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.

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.

Single-dose versus multiple-dose antibiotics prophylaxis for preventing caesarean section postpartum infections: A randomized controlled trial.

BACKGROUND: Caesarean section, a common obstetric surgical procedure, is a major predisposing factor for puerperal infections, requiring the need for antibiotic prophylaxis. Evidence suggests that single-dose antibiotic prophylaxis has comparable efficacy to multiple-dose antibiotic prophylaxis, but with a lower cost and risk of antibiotic resistance. However, single-dose antibiotic prophylaxis after caesarean section is not generally used in many centres in sub-Saharan Africa. OBJECTIVE: This study aimed to compare the effectiveness of single- versus multiple-dose antibiotic prophylaxis to prevent post-caesarean section infections. METHODOLOGY: This open-label, randomized controlled trial involved 162 consenting patients admitted for caesarean section (elective or emergency) at the Federal Medical Centre Keffi. They were distributed randomly into treatment arm A or B. Subjects in both arms received intravenous ceftriaxone (1 g) and metronidazole (500 mg) 30-60 min before incision; subjects in arm B received additional parenteral doses for 48 h and then cefuroxime 500 mg tablets every 12 h and metronidazole 400 mg tablets every 8 h for 5 days. The patients were monitored for 2 weeks for evidence of wound infection, febrile morbidity and clinical endometritis. RESULT: There was no statistical difference in the incidence of wound infection (6.6% versus 7.4%; p = .882) and febrile morbidity (11.8% versus 11.1%, p = .807). However, clinical endometritis (0.0% versus 6.1%, p = .028) was statistically significant with none reported in the single-dose arm. CONCLUSION: Single-dose ceftriaxone and metronidazole is as effective as multiple doses for antibiotic prophylaxis to prevent post-caesarean section infections. Adoption of this approach in low-risk patients would reduce the cost of prophylactic antibiotics, workload for staff and antibiotic resistance.

Infecção do sítio cirúrgico após cesariana em uma maternidade de Manaus, Brasil: a importância do uso racional da antibioticoterapia / Surgical site infection after cesarean section in a maternity hospital in Manaus, Brazil: the importance of rational antibiotic therapy

Objetivo: Descrever o perfil epidemiológico e microbiológico das puérperas com diagnóstico de infecção após cesárea, caracterizando as infecções de sítio cirúrgico e o tratamento. Métodos: Coorte prospectiva de parturientes submetidas a parto cesáreo em maternidade pública de Manaus, Amazonas, Brasil, com diagnóstico de infecção de sítio cirúrgico, entre 1º de julho de 2019 e 30 de abril de 2020. Foram coletados dados epidemiológicos. Para a investigação do perfil microbiológico, foi realizada a identificação da cultura a partir da secreção da infecção do sítio cirúrgico e do antibiograma das culturas. Resultados: Um total de 81 pacientes foi diagnosticado com infecção de sítio cirúrgico durante o período de estudo. A taxa de infecção de sítio cirúrgico na maternidade em estudo foi de 6,0%. As pacientes possuíam baixa escolaridade e baixa renda mensal, com ocupações que requerem menor qualificação, sendo a maioria solteira. Entre as pacientes, 70,4% eram obesas e 28,4% apresentaram sobrepeso; 45,6% delas tiveram parto cesáreo de emergência e 29,6% não usaram antibióticos profiláticos. Staphylococcus aureus foi a cultura identificada mais frequentemente e apresentou resistência ao antibiótico mais prescrito: a gentamicina. Conclusão: A taxa de infecção do sítio cirúrgico foi alta durante o período do estudo. Ressaltamos a necessidade de um protocolo eficaz de identificação bacteriana e acompanhamento da puérpera. O conhecimento das características epidemiológicas e microbiológicas pode auxiliar no planejamento dos cuidados realizados pelas instituições de saúde para minimizar os casos de infecção de sítio cirúrgico e suas consequências.(AU)

Objective: To describe the epidemiological and microbiological profiles of puerperal women diagnosed with the infection after cesarean sections, characterizing the surgical site infections and treatment. Methods: Prospective cohort of parturients underwent cesarean delivery at a public maternity hospital in Manaus, Amazonas, Brazil, diagnosed with surgical site infection between July 1, 2019, and April 30, 2020. Epidemiological data were collected. To investigate the microbiological profile, both culture identification from surgical site infection secretion and antibiogram for the cultures were performed. Results: A total of 81 patients were confirmed to have surgical site infection during this study period; The surgical site infection rate in the maternity hospital under study was 6.0%. The patients presented a low level of education and monthly income, with occupations that require lower qualification, and most of them are single. Seventy point four percent of the patients were obese, and 28.4% were overweight. Forty-five point six percent of patients had an emergency cesarean delivery, and 29.6% did not use prophylactic antibiotics. Staphylococcus aureus was the most frequent culture identified from surgical site infection secretion and presented resistance to the most prescribed antibiotic, Gentamicin. Conclusion: The rate of surgical site infection was high during the study period. We highlight the need for an effective bacterial identification protocol and monitoring of puerperal women. Knowledge of epidemiological and microbiological characteristics can assist in the planning of care performed by the health institutions to minimize cases of surgical site infection and its consequences.(AU)

Analysis of puerperal metritis treatment records in a grazing dairy farm in Argentina.

OBJECTIVE: To assess the efficacy of antibiotic usage for the treatment of puerperal metritis (PM) and its association with reproductive performance, a retrospective cohort study including a total of 9168 records of cows from a dairy farm in Argentina was run. MATERIAL AND METHODS: Cows having a PM3 (metricheck, scale 0-3) and treated with ceftiofur (ceftiofur crystalline free acid, 6.6 mg/kg) at 0-21 days postpartum (p. p.) (n = 2688), and cows having a PM 1-2 and not treated with an antibiotic at 0-21 days p. p. (n = 6480) were included in the study. All cows were reexamined with metricheck to assess the clinical cure (vaginal discharge [VD] score 0), partial cure (VD score similar or lower than previous), no cure (VD score higher than previous). Cows with a metricheck VD1-3 after 0-21 days p. p. were diagnosed as clinical endometritis (CE) 1-3. The occurrence of PM1-3, cure rate, calving to conception interval, the hazard of pregnancy, odds for non-pregnancy, and odds for CE were analyzed using SAS software. RESULTS: A total of 8876 PM1-3 records were included, 2435 records of PM3 treatments with ceftiofur (27.43 %), and 6441 records of PM1-2 (72.57 %) with no treatment. Cows having PM1 and PM2 became pregnant 14 and 12 days earlier than cows with PM3 (p < 0.001). The PM3 ceftiofur treated cows had a clinical cure of 24.85 % (PM0); 53.63 % had a partially cure; and 18.52 % no cure. Conversely, cows with PM1-2 had a 51.96 %, 20.70 %, and 24.53 % cure rate, respectively (p < 0.001). Cows having complete cure became pregnant 13 and 11 days earlier than cows having partial cure and no cure (p < 0.001). Cows that had PM3 during the first 21 days p. p. had twice the chances of developing CE compared to cows having PM1-2 (41.28 % vs. 24.14 %, p < 0.001). After 21 days p. p., less than 1 % of cows with clinical cure developed CE compared to 63.32 % that developed CE with partial cure, and 38.21 % with no cure (p < 0.001). CONCLUSION AND CLINICAL RELEVANCE: After ceftiofur treatment, 78 % of cows were cured when measured by disappearance of fetid VD but only 25 % of cows had clinical cure when measured by appearance of a clear VD. The cows that remained with clinical metritis had more chances of having CE after 21 days p. p. and had more days open than cows with clear normal VD.

Routine uterine culture swab during cesarean section and its clinical correlations: A retrospective comparative study.

OBJECTIVES: Cesarean sections, particularly non-elective cesareans, are an important risk factor for the development of postpartum endometritis, a leading cause of postpartum febrile morbidity. We evaluated the yield of obtaining routine intrauterine culture during elective and non-elective cesarean sections, in the prevention and management of postpartum endometritis. STUDY DESIGN: A retrospective comparative study investigating the distribution of uterine cultures obtained immediately after fetus and placenta delivery during cesarean sections performed in a single tertiary hospital during 2017. True pathogenic bacteria were included in the study analysis and considered as positive results, while other contaminant bacteria were excluded. RESULTS: Positive uterine cultures were identified in 10.7 % (88/821) of cesarean sections, with no significant difference in prevalence between elective and non-elective cesareans. Escherichia coli (E.coli), isolated in 40.9 % of the positive cultures of all women, was the most common organism in non-elective cesareans vs. Group B Streptococcus (GBS) in elective cesareans. Higher rate of positive cultures was found in term vs. preterm cesareans (17.5 % vs 10.5 %, respectively, p-value = 0.04). E.coli was the most frequent pathogen reported in both women with intact membranes or premature rupture of membranes (46.3 % and 47.3 % respectively). Eight women (9.1 %) with positive cultures presented with postpartum fever; all had undergone non-elective cesarean section. In one-third of these cases the empirical antibiotic treatment was adjusted according to the uterine culture results and susceptibility testing results. CONCLUSIONS: Obtaining routine intrauterine cultures during non-elective cesarean sections might be useful for detecting significant pathogens and tailoring the antibiotic treatment in postpartum endometritis.

Resistencia de Staphylococcus aureus frente a cefalosporinas en la sepsis neonatal y puerperal / Staphylococcus Aureus Resistance against Cephalosporins in Neonatal and Puerperal Sepsis

Introducción: El mecanismo más común de actividad antibiótica es la interferencia en la síntesis de la pared celular bacteriana. Las cefalosporinas tienen el mismo mecanismo de acción que las penicilinas; sin embargo, tienen un espectro antibacteriano más amplio, son resistentes a muchas b-lactamasas y tienen propiedades farmacocinéticas mejoradas. Objetivos: Identificar por servicios los gérmenes aislados y determinar la resistencia del Staphylococcus aureus a las cefalosporinas. Método: Se realizó un estudio retrospectivo, transversal y descriptivo en hospital Ginecobstétrico de Guanabacoa desde enero de 2014 hasta diciembre de 2016. Se seleccionaron como variables los gérmenes aislados y el patrón de resistencia del germen que predominó frente a todas las generaciones de cefalosporinas. Resultados: En el servicio de neonatología el mayor aislamiento fue en el hemocultivo seguido del catéter venoso (19 pacientes) y tubo endotraqueal. En el servicio de Obstetricia, los loquios y el sitio quirúrgico fue donde se aisló mayor número (69 y 31 pacientes, respectivamente). Conclusiones: El germen más frecuente aislado en ambos servicios fue el Staphylococcus aureus y la resistencia a las cefalosporinas fue muy elevado(AU)

Introduction: The synthesis interference of bacterial cell wall is the most common antibiotic mechanism. Cephalosporins have the same mechanism of action as penicillin. However, they have wider antibacterial spectrum, they are more resistant to B-lactamases and better pharmacokinetics properties. Additionally, cephalosporins have higher activity in front of gram-negative bacteria than penicillin. Objective: To identify isolated germs in these services and to determine the Staphylococcus aureus resistance to cephalosporins. Method: A retrospective, transversal and descriptive study was conducted in Guanabacoa Gynecobstetric hospital from January 2014 to December 2016. selected variables as isolated microorganism, and resistance pattern in front of cephalosporin generations. The isolated germs and the resistance pattern of the germ that prevailed against all generations of cephalosporins were selected as variables. In the Obstetrics Service, the largest number of germs was isolated in the lochia and surgical sites. (69 and 31, respectively). Results: In neonatology service, the most frequent isolation occurred in blood culture (35), venous catheter (19) and endotracheal tube (10). In Obstetric service, the most frequent isolation occurred in liquors (69) and the surgical site isolated (31). Conclusions: Staphylococcus Aureus was the main microorganism isolated in hospital and its cephalosporin resistance was very high(AU)

Chlamydia ascites: a call for sexually transmitted infection testing.

A 26-year-old gravida 2, para 2-0-0-2 woman with a recent uncomplicated vaginal delivery 10 weeks prior presented to our hospital with 5 weeks of abdominal swelling and discomfort. Four weeks after delivery, the patient began having right upper quadrant pain and was found to have cholelithiasis. She underwent an elective laparoscopic cholecystectomy 6 weeks prior to admission, but started to develop worsening abdominal swelling 1 week postoperatively. Abdominal distension and shifting dullness were present on examination. CT of the abdomen and pelvis was remarkable for moderate-volume ascites and mild enhancement of the pelvic peritoneum. Paracentesis removed 2.46 L of ascites fluid with 76% lymphocytic predominance. Results for Chlamydia trachomatis were positive in urine, cervical swab and ascitic fluid. Doxycycline was prescribed for a diagnosis of pelvic inflammatory disease exudative ascites. Since discharge, she has completed her antibiotic course and reports resolution of all symptoms without recurrence of ascites.

Sepse em gestantes atendidas em um hospital público de Curitiba - PR / Sepsis in pregnant women attended at a public hospital in Curitiba - PR

OBJETIVO: Avaliar a frequência de sepse em gestantes e puérperas atendidas em um hospital, identificar os principais focos originários de sepse na gestação e puerpério, e verificar os principais agentes etiológicos envolvidos em sua etiopatogenia. MÉTODOS: Estudo do tipo transversal descritivo realizado no Hospital do Trabalhador, em Curitiba (PR), de agosto de 2014 a agosto de 2016. Revisão e análise de 71 prontuários de pacientes diagnosticadas com sepse, sepse grave ou choque séptico. Os aspectos estudados foram idades gestacional, agente etiológico, foco infeccioso, principal trimestre gestacional acometido e prevalência de cada tipo de sepse. RESULTADOS: A frequência de sepse durante a gestação e o puerpério no período estudado foi de nove casos para cada mil gestantes. A ocorrência de sepse foi relacionada principalmente ao segundo semestre gestacional (39,4%). Os casos de sepse somaram 73,2% do total, enquanto os demais evoluíram com quadros de sepse grave e choque séptico . Escherichia coli representou 33,8%, sendo o urinário o foco infeccioso mais prevalente (70,4%). Ceftriaxona foi o antibiótico mais utilizado, tanto isoladamente quanto em associação (84,4%). Entre os desfechos para o feto, 85,9% não tiveram complicações. CONCLUSÕES: Os novos conceitos de sepse publicados pela Society of Critical Care Medicine (SCCM) e pela European Society of Critical Care Medicine (ESICM) contrariam os interesses dos países conhecidos como de baixos e médios recursos. Foi encontrado aumento da incidência de sepse gestacional, ocorrendo prevalência do foco urinário; consequentemente, o agente principal foi E. coli. Ademais, ocorreram importantes consequências perinatais como mortalidade e prematuridade. (AU)

OBJECTIVE: To evaluate the frequency of sepsis in pregnant and puerperal patients attended in a hospital, and to identify the main focus of sepsis during gestation and puerperium, and check the main etiological agents involved in its pathogenesis. METHODS: This is a cross-sectional and descriptive study carried out at Hospital do Trabalhador (city of Curitiba, state of Paraná), from August 2014 to August 2016. It is a review and analysis of the charts of 71 patient diagnosed with sepsis, severe sepsis, or septic shock. Aspects studied: gestational age, etiologic agent, infectious focus, main affected gestational trimester, and prevalence of each type of sepsis. RESULTS: The frequency of sepsis during pregnancy and puerperium was 9 cases for 1000 pregnant women. The occurrence of sepsis was mainly related to the second gestational semester (39.4%). Severe sepsis and septic shock comprised 73.2% of the cases. Escherichia coli accounted for 33.8%, and the most prevalent infectious focus was urinary (70.4%). Ceftriaxone was the most commonly used antibiotic, both alone and in combination (84.4%). Among the outcomes for the fetus, 85.9% had no complications. CONCLUSIONS: The new concepts of sepsis, published by the Society of Critical Care Medicine (SCCM), and by the European Society of Critical Care Medicine (ESICM) contradict the interests of the countries with low and medium resources. An increase in the incidence of gestational sepsis occurred, with a prevalence of urinary focus; consequently the main agent was Escherichia coli. In addition, there were important perinatal consequences such as mortality and prematurity. (AU)

Microbiology and clinical outcomes of puerperal sepsis: a prospective cohort study.

The objectives of this study were to determine the identity and antibacterial susceptibility profiles of bacteria colonising the female genital tract and blood stream and their association with clinical outcomes in women with puerperal sepsis. A prospective descriptive cohort study was conducted at two tertiary hospitals in Zimbabwe. Endocervical swabs and blood were collected for culture and susceptibility testing from 151 consecutive women who met the World Health Organisation criteria for puerperal sepsis. Medical records were reviewed for assessment of clinical outcomes. The commonest bacterial isolates were Escherichia coli (30.6%) and Klebsiella pneumoniae (15.3%). Multidrug-resistant organisms (MDRO) accounted for 10.9% of all isolates. MDRO were associated with prolonged hospital stay, 23.0 days compared to 10.5 days in women without MDRO (p = .009). Puerperal sepsis case fatality rate was 7.3%. Clinical culture surveillance to monitor epidemiologic trends, identify MDRO, robust infection control strategies and emphasis on rational drug use are recommended. Impact statement What is already known? Puerperal sepsis is often a polymicrobial infection. Escherichia coli has been reported as a common cause of severe maternal sepsis originating from the genital tract. Other bacteria include Group A Streptococcus, S. aureus, Streptococcus spp. Klebsiellae spp, Pseudomonas spp. and anaerobes. What does this study add? This study confirms Escherichia coli as the commonest cause of sepsis in Harare. There is high level resistance to first-line antibiotic regimens on most Gram-negative isolates from the endocervix among women with puerperal sepsis. Emerging resistance to carbapenems is demonstrated. MDRO significantly increased length of hospital stay, and there was a clinically important trend towards higher rates of pelvic abscess, septic shock, death, need for laparotomy and ICU admission specific to puerperal sepsis. What are the implications for clinical practice and further research? Clinical culture surveillance to monitor epidemiologic trends in conjunction with robust infection control strategies and rational drug use may assist in prevention of community acquired and nosocomial multidrug-resistant infections.

Pregnancy in fanconi anaemia with bone marrow failure: a case report and review of the literature.

BACKGROUND: Fanconi anaemia is a rare inherited disease characterized by congenital abnormalities, progressive bone marrow failure and predisposition to malignancy. Successful pregnancies in transplanted patients have been reported. In this paper we will describe the pregnancy of a patient with Fanconi anaemia without transplantation. CASE PRESENTATION: A 34-year-old nulliparous woman with Fanconi anaemia was referred to our institution. Pregnancy was complicated by progressive pancytopenia and two severe infections. C-section was performed at 36 weeks. Both infant and mother are well. CONCLUSION: Successful pregnancy in a Fanconi anaemia patient with bone marrow failure is possible. The mode of delivery in patients with bone marrow failure should be determined by obstetric indications. The case highlights the safe outcome of the pregnancy with strict clinical and laboratory control by a multidisciplinary team.

Botulism During Pregnancy and the Postpartum Period: A Systematic Review.

Background: Maternal and fetal outcomes associated with botulism and botulinum antitoxin use during pregnancy and the postpartum period have not been systematically reviewed. Methods: We searched Global Health, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Medline databases from inception to May 2015 for studies published on botulism or botulinum antitoxin use during pregnancy and the postpartum period, as well as the Centers for Disease Control and Prevention National Botulism Surveillance database. Our search identified 4517 citations. Results: Sixteen cases of botulism during pregnancy (11 in the third trimester) and 1 case during the postpartum period were identified. Ten cases were associated with confirmed or likely foodborne exposure; 2 cases were attributed to wound contamination related to heroin use, and the source of 5 cases was unknown. Eleven women with botulism had progressive neurologic deterioration and respiratory failure, requiring intensive care unit admission. Four women had adverse outcomes, including 2 deaths and 2 women who remained in a persistent vegetative state. No neonatal losses or cases of congenital botulism were reported. Among the 12 cases that reported neonatal data, 6 neonates were born preterm. No adverse maternal or neonatal events were identified as associated with botulinum antitoxin therapy among 11 patients who received it. Conclusions: Our review of 17 cases of botulism in pregnant/postpartum women found that more than half required ventilator support, 2 women died, and 6 infants were born prematurely. A high level of clinical suspicion is key for early diagnosis and treatment of botulism. Care of pregnant women or new mothers with botulism can include preparation for possible intubation.

A longitudinal cohort study of acute puerperal metritis cases in Swedish dairy cows.

BACKGROUND: Acute puerperal metritis affects cows during the early postpartum period and causes fever, fetid vaginal discharge and general depression. The disease is severe and treatment with antimicrobials is often required. This study followed 79 Swedish dairy cows with acute puerperal metritis with registered treatment and outcome in terms of recovery. Bacteria isolated from the uterus and their susceptibility to penicillin were studied. Clinical cases were assigned by participating practitioners who examined the cows, performed uterine swab sampling, decided treatment and provided information about cow health and calving conditions. Fertility and culling data were collected from the official Swedish milk and health recording scheme. Recovery from disease was defined in four levels; as a cow that survived 1 or 4 months, was inseminated and subsequently became pregnant. Intervals from dates of first and latest calving to insemination date were studied. RESULTS: The most common bacterial findings were a mixed culture of Escherichia coli and bacteria such as Gram positive cocci, Fusobacterium necrophorum, Clostridium spp. or Trueperella pyogenes. The Gram positive cocci, Pasteurella spp. and F. necrophorum were generally susceptible to penicillin. The majority of cows (70%) were treated with penicillin in accordance with the Swedish policy on treatment of metritis while 19% were treated with tetracycline and 8% were not treated with antimicrobials. Recovery rates were similar between treatments. Besides "calving to last insemination" interval (CLI) that was 5 days shorter than the national mean, fertility was slightly reduced compared to national means. "Calving to first insemination" interval (CFI) was 4 days longer than national mean and number of inseminations/cow increased from 1.9 to 2.1. Escherichia coli culture positive cows did not become pregnant to the same extent as cows without E. coli in the uterus (P = 0.046). Twin births resulted in a longer CFI (P = 0.034). The culling rate was generally high (42% within 300 days after occurrence of metritis), though death associated with acute disease was low (6%). CONCLUSIONS: Escherichia coli was the most common bacterial pathogen isolated from cases of acute puerperal metritis in the present study. This bacterium is inherently resistant to penicillin, but although most cows were treated with penicillin, death due to acute disease was low and recovery and final fertility results were acceptable. In times of emerging antimicrobial resistance and demand for prudent antimicrobial use, we suggest that penicillin is a "good enough" choice if antimicrobial treatment of acute puerperal metritis is needed.

Disseminated tuberculosis after pregnancy progressed to paradoxical response to the treatment: report of two cases.

BACKGROUND: Early postpartum women are more likely to develop tuberculosis than nonpregnant women mainly due to immune reconstitution after delivery. Paradoxical response (PR) during antituberculosis treatment also arises via recovery from immunosuppression. However, no study focused on PR during antituberculosis treatment in a postpartum patient has been reported. CASE PRESENTATION: We present two sequential cases (Patient 1: 26-year-old; Patient 2: 29-year-old) of postpartum tuberculosis with pulmonary and extrapulmonary lesions (Patient 1: peritonitis; Patient 2: psoas abscess secondary to spondylitis). Both cases progressed to PR (worsening of pre-existing lung infiltrations (Patients 1, 2) and new contralateral effusion (Patient 2)) in a relatively short time after initiation of treatment (Patient 1: 1 week; Patient 2: 3 weeks), suggesting that immune modulations during pregnancy and delivery may contribute to the pathogenesis of both disseminated tuberculosis and its PR. The pulmonary lesions and effusion of both cases gradually improved without change of chemotherapy regimen. CONCLUSION: Physicians should recognize PR in tuberculosis patients with postpartum and then evaluate treatment efficacy.

The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan.

BACKGROUND: Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk. METHODS/DESIGN: The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics. DISCUSSION: This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.

Acupuncture and postpartum pyogenic sacroiliitis: a case report.

INTRODUCTION: Pyogenic sacroiliitis, a rare form of septic arthritis, occurs in patients following trauma, intravenous drug use, genitourinary infections and pregnancy. Here we report a rare case where both acupuncture and pregnancy served as predisposing risk factors to the development of this infection. CASE PRESENTATION: A 33-year-old white woman received several sessions of acupuncture treatment during her gestation at the site of her sacroiliac joint for sciatica; she developed biopsy-confirmed sacroiliitis with methicillin-sensitive Staphylococcus aureus during the immediate postpartum period. The diagnosis, medical management and treatment course are described. CONCLUSIONS: Low back and pelvic pain are common conditions during pregnancy and postpartum. Acupuncture is a common modality of medication-free treatment used by many patients. Recognition of the potential complications of such therapies can lead to early diagnosis, accurate treatment, decreased morbidity and increased chances for a successful outcome.

Toxic epidermal necrolysis complicating antibiotic treatment of puerperal endometritis: a case report.

The aim of the study is to describe a case report of Lyell syndrome (toxic epidermal necrolysis) involving 63% of body surface which has been associated with antibiotic therapy of mild peurperal endometritis in woman 3 weeks postpartum. Lyell syndrome is a severe life-threatening condition developing due to idiosyncrazy (alergic reaction type IV), most commonly after administration of drugs. Incidence quoted in literature is around 1:1-2000000. Illness severity can be assessed using a SCORTEN scoring system, which predicts patient mortality based on seven independent factors. Lyell syndrome is a very rare but potentially lethal complication of antibiotic treatment.