care unit and neonatal encephalopathy). Antecedents associated with severe motor impairment were antepartum (congenital infection, small head circumference and brain maldevelopment) or intrapartum and postpartum (emergency cesarean section and maternal antibiotic therapy). Comparisons between mild and severe motor impairment revealed congenital infection, maldevelopment, neonatal encephalopathy and meconium aspiration syndrome significantly more often in the group with severe motor impairment (p < 0.05). White matter injury was the most common neuroimaging pattern in mild motor impairment, whereas maldevelopment and cortical/subcortical lesions were most common in the severe motor impairment group.

CONCLUSIONS

Our results suggest a variation in antecedents associated with cerebral palsy, related to severity of motor impairment. Timing of antecedents corresponded to neuroimaging patterns.

Design and conduct of a large obstetric or neonatal randomized controlled trial

As event rates fall, if mortality and disability are to improve further there is increasing need for large, well-designed trials. These should enroll more patients, more rapidly and at lower cost, with better representation of infants at highest risk and greater integration with routine care. This may require simpler datasets, linkage with routinely collected data, and international collaboration. It may be helpful to draw attention to recent evidence that participation in Phase III randomized controlled trials (RCTs) is at least as safe as receiving established care. Nationally coordinated clinical research networks employing local research staff may be the single most effective strategy to integrate clinical trials into routine practice. Other goals are: international standardization of outcomes; consensus on composite endpoints, biomarkers, surrogates and measures of disability; greater efficiency through randomized factorial designs and cluster or cross-over cluster RCTs; and equipping parents as partners in all aspects of the conduct of RCTs and in implementing their results.

Applying developmental programming to clinical obstetrics: my ward round

The theory of developmental programming is supported by accumulating evidence, both observational and experimental. The direct application of the principles of developmental programming by clinicians to benefit pregnant women remains an area of limited attention. Examining a selection of inpatients at an obstetric referral center, I searched for situations in which clinical decision making could be driven by the principles of developmental programming. I also looked for situations in which the clinical research agenda could be dictated by these concepts. In the decision to undertake preventive measures to avoid preeclampsia, the offspring’s perspective may support more liberal application of calcium and aspirin. Consideration of the long-term health perspective of the offspring could drive choices in the management of obesity and diabetes in pregnancy. The administration of corticosteroids in women delivering by elective cesarean at term may have modest short-term benefits, but additional trials are necessary to investigate long-term offspring health. The offspring of women suffering hyperemesis gravidarum may benefit from nutritional therapy. The long-term health of the offspring could affect couples’ choice for IVF or expectant management. Applying the principles of developmental programming to the management of pregnant women could drive clinical decision making and is driving the clinical research agenda. Increasingly, developmental programming concepts are becoming an integral part of clinical practice, as well as determining the choice of outcomes in trials in obstetrics and fertility medicine. The presented cases underscore the need for more research to guide clinical practice.

Prophylactic antibiotics for inhibiting preterm labour with intact membranes

BACKGROUND

The aetiology of preterm birth is complex and there is evidence that subclinical genital tract infection influences preterm labour in some women but the role of prophylactic antibiotic treatment in the management of preterm labour is controversial. Since rupture of the membranes is an important factor in the progression of preterm labour, it is important to see if the routine administration of antibiotics confers any benefit or causes harm, prior to membrane rupture.

OBJECTIVES

To assess the effects of prophylactic antibiotics administered to women in preterm labour with intact membranes, on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2013).

SELECTION CRITERIA

Randomised trials that compared antibiotic treatment with placebo or no treatment for women in preterm labour (between 20 and 36 weeks' gestation) with intact membranes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, and undertook quality assessment and data extraction. We contacted study authors for additional information. Results are presented using risk ratio (RR) for categorical data and mean difference (MD) for data measured on a continuous scale with their respective 95% confidence intervals (CI). The number needed to treat to benefit (NNTB) and the number needed to treat to harm (NNTH) was calculated where appropriate.

MAIN RESULTS

In this update (2013), with the addition of three trials (305 women), the large ORACLE II 2001 trial continues to dominate the results of this review. This review now includes a total of 14 studies randomising 7837 women. No significant difference was shown in perinatal or infant mortality for infants of women allocated to any prophylactic antibiotics compared with no antibiotics. However, an increase in neonatal deaths was shown for infants of women receiving any prophylactic antibiotics when compared with placebo (RR 1.57, 95% CI 1.03 to 2.40; NNTH 149, 95% CI 2500 to 61). No reduction in preterm birth or other clinically important short-term outcomes for the infant were shown.Long-term child outcomes to seven years of age were available for infants in the UK enrolled in the ORACLE II trial. Comparing any antibiotics with placebo, a marginally non-statistically significant increase was shown in any functional impairment (RR 1.10, 95% CI 0.99 to 1.23) and cerebral palsy (CP) (RR 1.82, 95% CI 0.99 to 3.34). In subgroup analysis, CP was statistically significantly increased for infants of women allocated to macrolide and beta-lactam antibiotics combined compared with placebo (RR 2.83, 95% CI 1.02 to 7.88; NNTH 35, 95% CI 333 to 9).Further, exposure to any macrolide antibiotics (including erythromycin alone or erythromycin plus co-amoxiclav) versus no macrolide antibiotics (including placebo and co-amoxiclav alone) was shown to increase neonatal death (RR 1.52, 95% CI 1.05 to 2.19; NNTH 139, 95% CI 1429 to 61), any functional impairment (RR 1.11, 95% CI 1.01 to 1.20; NNTH 24, 95% CI 263 to 13) and CP (RR 1.90, 95% CI 1.20 to 3.01; NNTH 64, 95% CI 286 to 29). Exposure to any beta-lactam (beta-lactam alone or in combination with macrolide antibiotics) versus no beta-lactam antibiotics resulted in more neonatal deaths (RR 1.51, 95% CI 1.06 to 2.15; NNTH 143, 95% CI 1250 to 63) and CP (RR 1.67, 95% CI 1.06 to 2.61; NNTH 79, 95% CI 909 to 33), however no difference was shown in functional impairment.Maternal infection was reduced with the use of any prophylactic antibiotics compared with placebo (RR 0.74, 95% CI 0.63 to 0.86; NNTB 34, 95% CI 24 to 63) and any beta-lactam compared with no beta-lactam antibiotics (RR 0.80, 95% CI 0.69 to 0.92; NNTB 47, 95% CI 31 to 119). However, caution should be exercised with this finding due to the possibility of bias shown by funnel plot asymmetry. Any beta-lactam compared with no beta-lactam antibiotics was associated with an increase in maternal adverse drug reaction (RR 1.61, 95% CI 1.02 to 2.54; NNTH 17, 95% CI 526 to 7).

AUTHORS' CONCLUSIONS

This review did not demonstrate any benefit in important neonatal outcomes with the use of prophylactic antibiotics for women in preterm labour with intact membranes, although maternal infection may be reduced. Of concern, is the finding of short- and longer-term harm for children of mothers exposed to antibiotics. The evidence supports not giving antibiotics routinely to women in preterm labour with intact membranes in the absence of overt signs of infection.Further research is required to develop sensitive markers of subclinical infection for women in preterm labour with intact membranes, as this is a group that might benefit from future novel interventions, including new modalities of antibiotic therapy. The results of this review demonstrate the need for future trials in the area of preterm birth to include assessment of long-term neurodevelopmental outcome.

Antibiotics for preterm rupture of membranes

BACKGROUND

Premature birth carries substantial neonatal morbidity and mortality. Subclinical infection is associated with preterm rupture of membranes (PROM). Prophylactic maternal antibiotic therapy might lessen infectious morbidity and delay labour, but could suppress labour without treating underlying infection.

OBJECTIVES

To evaluate the immediate and long-term effects of administering antibiotics to women with PROM before 37 weeks, on maternal infectious morbidity, neonatal morbidity and mortality, and longer-term childhood development.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013).

SELECTION CRITERIA

Randomised controlled trials comparing antibiotic administration with placebo that reported clinically relevant outcomes were included as were trials of different antibiotics. Trials in which no placebo was used were included for the outcome of perinatal death alone.

DATA COLLECTION AND ANALYSIS

We extracted data from each report without blinding of either the results or the treatments that women received. We sought unpublished data from a number of authors.

MAIN RESULTS

We included 22 trials, involving 6872 women and babies.The use of antibiotics following PROM is associated with statistically significant reductions in chorioamnionitis (average risk ratio (RR) 0.66, 95% confidence interval (CI) 0.46 to 0.96, and a reduction in the numbers of babies born within 48 hours (average RR 0.71, 95% CI 0.58 to 0.87) and seven days of randomisation (average RR 0.79, 95% CI 0.71 to 0.89). The following markers of neonatal morbidity were reduced: neonatal infection (RR 0.67, 95% CI 0.52 to 0.85), use of surfactant (RR 0.83, 95% CI 0.72 to 0.96), oxygen therapy (RR 0.88, 95% CI 0.81 to 0.96), and abnormal cerebral ultrasound scan prior to discharge from hospital (RR 0.81, 95% CI 0.68 to 0.98). Co-amoxiclav was associated with an increased risk of neonatal necrotising enterocolitis (RR 4.72, 95% CI 1.57 to 14.23).One study evaluated the children's health at seven years of age (ORACLE Children Study) and found antibiotics seemed to have little effect on the health of children.

AUTHORS' CONCLUSIONS

Routine prescription of antibiotics for women with preterm rupture of the membranes is associated with prolongation of pregnancy and improvements in a number of short-term neonatal morbidities, but no significant reduction in perinatal mortality. Despite lack of evidence of longer-term benefit in childhood, the advantages on short-term morbidities are such that we would recommend antibiotics are routinely prescribed. The antibiotic of choice is not clear but co-amoxiclav should be avoided in women due to increased risk of neonatal necrotising enterocolitis.

Prevalence, Spectrum and Antibiotic Susceptibility of Bacterial and Candida Colonization between the 21st and 33rd Week of Gestation in Women with PPROM - 5 Years' Experience in 1 Perinatal Center

Objective: The aim of this study was to evaluate the prevalence, spectrum and antibiotic susceptibility of bacterial and Candida colonization of the vagina between the 21st and the 33rd week of gestation in women who had preterm premature rupture of membranes (PPROM). Study design: High vaginal swabs from 245 subjects with PPROM were analyzed in a retrospective cohort study using cultivation-dependent methods. Patients were additionally divided into two groups: women with PPROM between the 21st and 27th week of gestation (group A) and women with PPROM between the 28th and 33rd week of gestation (group B). A subgroup analysis comparing the two groups was done. Results: The prevalence of pathological bacterial colonization was similar in both study groups (40.8 vs. 41.4 %; p > 0.05), however, a difference in antibiotic susceptibility was noted, which did not reach statistical significance (resistance to ampicillin 71.4 vs. 52.5 %; cefuroxime 9.5 vs. 11.7 %; gentamicin 28.6 vs. 16.4 %; ciprofloxacin 5.0 vs. 5.4 %). In group A there was a statistically significant lower rate of Candida colonization (11.1 vs. 24.3 %; p = 0.04). Conclusion: In patients with early PPROM, the rate of Candida colonization (group A) is lower and there are indications of a difference in antibiotic susceptibility of the colonizing bacteria depending on gestational age. Larger study groups are required to confirm these preliminary results.

Providing the results of research to participants: a mixed-method study of the benefits and challenges of a consultative approach

BACKGROUND

How best to provide the findings of research to study participants remains poorly understood.

PURPOSE

We aimed to develop, deliver, and evaluate a consultative approach to inform provision of feedback about research findings to participants in the Oracle Children Study (OCS). The OCS had identified adverse outcomes for some children whose mothers had been prescribed antibiotics as part of a trial in pregnancy.

METHODS

An iterative process, including focus groups with OCS participants and consultation with other OCS stakeholders, was used to inform the development of a feedback package, including a results leaflet, for OCS participants. A questionnaire survey of participants' reactions to receiving the results leaflet was conducted. The Kolmogorov-Smirnov two-sample test was used to compare responses between different groups of respondents. Analysis of open-ended comments on the questionnaire was based on the constant comparative method.

RESULTS

Three focus groups with study participants provided insight into the potential emotional impact of receiving the results and into how the results might most clearly be explained. Negotiations with other stakeholders identified other priorities, including the need for scientific credibility. These multiple needs had to be balanced. The results leaflet was posted to all 4676 UK OCS participants. Survey responses were received from 1124 (25%) of participants. They indicated that the feedback was mostly well received by participants. Those whose children were affected by conditions associated with increased risk from trial participation were more likely to experience emotional distress on receiving the trial results, but there was also evidence of some other unanticipated impacts.

LIMITATIONS

This study is limited by the low response rate to the survey.

CONCLUSIONS

Important lessons can be learned from using a consultative approach to developing feedback about research results for study participants. Especially where the findings are unwelcome, feedback development may involve methodological, ethical, emotional, and practical challenges, be resource-intensive, and need early planning.

Has publication of the results of the ORACLE Children Study changed practice in the UK?

OBJECTIVE

  To investigate whether publication of the results of the ORACLE Children's Study, a 7-year follow-up of the ORACLE trial, changed practice with regard to the routine prescription of antibiotics to women with preterm rupture of membranes or spontaneous preterm labour (intact membranes).

DESIGN

  A comparative questionnaire survey of clinical practice in November 2007 (before publication) and March 2009 (after publication).

POPULATION

  Lead obstetricians for labour wards of all maternity units in the UK.

METHODS

  Self-administered questionnaires requested information about the routine prescription of antibiotics to women with either preterm rupture of membranes or spontaneous preterm labour (intact membranes).

MAIN OUTCOME MEASURES

  Change in practice for prescription of antibiotics.

RESULTS

  The response rate was 166/214 (78%) in 2007 and 158/209 (76%) in 2009. In total, 120 maternity units responded on both occasions. For women with preterm rupture of membranes, 162/214 (98%) in 2007 and 151/158 (96%) in 2009 maternity units reported that they prescribed antibiotics, with the majority using erythromycin (98%). For women with spontaneous preterm labour (intact membranes), 35/166 (21%) in 2007 and 25/158 (16%) in 2009 maternity units reported that they routinely prescribed antibiotics. The findings from units who responded on both occasions are similar.

CONCLUSIONS

  There has been little change in the reported prescription of antibiotics to women with either preterm rupture of membranes or spontaneous preterm labour following publication of the ORACLE Children's Study. This suggests that current practice may require updated guidance.

Antibiotics for preterm rupture of membranes

BACKGROUND

Premature birth carries substantial neonatal morbidity and mortality. Subclinical infection is associated with preterm rupture of membranes (PROM). Prophylactic maternal antibiotic therapy might lessen infectious morbidity and delay labour, but could suppress labour without treating underlying infection.

OBJECTIVES

To evaluate the immediate and long-term effects of administering antibiotics to women with PROM before 37 weeks, on maternal infectious morbidity, neonatal morbidity and mortality, and longer-term childhood development.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 April 2010).

SELECTION CRITERIA

Randomised controlled trials comparing antibiotic administration with placebo that reported clinically relevant outcomes were included as were trials of different antibiotics. Trials in which no placebo was used were included for the outcome of perinatal death alone.

DATA COLLECTION AND ANALYSIS

We extracted data from each report without blinding of either the results or the treatments that women received. We sought unpublished data from a number of authors.

MAIN RESULTS

We included 22 trials, involving 6800 women and babies.The use of antibiotics following PROM is associated with statistically significant reductions in chorioamnionitis (average risk ratio (RR) 0.66, 95% confidence interval (CI) 0.46 to 0.96, and a reduction in the numbers of babies born within 48 hours (average RR 0.71, 95% CI 0.58 to 0.87) and seven days of randomisation (average RR 0.79, 95% CI 0.71 to 0.89). The following markers of neonatal morbidity were reduced: neonatal infection (RR 0.67, 95% CI 0.52 to 0.85), use of surfactant (RR 0.83, 95% CI 0.72 to 0.96), oxygen therapy (RR 0.88, 95% CI 0.81 to 0.96), and abnormal cerebral ultrasound scan prior to discharge from hospital (RR 0.81, 95% CI 0.68 to 0.98). Co-amoxiclav was associated with an increased risk of neonatal necrotising enterocolitis (RR 4.72, 95% CI 1.57 to 14.23).One study evaluated the children's health at seven years of age (ORACLE Children Study) and found antibiotics seemed to have little effect on the health of children.

AUTHORS' CONCLUSIONS

The decision to prescribe antibiotics for women with PROM is not clearcut. Benefits in some short-term outcomes (prolongation of pregnancy, infection, less abnormal cerebral ultrasound before discharge from hospital) should be balanced against a lack of evidence of benefit for others, including perinatal mortality, and longer term outcomes. If antibiotics are prescribed it is unclear which would be the antibiotic of choice.Co-amoxiclav should be avoided in women at risk of preterm delivery due to increased risk of neonatal necrotising enterocolitis.

Asthma and pregnancy: emerging evidence of epigenetic interactions in utero

PURPOSE OF REVIEW

Pregnancy is arguably the most critical period of developmental programming. Here, we particularly focus on the emerging paradigm that disease propensity is epigenetically determined by maternal exposures that have the capacity to activate or silence fetal genes through alterations in DNA and histone methylation, histone acetylation, and chromatin structure.

RECENT FINDINGS

The most notable recent candidate to emerge in this role has been dietary folate, a methyl donor clearly associated with changes in gene expression and disease susceptibility through gene hypermethylation. Animal studies also provide the first evidence that the allergy protective effects of microbial exposure in pregnancy may be mediated by changes in methylation of Th1 genes of the offspring. There is also emerging evidence that perinatal differences in immune function of allergy-prone newborns extend beyond previously recognized differences in effector T cell (Th1/Th2) function, to also include differences in neonatal regulatory T cell (Treg) and Th17 function, and moreover, that these pathways are also epigenetically regulated.

SUMMARY

New studies reinforce the importance of in-utero exposures (including dietary nutrients, microbial products, cigarette smoking, and certain maternal mediations) in fetal immune development and in programming the susceptibility to asthma and allergic disease.

Childhood outcomes after prescription of antibiotics to pregnant women with preterm rupture of the membranes: 7-year follow-up of the ORACLE I trial

BACKGROUND

The ORACLE I trial compared the use of erythromycin and/or amoxicillin-clavulanate (co-amoxiclav) with that of placebo for women with preterm rupture of the membranes without overt signs of clinical infection, by use of a factorial randomised design. The aim of the present study--the ORACLE Children Study I--was to determine the long-term effects on children of these interventions.

METHODS

We assessed children at age 7 years born to the 4148 women who had completed the ORACLE I trial and who were eligible for follow-up with a structured parental questionnaire to assess the child's health status. Functional impairment was defined as the presence of any level of functional impairment (severe, moderate, or mild) derived from the mark III Multi-Attribute Health Status classification system. Educational outcomes were assessed with national curriculum test results for children resident in England.

FINDINGS

Outcome was determined for 3298 (75%) eligible children. There was no difference in the proportion of children with any functional impairment after prescription of erythromycin, with or without co-amoxiclav, compared with those born to mothers who received no erythromycin (594 [38.3%] of 1551 children vs 655 [40.4%] of 1620; odds ratio 0.91, 95% CI 0.79-1.05) or after prescription of co-amoxiclav, with or without erythromycin, compared with those born to mothers who received no co-amoxiclav (645 [40.6%] of 1587 vs 604 [38.1%] of 1584; 1.11, 0.96-1.28). Neither antibiotic had a significant effect on the overall level of behavioural difficulties experienced, on specific medical conditions, or on the proportions of children achieving each level in reading, writing, or mathematics at key stage one.

INTERPRETATION

The prescription of antibiotics for women with preterm rupture of the membranes seems to have little effect on the health of children at 7 years of age.

FUNDING

UK Medical Research Council.

Antibiotics for preterm labour with intact membranes

BACKGROUND

There may be a link between infection and preterm birth.

OBJECTIVES

Since rupture of the membranes is an important factor in the progression of preterm labour, it is important to see if antibiotics are of any benefit prior to membrane rupture. The objective of this review was to assess the effects of antibiotics administered to women in preterm labour with intact membranes, on maternal and neonatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and reference lists of articles. We contacted experts in the field.

SELECTION CRITERIA

Randomised trials which compared antibiotic treatment with placebo or no treatment for women in preterm labour (between 20 and 36 weeks gestation) with intact membranes.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing data.

MAIN RESULTS

Meta-analysis of the ten included trials demonstrated a statistically significant prolongation of pregnancy associated with the use of antibiotics (5. 4 days, 95% confidence interval (CI) 0.9- 9.8 days). Antibiotic treatment was also associated with a statistically significant reduction in maternal infection (odds ratio (OR) 0.59, 95% CI 0.36, 0.97) and neonatal necrotising enterocolitis (OR 0.33, 95% CI 0.13, 0.88). No statistically significant effect was detected on the neonatal outcomes of respiratory distress syndrome and neonatal sepsis, although there was a trend towards the latter (OR 0.67, 95% CI 0.42, 1.07). An increase in perinatal mortality was observed in the group receiving antibiotics (OR 3.36, 95% CI 1.21, 9.32).

REVIEWER'S CONCLUSIONS

Although a prolongation in time to delivery and a trend towards a reduction in neonatal sepsis was detected, this review fails to demonstrate a clear overall benefit from antibiotic treatment for preterm labour with intact membranes on neonatal outcomes and raises concerns about increased perinatal mortality for those who received antibiotics. This treatment cannot therefore be currently recommended for routine practice. Further research is required to identify a subgroup of women (and their babies) who are more likely to experience benefit from antibiotic treatment for preterm labour prior to membrane rupture, and to identify which antibiotic or combination of antibiotics is most effective. The results of the ongoing ORACLE trial should help resolve some of the uncertainties revealed by this review.