Early online.

BACKGROUND: Caesarean section is a life-saving procedure which is associated with high rates of maternal and neonatal complications. It has been estimated that globally, 29.7 million births occur by caesarean section annually. The risk of postpartum infection is estimated to be five to ten times higher compared to normal vaginal delivery. Pregnancy-related sepsis was listed as a top six cause of maternal mortality in the South African Saving Mothers report between 2017 and 2019. Multiple trials have been conducted in an attempt to optimise administration of prophylactic antibiotics in an effort to reduce postpartum infection and maternal sepsis, and current practice guidelines suggest that there is sufficient evidence that extended spectrum antibiotics, in combination with kefazolin, result in reduction of postpartum infections Objectives. To investigate the effect of perioperative administration of kefazolin alone compared to kefazolin plus metronidazole on postpartum infection in women undergoing caesarean section at Kalafong Provincial Tertiary Hospital. METHOD: All patients undergoing emergency or elective caesarean section were randomised and then sequentially numbered in opaque sealed envelopes, which were placed in the caesarean section operating theatre. The intervention group received kefazolin and a sealed envelope with metronidazole. The control group received kefazolin and a sealed envelope with normal saline. RESULTS: A total of 57/1 010 patients (5.64%) had surgical site infections, of which 27 (5.33%) were in the control group, and 30 (5.96%) were in the intervention group (p=0.66). Two patients in each arm (0.40% in the intervention arm and 0.39% in the control arm) underwent laparotomy procedures, while three women (0.60%) in the intervention arm and four women (0.79%) in the control arm underwent hysterectomy procedures. There were no statistically significant differences in all the measured secondary outcomes between the two groups. CONCLUSION: The overall sepsis rate in this study was 5.64%. Postpartum infection is multifactorial and there are multiple factors that can be addressed in strengthening the sepsis care bundle. We do not recommend the addition of metronidazole to kefazolin as prophylaxis at caesarean section.

A randomised trial comparing preoperative administration of single-dose kefazolin to kefazolin plus metronidazole as prophylactic antibiotics at caesarean section.

BACKGROUND: Caesarean section is a life-saving procedure which is associated with high rates of maternal and neonatal complications. It has been estimated that globally, 29.7 million births occur by caesarean section annually. The risk of postpartum infection is estimated to be five to ten times higher compared with normal vaginal delivery. Pregnancy-related sepsis was listed as a top-six cause of maternal mortality in the South African Saving Mothers report between 2017 and 2019. Multiple trials have been conducted in an attempt to optimise administration of prophylactic antibiotics in an effort to reduce postpartum infection and maternal sepsis, and current practice guidelines suggest that there is sufficient evidence that extended-spectrum antibiotics, in combination with kefazolin, result in reduction of postpartum infections. OBJECTIVES: To investigate the effect of perioperative administration of kefazolin alone compared with kefazolin plus metronidazole on postpartum infection in women undergoing caesarean section at Kalafong Provincial Tertiary Hospital, Pretoria, South Africa. METHOD: All patients undergoing emergency or elective caesarean section were randomised and then sequentially numbered in opaque sealed envelopes, which were placed in the caesarean section operating theatre. The intervention group received kefazolin and a sealed envelope with metronidazole. The control group received kefazolin and a sealed envelope with normal saline. RESULTS: A total of 57/1 010 patients (5.64%) had surgical site infections, of which 27 (5.33%) were in the control group, and 30 (5.96%) were in the intervention group (p=0.66). Two patients in each arm (0.40% in the intervention arm and 0.39% in the control arm) underwent laparotomy procedures, while three women (0.60%) in the intervention arm and four women (0.79%) in the control arm underwent hysterectomy procedures. There were no statistically significant differences in all the measured secondary outcomes between the two groups. CONCLUSION: The overall sepsis rate in this study was 5.64%. Postpartum infection is multifactorial and there are multiple factors that can be addressed in strengthening the sepsis care bundle. We do not recommend the addition of metronidazole to kefazolin as prophylaxis at caesarean section.

The relation between low-grade fever during prolonged rupture of membranes (>12 hours) at term and infectious outcomes: a retrospective cohort study.

BACKGROUND: Intrapartum fever (>38°C) is associated with adverse maternal and neonatal outcomes. However, the correlation between low-grade fever (37.5°C-37.9°C) and adverse perinatal outcomes remains controversial. OBJECTIVE: This study aimed to compare maternal and neonatal outcomes of women with prolonged rupture of membranes (≥12 hours) at term between those with low-grade fever and those with normal body temperature. STUDY DESIGN: This retrospective study included women hospitalized in a tertiary university-affiliated hospital between July 2021 and May 2023 with singleton term and rupture of membranes ≥12 hours. Women were classified as having intrapartum low-grade fever (37.5°C-37.9°C) or normal body temperature (<37.5°C). The co-primary outcomes, postpartum endometritis and neonatal intensive care unit admission rates, were compared between these groups. The secondary maternal outcomes were intrapartum leukocytosis (>15,000/mm2), cesarean delivery rate, postpartum hemorrhage, postpartum fever, surgical site infection, and postpartum length of stay. The secondary neonatal outcomes were early-onset sepsis, 5-minute Apgar score of <7, umbilical artery cord pH<7.2 and pH<7.05, neonatal intensive care unit admission length of stay, and respiratory distress. The data were analyzed according to rupture of membranes 12 to 18 hours and rupture of membranes ≥18 hours. In women with rupture of membranes ≥18 hours, intrapartum ampicillin was administered, and chorioamniotic membrane swabs were obtained. The likelihood ratios and 95% confidence intervals were calculated for the co-primary outcomes. A multivariate logistic regression model was used to predict puerperal endometritis controlled for rupture of membranes duration, low-grade fever (compared with normal body temperature), positive group B streptococcus status, mechanical cervical ripening, cervical ripening by prostaglandins, artificial rupture of membranes, meconium staining, epidural analgesia, and cesarean delivery. A multivariate logistic regression model was used to predict neonatal intensive care unit admission controlled for rupture of membranes duration, low-grade fever, positive group B streptococcus status, mechanical cervical ripening, artificial rupture of membranes, meconium staining, cesarean delivery, and neonatal weight of <2500 g. RESULTS: This study included 687 women with rupture of membranes 12 to 18 hours and 1109 with rupture of membranes ≥18 hours. In both latency groups, the rates were higher for cesarean delivery, endometritis, surgical site infections, umbilical cord pH<7.2, neonatal intensive care unit admission, and sepsis workup among those with low-grade fever than among those with normal body temperature. Among women with low-grade fever, the positive likelihood ratios were 12.7 (95% confidence interval, 9.6-16.8) for puerperal endometritis and 3.2 (95% confidence interval, 2.0-5.3) for neonatal intensive care unit admission. Among women with rupture of membranes ≥18 hours, the rates were higher of Enterobacteriaceae isolates in chorioamniotic membrane cultures for those with low-grade fever than for those with normal intrapartum temperature (22.0% vs 11.0%, respectively; P=.006). Low-grade fever (odds ratio, 9.0; 95% confidence interval, 3.7-21.9; P<.001), artificial rupture of membranes (odds ratio, 4.2; 95% confidence interval, 1.5-11.7; P=.007), and cesarean delivery (odds ratio, 5.4; 95% confidence interval, 2.2-13.4; P<.001) were independently associated with puerperal endometritis. Low-grade fever (odds ratio, 3.2; 95% confidence interval, 1.7-6.0; P<.001) and cesarean delivery (odds ratio, 1.9; 95% confidence interval, 1.1-13.1; P=.023) were independently associated with neonatal intensive care unit admission. CONCLUSION: In women with rupture of membranes ≥12 hours at term, higher maternal and neonatal morbidities were reported among those with low-grade fever than among those with normal body temperature. Low-grade fever was associated with a higher risk of Enterobacteriaceae isolates in chorioamniotic membrane cultures. Moreover, low-grade fever may be the initial presentation of peripartum infection.

Determinants of puerperal sepsis among postpartum women: a case-control study in East Shoa Zone public hospitals, Central Ethiopia.

OBJECTIVE: To identify determinants of puerperal sepsis among postpartum women attending East Shoa Zone public hospitals, Central Ethiopia, 2023. DESIGN AND SETTING: An institutional-based, unmatched case-control study was conducted from 19 June 2023 to 4 September 2023, in East Shoa Zone public hospitals. PARTICIPANTS: 495 postpartum women (100 cases and 395 controls) were selected using systematic sampling techniques. Data were collected through face-to-face interviews and from medical charts using a pretested, structured questionnaire. The AOR with its corresponding 95% CI was used to identify determinant variables. Findings were presented in texts and tables. OUTCOME MEASURES: The medical charts of participants were reviewed to identify those who had developed puerperal sepsis. RESULTS: Anaemia (AOR 6.05; 95% CI 2.57 to 14.26), undernourishment (AOR 4.43; 95% CI 1.96 to 10.01), gestational diabetes mellitus (AOR 3.26; 95% CI 1.22 to 8.74), postpartum haemorrhage (AOR 3.17; 95% CI 1.28 to 7.87), obstructed labour (AOR 2.76; 95% CI 1.17 to 6.52), multiparity (AOR 2.54; 95% CI 1.17 to 5.50), placenta previa (AOR 2.27; 95% CI 1.11 to 4.67) and vaginal examination ≥5 times (AOR 2.19; 95% CI 1.05 to 4.54) were the independent determinants of puerperal sepsis in this study. CONCLUSION: This study found that gestational diabetes mellitus, anaemia, undernourishment, placenta previa, obstructed labour, postpartum haemorrhage and five or more per-vaginal examinations during labour were the determinants of puerperal sepsis. Therefore, it is recommended that obstetric care providers strictly adhere to guidelines on the number of vaginal exams that should be performed throughout labour and that they perform these exams using the appropriate infection-prevention techniques. In addition, they should provide comprehensive health education on nutrition during pregnancy and postnatal periods and the importance of iron supplements.

Postpartum infections and antimicrobial resistance of responsible pathogens in Ukraine: results a multicenter study (2020-2022).

OBJECTIVE: Aim: To determine the current prevalence of postpartum infections and antimicrobial resistance and antimicrobial resistance of responsible pathogens in Ukraine. PATIENTS AND METHODS: Materials and Methods: Multicenter prospective cohort study was conducted from January 2020 to December 2022 in fifteen hospitals from twelve regions of Ukraine. Definitions of healthcare- associated postpartum infection were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Antibiotic susceptibility was done by the disc diffusion test as recommended by EUCAST. RESULTS: Results: Among 21,968 women, 6,175 (28.1%) postpartum infections were observed. Of all postpartum infection cases, 83.1% were detected after hospital discharge. The postpartum infection rates were 17.3% after cesarean section and 10.8% after vaginal delivery. The most common postpartum infection types were endometritis (17.3%), followed by urinary tract Infection (3.5%), mastitis (3.4%), surgical site infection (excluding endometritis) (2.4%), and episiotomy site infection (1.5%). The predominant postpartum infection pathogens in Ukraine were: Escherichia coli (10.4%), Enterococcus spp. (9.6%), Staphylococcus aureus (6.7%), Pseudomonas aeruginosa (5.8%), Enterobacter spp. (5.8%). In our study pathogens of postpartum infection had differently levels of resistance to antibiotics. CONCLUSION: Conclusions: Our results indicate that postpartum infections requiring medical attention are common in Ukraine and that most postpartum infections occur after hospital discharge, so that use of routine inpatient surveillance methods alone will lead to underestimation of postpartum infection rates. Optimizing the antibiotic prophylaxis may reduce the burden of postpartum infection, but prevention is the key element.

Burden of Antimicrobial Resistance Among Women with Post-Partum Infections in Low-Middle Income Countries: A Systematic Review.

BACKGROUND: Due to the rising incidence of multidrug-resistant (MDR) pathogens, especially in Low-Middle-Income Countries (LMIC), post-partum infections represent a significant treatment challenge. METHODS: We performed a systematic review of the literature from January 2005 to February 2023 to quantify the frequency of maternal post-partum infections due to MDR pathogens in LMICs, focusing on methicillin-resistant Staphylococcus aureus (MRSA) and/or extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales. SECONDARY OBJECTIVES: description of antimicrobials' prescriptions. FINDINGS: We included 22 studies with 14,804 total bacterial isolates from 12 countries, mostly from WHO African-Region. Twelve papers described wound- and 10 puerperal-infections. Seven were high-quality articles. Seventeen studies reported data on MRSA, and 18 on ESBL-producing Enterobacterales. Among high-quality studies, MRSA ranged from 9.8% in Ghana to 91.2% in Uganda; ESBL-producing Enterobacterales ranged from 22.8% in Ukraine to 95.2% in Uganda. Nine articles, mostly on C-sections, described different protocols for antibiotic prophylaxis and/or post-partum treatment. INTERPRETATION: We described a high burden of post-partum infections caused by MRSA and/or ESBL-producing Enterobacterales in LMICs, but only a few studies met quality standards. There is an urgent need for high-quality studies to better describe the real burden of antimicrobial resistance in low-resource settings and inform policies to contain the spread of multidrug-resistant organisms.

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.

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.

Timing of antibiotic prophylaxis in term prelabor rupture of membranes: A retrospective cohort study using propensity-score matching.

OBJECTIVE: To assess whether earlier administration of antibiotic prophylaxis after prelabor rupture of membranes (PROM) at term would decrease the incidence of maternal and neonatal infections. METHODS: This is a retrospective cohort study comparing women with term PROM who were initiated antibiotic prophylaxis within or after 6 h, and within or after 12 h from PROM to delivery during January 2019 to December 2021. Women with term PROM receiving cephalosporin and without contraindications to vaginal delivery or confirmed or suspected infection were included in the study. The primary outcome was puerperal infection, which refers to the reproductive tract infection occurring within 42 days of delivery. The type of pharmacoeconomic evaluation was selected based on the results of compared effectiveness between the early group and the late group. Propensity-score matching (PSM) was used to adjust confounding. Subgroup and sensitivity analyses were used to verify the robustness of results. RESULTS: We enrolled 5353 women with term PROM, including 4331 initiated with antibiotic within 6 h, 1022 after 6 h, 5077 within 12 h, and 276 after 12 h. After PSM, no significant difference was observed in the baseline characteristics of the groups. There was no statistical difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in puerperal infection (4.6% vs. 4.3%, P = 0.826; 2.9% vs. 4.6%, P = 0.471, respectively), total maternal infection, neonatal sepsis, and total neonatal infection. Cost-minimization analysis showed there was no significant difference between antibiotic use within 6 h and after 6 h, or within 12 h and after 12 h, in direct medical costs. CONCLUSION: This study showed that there was no statistical difference in the efficacy and economy of antibiotic prophylaxis used within 6-12 h after rupture of membranes versus after 6-12 h in women with term PROM.

Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study.

OBJECTIVE: The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period. DESIGN: A population-based cohort study. SETTING: Regions of Stockholm and Gotland, Sweden, 2008-2020. POPULATION: A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups. METHODS: The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed. MAIN OUTCOME MEASURES: Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures. RESULTS: The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage. CONCLUSIONS: Increasing active first stage duration is associated with maternal complications in the early postpartum period.

Risk Factors, Trends, and Outcomes Associated With Postpartum Sepsis Readmissions.

OBJECTIVE: To evaluate the prevalence, timing, clinical risk factors, and adverse outcomes associated with postpartum readmissions for maternal sepsis. METHODS: We conducted a retrospective cohort study of delivery hospitalizations and 60-day postpartum readmissions for females aged 15-54 years with and without sepsis using the 2016-2020 Nationwide Readmissions Database. Temporal trends in sepsis diagnoses during delivery hospitalizations and 60-day postpartum readmissions were analyzed with the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% CIs. Logistic regression models were fit to determine whether delivery hospitalization characteristics were associated with postpartum sepsis readmissions, and unadjusted and adjusted odds ratios with 95% CIs were reported. Adverse outcomes associated with sepsis during delivery hospitalization and readmission were described, including death, severe morbidity, a critical care composite, and renal failure. RESULTS: Overall, 15,268,190 delivery hospitalizations and 256,216 associated 60-day readmissions were included after population weighting, of which 16,399 (1.1/1,000 delivery hospitalizations) had an associated diagnosis of sepsis at delivery, and 20,130 (1.3/1,000 delivery hospitalizations) had an associated diagnosis of sepsis with postpartum readmission. A sepsis diagnosis was present in 7.9% of all postpartum readmissions. Characteristics associated with postpartum sepsis readmission included younger age at delivery, Medicaid insurance, lowest median ZIP code income quartile, and chronic medical conditions such as obesity, pregestational diabetes, and chronic hypertension. Postpartum sepsis readmissions were associated with infection during the delivery hospitalization, including intra-amniotic infection or endometritis, wound infection, and delivery sepsis. Sepsis diagnoses were associated with 24.4% of maternal deaths at delivery and 38.4% postpartum, 2.2% cases of nontransfusion severe morbidity excluding sepsis at delivery and 13.6% postpartum, 15.6% of critical care composite diagnoses at delivery and 30.1% postpartum, and 11.1% of acute renal failure diagnoses at delivery and 36.4% postpartum. CONCLUSION: Sepsis accounts for a significant proportion of postpartum readmissions and is a major contributor to adverse outcomes during delivery hospitalizations and postpartum readmissions.

Performance Characteristics of Sepsis Screening Tools During Antepartum and Postpartum Admissions.

OBJECTIVE: To evaluate the performance characteristics of existing screening tools for the prediction of sepsis during antepartum and postpartum readmissions. METHODS: This was a case-control study using electronic health record data obtained between 2016 and 2021 from 67 hospitals for antepartum sepsis admissions and 71 hospitals for postpartum readmissions up to 42 days. Patients in the sepsis case group were matched in a 1:4 ratio to a comparison cohort of patients without sepsis admitted antepartum or postpartum. The following screening criteria were evaluated: the CMQCC (California Maternal Quality Care Collaborative) initial sepsis screen, the non-pregnancy-adjusted SIRS (Systemic Inflammatory Response Syndrome), the MEWC (Maternal Early Warning Criteria), UKOSS (United Kingdom Obstetric Surveillance System) obstetric SIRS, and the MEWT (Maternal Early Warning Trigger Tool). Time periods were divided into early pregnancy (less than 20 weeks of gestation), more than 20 weeks of gestation, early postpartum (less than 3 days postpartum), and late postpartum through 42 days. False-positive screening rates, C-statistics, sensitivity, and specificity were reported for each overall screening tool and each individual criterion. RESULTS: We identified 525 patients with sepsis during an antepartum hospitalization and 728 patients with sepsis during a postpartum readmission. For early pregnancy and more than 3 days postpartum, non-pregnancy-adjusted SIRS had the highest C-statistics (0.78 and 0.83, respectively). For more than 20 weeks of gestation and less than 3 days postpartum, the pregnancy-adjusted sepsis screening tools (CMQCC and UKOSS) had the highest C-statistics (0.87-0.94). The MEWC maintained the highest sensitivity rates during all time periods (81.9-94.4%) but also had the highest false-positive rates (30.4-63.9%). The pregnancy-adjusted sepsis screening tools (CMQCC, UKOSS) had the lowest false-positive rates in all time periods (3.9-10.1%). All tools had the lowest C-statistics in the periods of less than 20 weeks of gestation and more than 3 days postpartum. CONCLUSION: For admissions early in pregnancy and more than 3 days postpartum, non-pregnancy-adjusted sepsis screening tools performed better than pregnancy-adjusted tools. From 20 weeks of gestation through up to 3 days postpartum, using a pregnancy-adjusted sepsis screening tool increased sensitivity and minimized false-positive rates. The overall false-positive rate remained high.

Can Clean Delivery Kits Prevent Infections? Lessons from Traditional Birth Attendants in Nigeria.

Background: In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as a tool to reduce the risk of infection-related deaths. This study aims to assess the acceptability and effectiveness of CDKs in preventing infections in deliveries attended by traditional birth attendants (TBAs) in Abeokuta, Nigeria. Methods: The study was a cluster-randomized trial with 67 birth centres/clusters, 453 births/mothers, and 457 babies randomized to intervention or control arms; intervention involved supplementation of delivery with JANMA CDKs. Interviews were conducted at the birth homes, and the primary outcomes were neonatal infection and puerperal fever. The association between infection and perinatal risk factors was tested using the Chi-square and Fisher's exact tests. Results: CDKs were well accepted by TBAs. The incidence of puerperal fever and neonatal infection was 1.1% and 11.2%, respectively. Concurrent infection was found in 1 (0.22%) of the mother-neonate pair. There was no significant association between any of the sociodemographic factors and infection for both mothers and neonates. PROM and prolonged labour were significantly associated with puerperal infection. All mothers with puerperal fever were from the control group. Compared to the control group, the relative risk of puerperal infection and neonatal infection in the intervention group was 0.08 (0.004 -1.35, p = 0.079) and 0.64 (0.37 to 1.1, p = 0.10), respectively. Conclusion: CDKs hold promising results in attenuating maternal infections in resource-poor settings. Larger studies with greater statistical power are required to establish statistically reliable information.

Group A Streptococcal Endometritis and Toxic Shock causing Septic Pelvic Thrombophlebitis and Septic Pulmonary Emboli.

Group A Streptococcus (GAS) in the setting of postpartum endometritis can have severe and life-threatening complications. We report a rare case of septic pulmonary emboli that we surmised to have originated from septic pelvic thrombosis in the setting of GAS toxic shock syndrome (TSS) secondary to postpartum endometritis and intrauterine demise. Although the patient had source control with hysterectomy, she continued to have new septic emboli to the lungs seen on CT scans. CT scan of the pelvis demonstrated several filling defects in the renal and pelvic veins. The patient eventually responded well to anticoagulation in addition to antibiotics, which is similar to cases of Lemierre's syndrome. Additionally, we would like to bring attention to how important radiological findings can be missed if there is lack of interspecialty communication about the patient's clinical situation.

Incidence, temporal trends and risk factors of puerperal infection in Mainland China: a meta-analysis of epidemiological studies from recent decade (2010-2020).

BACKGROUND: Puerperal infection (PI) is a severe threat to maternal health. The incidence and risk of PI should be accurately quantified and conveyed for prior decision-making. This study aims to assess the quality of the published literature on the epidemiology of PI, and synthesize them to identify the temporal trends and risk factors of PI occurring in Mainland China. METHODS: This review was registered in PROSPERO (CRD42021267399). Putting a time frame on 2010 to March 2022, we searched Cochrane library, Embase, Google Scholar, MEDLINE, Web of Science, China biology medicine, China national knowledge infrastructure and Chinese medical current contents, and performed a meta-analysis and meta-regression to pool the incidence of PI and the effects of risk factors on PI. RESULTS: A total of 49 eligible studies with 133,938 participants from 17 provinces were included. The pooled incidence of PI was 4.95% (95%CIs, 4.46-5.43), and there was a statistical association between the incidence of PI following caesarean section and the median year of data collection. Gestational hypertension (OR = 2.14), Gestational diabetes mellitus (OR = 1.82), primipara (OR = 0.81), genital tract inflammation (OR = 2.51), anemia during pregnancy (OR = 2.28), caesarean section (OR = 2.03), episiotomy (OR = 2.64), premature rupture of membrane (OR = 2.54), prolonged labor (OR = 1.32), placenta remnant (OR = 2.59) and postpartum hemorrhage (OR = 2.43) have significant association with PI. CONCLUSIONS: Maternal infection remains a crucial complication during puerperium in Mainland China, which showed a nationwide temporal rising following caesarean section in the past decade. The opportunity to prevent unnecessary PI exists in several simple but necessary measures and it's urgent for clinicians and policymakers to focus joint efforts on promoting the bundle of evidence-based practices.

Popperian methodology and the Semmelweis case.

Semmelweis' discovery of the etiology of childbed fever has long attracted the attention of historians of medicine and biographers. In recent years it has also become of increasing interest to philosophers. In this paper I discuss the interpretation of Semmelweis' methodology from the viewpoint of the inference to the best explanation and argue that Popperian methodology is better at capturing the dynamics of the growth of knowledge. Furthermore, I criticize the attempts to explain the failure of Semmelweis to have his discovery accepted on the basis of the Kuhnian concept of paradigms, and warn that this view may endorse dogmatism as the norm The Kuhnian position also raises the problem of the authoritarian nature of scientific institutions which defend a paradigm against unorthodox, rebellious views, such as in the case of Semmelweis. Popperian philosophy is seen as a challenge to promote a link between an open society and open science with its main aim being to cherish a free critical spirit.

Determinants of term premature rupture of membrane: case-control study in Saint Paul's Millennium Medical College Hospital, Addis Ababa, Ethiopia.

BACKGROUND: The term premature rupture of the membranes is the rupture of the membranes before the onset of labor beyond 37 weeks of gestation. Several factors, including obstetric, gynecologic, socioeconomic, and medical, are identified as potential risk factors. This clinical event has detrimental maternal and neonatal complications. OBJECTIVES: This study aimed to investigate the determinants of the term premature rupture of the membranes in Ethiopia. METHODS: This institution-based unmatched case-control study was conducted on 246 women admitted to Saint Paul's hospital millennium medical college from October 2019 to January 2020 (82 cases and 164 controls). Data were collected using an interviewer-based questionnaire and data extraction tools, and data were entered using Epi data 3.1 and analyzed using SPSS 20. The association between independent variables and premature rupture of the membrane was estimated using an odds ratio with 95% confidence intervals and P-value < 0.05. RESULTS: Factors like a history of vaginal discharge (AOR 3.508;95% CI:1.595.7.716), place of Antenatal care follow-up (health center and Mercy Ethiopia) (AOR 5.174;95% CI:2.165,12.362), the previous history of rupture of membrane (AOR 9.955;95% CI:3.265,20.35), and gestational age (AOR 3.018;95% CI:1.338,6.811) were associated with term premature rupture of membrane. There were more maternal and neonatal complications, including puerperal sepsis, wound infection, anemia/PPH, a hospital stays of more than seven days, clinical amnionitis, neonatal hypoglycemia, early onset neonatal sepsis, and respiratory distress encountered by women who presented with premature rupture of membrane. CONCLUSION: Proper screening, close monitoring, and early interventions in those mothers with identified risk factors would help to reduce its negative consequences. Moreover, the provision of continuous professional skill development and improving the quality of ANC service is needed.

Antibiotic Recommendations After Postpartum Uterine Exploration or Instrumentation.

Importance: Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care. Objective: To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario. Evidence Acquisition: Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed. Results: These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B Streptococcus prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens. Conclusions: Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B Streptococcus, we recommend 1-time dose of metronidazole 500 mg IV. Relevance: Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.

Assisted vaginal births: women who tear or have a surgical cut need prompt antibiotics.

The studyHumphries ABC, Linsell L, Knight M. Factors associated with infection after operative vaginal birth-a secondary analysis of a randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth. AJOG 2023;228:328.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/assisted-vaginal-births-women-need-prompt-antibiotics/.

Human CEACAM1 is targeted by a Streptococcus pyogenes adhesin implicated in puerperal sepsis pathogenesis.

Life-threatening bacterial infections in women after childbirth, known as puerperal sepsis, resulted in classical epidemics and remain a global health problem. While outbreaks of puerperal sepsis have been ascribed to Streptococcus pyogenes, little is known about disease mechanisms. Here, we show that the bacterial R28 protein, which is epidemiologically associated with outbreaks of puerperal sepsis, specifically targets the human receptor CEACAM1. This interaction triggers events that would favor the development of puerperal sepsis, including adhesion to cervical cells, suppression of epithelial wound repair and subversion of innate immune responses. High-resolution structural analysis showed that an R28 domain with IgI3-like fold binds to the N-terminal domain of CEACAM1. Together, these findings demonstrate that a single adhesin-receptor interaction can drive the pathogenesis of bacterial sepsis and provide molecular insights into the pathogenesis of one of the most important infectious diseases in medical history.

[Invasive group A streptococcal infections in the Netherlands]. / Invasieve groep A-streptokokkeninfecties in Nederland.

Group A streptococcal (GAS) infections are caused by the Gram-positive bacterium Streptococcus pyogenes. Infection can occur via droplet infection from the throat and via (in)direct contact with infected people. GAS can cause a wide variety of diseases, ranging from superficial skin infections, pharyngitis and scarlet fever, to serious invasive diseases such as puerperal sepsis, pneumonia, necrotising soft tissue infections (NSTI) (also known as necrotising fasciitis/myositis), meningitis and streptococcal toxic shock syndrome (STSS). In invasive GAS infections, the bacteria has penetrated into a sterile body compartment (such as the bloodstream, deep tissues, or the central nervous system). Invasive GAS infections are rare but serious, with high morbidity and mortality. Since March 2022, the National Institute for Public Health and the Environment (RIVM) reported a national increase in notifiable invasive GAS infections (NSTI, STSS and puerperal fever). Particularly NSTI has increased compared to the years before the SARS-CoV-2 pandemic. Remarkably, the proportion of children aged 0 to 5 years with invasive GAS-infections is higher in 2022 than in the previous years (12% compared to 4%). While seasonal peaks occur, the current elevation exceeds this variation. To promote early recognition and diagnosis of invasive GAS infections different clinical cases are presented.