The cost-effectiveness of ertapenem for the treatment of chorioamnionitis after cesarean delivery.

Background: Chorioamnionitis affects 1-4% of pregnancies, and patients who undergo cesarean delivery in the setting of chorioamnionitis have an increased risk of endometritis and surgical site infection (SSI). The standard treatment for chorioamnionitis after cesarean delivery is a combination regimen of intravenous ampicillin, gentamicin, and clindamycin with variable duration (single dose to 24 h). However, newer evidence suggests that ertapenem may decrease the risk of postoperative infectious morbidity with the added benefit of a single postpartum dose, compared to between 3 and 10 doses of AGC. Concerns regarding the cost of ertapenem have been cited as a deterrent for this regimen.Objective: The objective of this study was to investigate the cost-effectiveness of single-dose ertapenem compared to existing standard regimens.Methods: A decision analytic cost-effectiveness model was designed from a hospital perspective to compare four strategies for the postpartum management of chorioamnionitis after cesarean delivery: (i) no antibiotics; (ii) a one-time intravenous dose of ampicillin, gentamicin, and clindamycin (AGC-1); (iii) 24-h coverage with intravenous ampicillin, gentamicin, and clindamycin (AGC-24); and (iv) intravenous ertapenem, one dose. Medical costs, rates of SSI and endometritis following cesarean delivery, and costs of postcesarean infection (SSI or endometritis) were abstracted from the literature. Antibiotic drug costs were obtained from the pharmacy department at a private academic hospital. The cost of each regimen was calculated as costs to the hospital and included antibiotics (no antibiotics $0, AGC-1 $66, ertapenem $140, and AGC-24 $208), administration, and labor costs. Effectiveness was quantified as percentage of patients who avoided postcesarean infectious morbidity (endometritis or SSI).Results: The base case cost of each strategy was: AGC-1 $704, ertapenem $733, AGC-24 $846, and no antibiotics $971. Ertapenem had an effectiveness of 88%, AGC-1 and AGC-24 were 87% each, and no antibiotics was 81%. No antibiotics and AGC-24 were more costly and equally or less effective than comparators (dominated strategies). Ertapenem was more costly, but more effective than AGC-1, with an incremental cost-effectiveness ratio of $3738 per infection avoided. In a sensitivity analysis comparing ertapenem to the most commonly used strategy of ACG-24, the ertapenem strategy remained less costly if the rate of endometritis with ertapenem was <11% (base case estimate 8%) or the rate of SSI with ertapenem was <7% (base case estimate 4%).Conclusions: Ertapenem is a cost-saving alternative to 24-h AGC treatment for chorioamnionitis in the setting of cesarean delivery, and may be considered a cost-effective treatment when compared to a one time dose of AGC depending on infection rates.

Assessment of fetal inflammatory syndrome by "classical" markers in the management of preterm labor: a possible lesson from metabolomics and system biology.

There exists a huge gap between protocols issued by scientific bodies and evidence derived by system biology studies on the multifactorial origin of threatened preterm delivery and their different associations with neonatal outcome. The objective of this prospective study was the analysis obstetrical and neonatal outcome in a cohort of pregnant patients treated for the risk of preterm delivery according to maternal and fetal assessment determined by amniotic fluid samples. Methods. Threatened preterm delivery and premature rupture of membranes between 24 + 1 and 32 + 6 weeks of gestation were treated by prolonged tocolytic regimens and if necessary by antibiotics for maternal infections when intra-amniotic inflammation (IAI) was excluded on the basis of negative white blood cell count in the amniotic fluid, or opposite, by delivery after a course of betamethasone and 48 hours maintenance tocolysis. Twenty-three cases were compared with 22 historical controls treated by the same teams according to the 48 hours treat and wait criteria. In addition to this, cases with normal and abnormal amniotic fluid white blood cell were compared. Results. Maternal and fetal conditions at admission were not significantly different between the study and control cohort for all maternal and fetal variables. Clinical indices were significantly improved as regard to latency from admission to delivery, number of newborns admitted to neonatal intensive care unit and length of stay in neonatal intensive care unit. Not any perinatal death or sepsis occurred in the study cohort. Overall, improved neonatal outcomes were observed in the study cohort. Composite major neonatal eventful outcomes occurred in 26% of cases vs. 50% in controls. The limited number of cases was not powered enough to reach a statistical significance for these variables. Continued tocolysis on demand and full regimen of mono or combined antibiotic regimen for maternal infection achieved significantly longer delay between admission to delivery with improved in neonatal outcome in cases negative for IAI: only 2 of 14 newborns suffered of major neonatal complications vs. 4 of 9 newborns delivered for IAI. Conclusions. Fetuses without IAI can be treated conservatively and their stay in utero prolonged without harm. However, we confirmed that when IAI is already active in utero a worse neonatal outcome is already partly predetermined. These positive findings must be interpreted with cautions given the limited number of cases considered by this study.