PUERPERAL INFECTION - ASID

PUERPERAL INFECTION

Joe McCormack Mater Hospitals & University of Queensland

OUTLINE

Historical aspects & definition Clinical syndromes Early & late infection Organisms involved Treatment Prevention A few other issues

HISTORICAL

Hippocrates 5th cent BC: De Muliebrium Morbis – attributed to retention of bowel contents

HISTORICAL

Semmelweis (1818-65), junior obstetrician, Vienna 1847 Dunn Arch Dis Child Fet Neonat Ed 2005 90:345-8

Role of Group A Streptococcus Lethal triad – pre-eclampsia ant/prenatal hemorrhage puerperal infection

DEFINITION

Infection of the genital tract after delivery Temp 38.0 (100.4) degrees on any 2 of the first

10 days postpartum, excluding day 1 Global: 500,000 maternal deaths/y; 99%

developing countries; 33% due to infection Direct extension from colonizing organisms McLure Int J Gyn Obs 2007 97:89-94; Mussey Am J Obst Gyn 1935 28:754 – Joint Committee on

Maternal Welfare 1919

OUTLINE


PUERPERAL INFECTION- clinical syndromes

Chorioamnionitis Endometritis Salpingitis Abscess Thrombophlebitis Peritonitis Septicemia Non-pelvic: Surgical site infection, cellulitis, mastitis,

breast engorgement, thrombophlebitis, UTI, RTI, meningitis etc

PUERPERAL INFECTION - early

Onset within days Risk factors: Caesarian section: x 3-20 Liu CMAJ 2007 176:455-60

Long labour Allen Obs Gyn 2009 113:1248-58

Prolonged rupture of membranes (ROM) Number of vaginal examinations Bacterial vaginosis: OR 5.8 [3.0-10.9] Watts Obs Gyn 1990 75:52

Gestation <37 wks Chaim Inf Dis Obs Gyn 2000 8:77-82 Shorter interpregnancy interval: <6mos vs >59mos Conde-Agudelo BMJ 2000 321:1255-9

PUERPERAL INFECTION - late

Days to weeks post partum Strong correlation with Chlamydia

trachomatis Approx 30% with untreated C

trachomatis developed infection, 2/3 late

Milder acute illness: salpingitis rare clinically

Risk of infertility increased, incidence ?

CHORIOAMNIONITIS 0.5 – 2% of term pregnancies, more preterm Prolonged ROM Polymicrobial Fever; uterine tenderness variable, discharge Bacteremia 2-3%; endometritis 10-50% Culture gold standard Amniotic fluid micro, C/S, glucose Immunoassay: Il-6/1/8, WBC esterase?? Antibiotics Delivery important but no evidence that accelerated delivery

significantly increases risk of maternal or fetal morbidity: apply same criteria for CS

Rouse Am J Obs Gyn 2004 191:211

EFFECTS on FETUS

20-40% of cases early neonatal sepsis & pneumonia assoc chorioamnionitis

Risk of fetal infection 10-20% Increased incidence cerebral palsy: OR 4.1 [1.6-

10.1] Wu JAMA 2003 290:2677-84

Caused by exuberant cytokine response, asphyxia, toxic injury Newton UpToDate 2009

ENDOMETRITIS

<3% vaginal delivery 1.3% of >4,000 women, Dallas 1987 6% if prolonged ROM >6 hrs, multiple PV

exams + fetal scalp monitoring 13% if chorioamnionitis Other risk factors: stillbirth, preterm, low birth

wt, HTN, serious neonatal morbidity Cunningham: Williams Obstetrics, McGraw Hill, 22 ed, chap 31, 2005; Chaim Inf Dis Obs Gyn 2000 8:77-

82

ENDOMETRITIS 35-65% non-elective CS without antimicrobial

prophylaxis 13% Uni Michigan Hospital 27% Wayne County Hospital Sweet Am J ObsGyn Scan 1973 117:1093

Prolonged ROM, multiple exams, fetal scalp monitoring, cephalopelvic disproportion

Twins, young maternal age, multip, obesity Single dose perioperative antibiotic prophylaxis has

done more for CS pelvic infection than any other measure in 25 years

Cunningham: Williams Obstetrics, McGraw Hill, NY, 22 ed; chap 31 2005; Holmes: Sexually transmitted diseases, McGraw Hill, NY, 4 ed; chap 81 2008.

ENDOMETRITIS

Increased incidence in pts delivered PV following one prior CS: 2.9%PV vs 1.8% repeat CS Landon NEJM 2004 351:2581-9

Infection rate OR 6.2 [4.7-8.2] Taylor MJA 2005 183:515-9

SALPINGITIS

Progression from endometritis or sexually acquired: C trachomatis & N gonorrhoeae

Adnexal pain/tenderness Diff Dx: appendicitis, ovarian cyst, others Short term: abscess Long term: infertility, dyspareunia, ectopic

pregnancies

OUTLINE


COLONIZING BARRIER

Cervix & vagina colonized Endometrium sterile

PUERPERAL INFECTION

From lower genital tract organisms Placental implantation site + adjacent

endo/myometrium Facilitated by blood, devitalized tissue, foreign

bodies & material: instruments, suture material

Bacteria colonizing amniotic fluid @ CS, ROM > 6 Hs

Polymicrobial: avge 2.5 bacteria Gilstrap Obs Gyn 1979 53:545

Anerobes + aerobes

63%

Anerobes 30%

Aerobes 7%

Anerobic Strep 45% Bacteroides 9% Clostridium 3% Enterococcus 14% Gr B Strep 8% E coli 9%

Isolates from endometrium 150 pts early postpartum endometritis

Group B Strep 8%

Enterococci 12%

S aureus 2%

Enterobacteriaceae 14%

Gardnerella vaginalis 38%

Bacteroides spp 29%

Peptostreptococci 43%

Other anerobes 4%

Chlamydia trachomatis 7%

Watts Obs Gyn 1998 73:52-60

PARTICULAR ORGANISMS

MRSA Group A Strep Group B Strep Clostridia Mycoplasmas, Ureaplasmas HIV

MRSA in PREGNANCY

Estim 14,000 infections/y USA 60% Mastitis Annual estim cost US$16 mill/y “modest burden” Universal screening not cost-effective

Beigi Obs Gyn 2009 113:983-91

Group A Strep Puerperal infection

4/257 puerperal infections, Florida: 1.6% 3 bacteremia; 1 TSS; all survived

Aronoff Inf Dis Obs Gyn 2008 796892 e pub dec 31

GROUP B STREP

Commensal GIT & GUT 30% women childbearing age

Screening low vaginal & perianal swabs 36wks – to prevent neonatal rather than puerperal infection

Therapeutic guidelines: antibiotic; Ohlsson Coch Database Syst Rev 2009 3:CD007467

CLOSTRIDIUM SORDELLII

Toxic shock: 4 fatal cases childbirth (3), abortion (1) Fischer NEJM 2005 353:2352-60

Assoc misoprostol use abortions (PGE2 pharmacomimetic): immunosuppressive

Endometritis rare & mild in 652 pts Zhang NEJM 2005 353:761-9

Not assoc with mifepristone (RU-486) Aronoff J Immunol 2008 180:8222-30

Case fatal TSS C perfringens Cohen Obs Gyn 2007 110:1027

MYCOPLASMA GENITALIUM

Assoc PID, salpingitis, infertility, chronic pelvic pain

Dx by PCR AZM: may not respond to doxycycline ? Role in puerperal infection ? Roles of M hominis, Ureaplasma urealyticum Haggerty Sex Transm Inf 2008 84:338-42; Cohen Sex Transm Inf 2005 81:463-6; Patai J Med Micro

2005 54:1249-50

HIV VERTICAL TRANSMISSION RATES

Viral Load Transmission

< 1,000 0 1,000 – 10,000 17% 10,000 – 100,000 21% 100,000 – 1 Mill 31%

(E. Abrams ICAAC 2004)

HIV and Puerperal Infection

Endometritis assoc CS [OR 4.1 & 6.2] & chorioamnionitis [OR 3.0] but not HIV pos

Cavasin Inf Dis Obs Gyn 2009 827405 epub; Sebitloane Eur J Obs Gyn Reprod Biol 2009 145:158-62; Louis Inf Dis Obs Gyn 2006 79512

OUTLINE


TREATMENT Delivery of baby in chorioamnionitis Surgical debridement endometritis: curettage Broad spectrum antibiotics: *Clindamycin + gentamicin: cure 90-97%; superior to others French Cochrane Database Syst Rev 2004 CD001067 *Ampicillin + gentamicin + metronidazole [AB guidelines]

*Timentin/Tazocin/Augmentin/Ampicillin +sulbactam

*Cefotetan/ Cefoxitin *Meropenem ? azithromycin also

FAILURE TO RESPOND

Resistant organisms: enterococci, MROs, mycoplasmas

Retained products of conception Abscess Thrombophlebitis/thrombosis Inadequate dosing

OUTLINE


ANTIBIOTIC PROPHYLAXIS in CS

Cephalothin 2g/ cefazolin 1g once only ? difference before/after cord clamping Puerperal infection & SSI rates reduced by 75% -

elective & non-elective CS Broader spectrum agents or multiple doses no extra

benefit Implementation of policies & practice a significant

barrier* Not routinely for vaginal deliveries Tita Obs Gyn 2009 113:675-82; Chelmow Am J Ob/Gyn 2001 184:656; Smaill Cochrane Lib 1 2003;

Noyes Inf Dis Obs Gyn 1998 6:220-3; Hopkins Cochrane Lib 1 2003; Amer Coll Ob/Gyn Pract Bull 47, 2003; Therapeutic Guidelines: Antibiotic; Rayburn Antimicrob Agents Chemother 1985 27:337-9; *Weinberg Arch Int Med 2001 161:2367-8

ANTIBIOTIC PROPHYLAXIS FOR CS

Uni Pittsburg Med Cent: Nov 2004 change after cord clamping to incision

4,229 >2 ys before vs 4,781 >2 ys after Endometritis OR 0.61 [0.47-0.79]

Wound infection OR 0.7 [0.55-0.9]

No adverse effect on neonate Owens Obstet Gyn 2009 114:573-9

ANTIBIOTIC PROPHYLAXIS IN ABORTION

Therapeutic Guidelines: cephalothin/ cefazolin + metro/tinidazole or cefoxitin

? Add AZM Penney Hum Reprod 1997 12:107-12

CHLORHEXIDINE 0.25%

Manual wipe at every PV exam pre-delivery vs no wipe

Blantyre, 3743 vs 3417 births Puerperal infection rates 1.7 vs 5.1 per 1,000

deliveries p<0.02 Taha BMJ 1997 315:216-9

Metanalysis 3 RCTs no benefit: RR 0.83 0.61-1.13 Lumbiganon Cochrane Datab Syst Rev 2004 CD004070

OUTLINE


OTHER MANAGEMENT ISSUES

Antibiotic selection pregnancy & breast feeding Antibiotic dosing & clearance eg vancomycin,

daily aminoglycosides Ward Clin Obs Gyn 2008 51:498-506

PARTICULAR PROBLEMS

Staff expectations of good outcome Staff difficulty to manage IV antibiotics

PARTICULAR PROBLEMS

Staff expectations of good outcome Staff difficulty to manage IV antibiotics Parental expectations of good outcome Parental emotional aspects inc LOS

Usually things work out well

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PUERPERAL INFECTION - ASID