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.

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.

Beta-endorphin inhibits the inflammatory response of bovine endometrial cells through δ opioid receptor in vitro.

Postpartum uterine infections are common reproductive diseases in postpartum cows. Evidence has shown that plasma ß-endorphins increase during bovine uterine inflammation. However, the effect of ß-endorphins on the inflammatory response in bovine endometrium has not been clarified. The aim of this study was to investigate the effect of ß-endorphins on the inflammatory response of bovine endometrial epithelial and stromal cells, and to explore the possible mechanism. The cells were treated with E. coli lipopolysaccharide (LPS) to simulate inflammation, which was characterized by the significant activation of NF-κB signaling pathway and the increased gene expression of the downstream proinflammatory cytokines (approximately 1.2- to 15-fold increase, P < 0.05). By using Western blot and qPCR techniques, we found that ß-endorphins inhibited the key protein expression of NF-κB pathway, and the gene expressions of TNF, IL1B, IL6, CXCL8, nitric oxide synthase 2, and prostaglandin-endoperoxide synthase 2 (P < 0.05). The co-treatment of ß-endorphins and opioid antagonists showed that the anti-inflammatory effect of ß-endorphins could be blocked (P < 0.05) by non-selective opioid antagonist naloxone or δ opioid receptor antagonist ICI 154129, but not the µ opioid receptor antagonist CTAP (P > 0.05). In conclusion, ß-endorphins may inhibit the inflammatory response of bovine endometrial epithelial and stromal cells through δ opioid receptor.

Genetic evolution of invasive emm28 Streptococcus pyogenes strains and significant association with puerperal infections in young women in Finland.

OBJECTIVES: Streptococcus pyogenes or group A streptococcus (GAS) is a human specific pathogen that annually infects over 700 million individuals. GAS strains of type emm28 are an abundant cause of invasive infections in Europe and North America. METHODS: We conducted a population-based study on bacteraemic emm28 GAS cases in Finland, from 1995 to 2015. Whole-genome sequencing (WGS) was used to genetically characterize the bacterial isolates. Bayesian analysis of the population structure was used to define genetic clades. Register-linkage analysis was performed to test for association of emm28 GAS with delivery- or postpartum-related infections. A genome-wide association study was used to search for DNA sequences associated with delivery or puerperal infections. RESULTS: Among 3060 bacteraemic cases reported during the study period, 714 were caused by emm28. Women comprised a majority of cases (59 %, 422/714), and were significantly over-represented (84.4 %, 162/192, p < 0.0001) among cases in the childbearing age group (20-40 years). Register-linkage analysis revealed strong association (p < 0.0001) of emm28 bacteraemias with delivery and puerperium. In this register-linkage analysis, 120 women with GAS bacteraemia were identified and linked to delivery, infections during delivery or puerperium time. Among these the proportion of cases caused by emm28 was significantly higher than any other emm type (55.8%, 67/120, p < 0.0001). Among the four genetic subclades identified, SC1B has dominated among the bacteraemic cases since 2000. Altogether 620 of 653 (94.9%) isolates belonged to SC1B. No specific sequence or genetic clade was found nonrandomly associated with delivery or puerperal infections. CONCLUSIONS: Women of childbearing age were significantly overrepresented among bacteraemic emm28 GAS cases, and in particular were strongly associated with delivery and puerperium cases over the 21 years studied. The molecular mechanisms behind these associations are unclear and warrant further investigation.

Intrauterine bacterial growth in elective and non-elective caesarean sections.

We assessed intrauterine bacterial growth for elective and non-elective caesarean sections (CSs). Aerobic uterine cultures were obtained from the uterine cavity immediately following placental removal from 1376 patients who underwent CS in one center during one year. About 13.8% (115/832) of elective CS were positive vs. 55.9% (304/544) of non-elective CS (p < .001). Of non-elective CSs, 28.6% (56/196) of those without ruptured membranes (ROM) were positive vs. 71.3% (248/348) with ROM (p < .001). Mean birth weight and 1-minute Apgar scores were significantly lower in women with positive cultures, elective and non-elective, than negative cultures. A higher percentage of women with positive uterine cultures presented with postpartum endometritis (p < .05). Intrauterine bacteria in elective CSs demonstrate that the uterine cavity is not sterile. Non-elective CS, particularly after membrane rupture, is a significant risk factor for positive uterine culture. Positive uterine culture is associated with lower birth weight, lower one-minute Apgar score and postpartum endometritis.Impact statementWhat is already known on this subject? Postpartum endometritis is a leading cause of postpartum febrile morbidity. Caesarean sections, in particular non-elective cesareans, are an important risk factor for the development of postpartum endometritis. Controversy exists concerning the sterility of the placenta and uterus. The diagnosis of endometritis is based mainly on clinical findings and does not necessitate bacterial isolation from the uterine cavity. Positive culture at caesarean section has been associated with positive postoperative culture and yet, currently, professional organisations do not recommend the routine sampling of intrauterine cultures during caesarean section.What do the results of this study add? Since positive uterine culture rate was higher in non-elective CSs and associated with lower birth weight and 1-minute Apgar score and postoperative endometritis, obtaining uterine culture in those cases might be of clinical value.What are the implications of these findings for clinical practice and/or further research? Obtaining routine intrauterine cultures during non-elective caesarean sections might be useful for detecting significant pathogens and tailoring antibiotic treatment in postpartum endometritis. Further studies are necessary in order to determine the impact of obtaining intrauterine cultures during caesarean sections, particularly non-elective cesareans.

The risk of urine bacterial colonisation in patients with a permanent catheter after caesarean section.

We present an observational study, conducted in Slovakia, concerning the occurrence of newly acquired urine colonisations in women with Foley catheters after a Caesarean section. A sample of urine was taken from each patient when the Foley catheter was first inserted, before the operation and was sent to the lab for culture. Later, a sample of urine was taken during the removal of the Foley catheter. Out of 176 women, the second urine sample culture result was positive in 13 women. Of those nine women had a positive pathogenic strain (5.1%). The prevalence of asymptomatic bacteriuria in our cohort was 7.7%. De novo acquired colonisation of urine was confirmed in 5.1% of cases. The only confirmed risk factor was delivery by an acute Caesarean section.Impact statementWhat is already known on this subject?: It is well known that catheterisation increases risk of colonisation of lower urinary tract by pathogens. However, the extent of this risk is not determined because there are no studies of de novo colonisation in women with sterile urine before catheterisation. According to literature approximately 8% of women have asymptomatic bacteriuria, which could be confounding factor in previous studies.What do the results of this study add?: Our study excluded women with positive bacteriuria before insertion of Foley catheter. Therefore, the study only assesses de novo colonisation, dependent on insertion of Foley catheter during caesarean section.What are the implications of these findings for clinical practice and/or further research?: De novo colonisation was observed in 5.1% of women in our cohort, with emergency caesarean section as a confirmed risk factor. Therefore, practitioners should consider avoiding catheterisation during caesarean section.

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)

Heart rate variability in dairy cows with postpartum fever during night phase.

Autonomic nervous function evaluated by heart rate variability (HRV) and blood characteristics were compared between Holstein Friesian cows that developed postpartum fever (PF; n = 5) and clinically healthy (CH; n = 6) puerperal cows in this case-control study. A cow was defined as having PF when its rectal temperature rose to ≥39.5°C between 1 and 3 days postpartum. We recorded electrocardiograms during this period using a Holter-type electrocardiograph and applied power spectral analysis of HRV. Comparisons between the groups were analyzed by t test or Mann-Whitney U test, and the relationship between rectal temperature and each parameter was analyzed using multiple regression analysis. Heart rate was higher in PF cows than in CH cows (Mean ± SE, 103.3 ± 2.7 vs. 91.5 ± 1.7 bpm). This result suggested that PF cows had a relatively dominant sympathetic nervous function. Total (44,472 ± 2,301 vs. 55,373 ± 1,997 ms) and low frequency power (24.5 ± 3.8 vs. 39.9 ± 5.3 ms) were lower in PF cows than in CH cows. These findings were possibly caused by a reduction in autonomic nervous function. The total white blood cell count (54.3 ± 5.1 vs. 84.5 ± 6.4 ×102/µL) and the serum magnesium (2.1 ± 0.1 vs. 2.4 ± 0.1 mg/dL) and iron (81.5 ± 8.0 vs. 134.4 ± 9.1 µg/dL) concentrations were lower and the serum amyloid A concentration (277 ± 33 vs. 149 ± 21 µg/mL) was higher in PF cows than in CH cows. These results imply that more inflammation was present in PF cows than in CH cows. Multiple regression analysis showed that both of low frequency power and concentration of serum iron were associated with rectal temperature. We found differences in changes in hematologic results, biochemical findings, and HRV patterns between PF cows and CH cows.

Out-of-season increase of puerperal fever with group A Streptococcus infection: a case-control study, Netherlands, July to August 2018.

We observed an increase in notifications of puerperal group A Streptococcus (GAS) infections in July and August 2018 throughout the Netherlands without evidence for common sources. General practitioners reported a simultaneous increase in impetigo. We hypothesised that the outbreak of puerperal GAS infections resulted from increased exposure via impetigo in the community.We conducted a case-control study to assess peripartum exposure to possible, non-invasive GAS infections using an online questionnaire. Confirmed cases were recruited through public health services while probable cases and controls were recruited through social media. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) with logistic regression analysis.We enrolled 22 confirmed and 23 probable cases, and 2,400 controls. Contact with persons with impetigo were reported by 8% of cases and 2% of controls (OR: 3.26, 95% CI: 0.98-10.88) and contact with possible GAS infections (impetigo, pharyngitis or scarlet fever) by 28% and 9%, respectively (OR: 4.12, 95% CI: 1.95-8.68). In multivariable analysis, contact with possible GAS infections remained an independent risk factor (aOR: 4.28, 95% CI: 2.02-9.09).We found an increased risk of puerperal fever after community contact with possible non-invasive GAS infections. Further study of this association is warranted.

[Bovine uterine diseases: Aspects of microbiology, molecular biology, and immunology]. / Gebärmuttererkrankungen des Rindes: mikrobiologische, molekularbiologische und immunologische Aspekte.

Postpartum uterine diseases, such as puerperal metritis and clinical endometritis may affect over 40 % of cows in dairy farms. Regardless of their severity, these diseases are one of the main reasons for impaired fertility, causing declines in dairy cow productivity and hence, resulting in economic losses. Although uterine diseases have been the topic of scientific discussion for many years, until now it was not possible to agree on uniform definitions for the different kinds of manifestation. By including technical innovations and testing procedures, enormous scientific progress and a deeper knowledge of the physiology as well as the pathologic mechanisms have been achieved. Bovine metritis and endometritis may be regarded as multifactorial diseases caused by a combination of microbial infection, the dysregulation of the immune system, and additional risk factors. These interactions have been analyzed on microbial and molecular biological levels as well as by the use of bioinformatics and molecular genetics. As a result, new species of bacteria and inflammatory mediators possibly contributing to the development of uterine diseases have recently been described. Additionally, metabolic and genetic risk factors and their roles in leading to fertility impairment have been evaluated. In conclusion, it was possible to identify new approaches for possible therapeutic and preventive methods, a subset of which may already be implemented into daily practical routine. This article provides an overview of recent scientific results concerning bovine metritis and endometritis with a focus on microbial, microbiological and immunological studies.

Invasive Group A streptococcal postpartum endometritis associated with multi-organ infarctions: an uncommon case presentation and literature review.

Background: Streptococcal Toxic Shock Syndrome (STSS) is a serious condition that can arise from streptococcal postpartum endometritis. It is associated with a substantial increase in mortality rate and can rarely result in multiorgan infarction. Early recognition plays a vital role in patients' outcome. Objective: To report a case of complicated STSS and review the literature for previous case reports of streptococcal postpartum endometritis to determine if STSS diagnostic criteria (published by the Centers for Disease Control and Prevention) were fulfilled. Case presentation: This is a 41-year-old woman who presented 5 days after an uncomplicated vaginal delivery with endometritis complicated by invasive group A ß-hemolytic streptococcus (GAS) infection and confirmed toxic shock syndrome. The patient was initially admitted to the critical care unit due to hemodynamic compromise requiring intravenous (IV) fluids, IV antibiotic therapy with penicillin and clindamycin, and IV immunoglobulin therapy. The patient subsequently developed multi-organ infarctions, acute respiratory distress syndrome requiring noninvasive respiratory support, and severe reactive arthritis. Literature review revealed 15 case reports of GAS postpartum endometritis, five met criteria for confirmed STSS. One patient died from severe septic shock leading to cardiopulmonary arrest. Thirteen out of 15 cases of postpartum endometritis occurred after uncomplicated vaginal delivery. Conclusion: STSS is a serious and possibly fatal medical condition that requires early diagnosis and treatment to prevent poor patient outcomes and death. Careful consideration to the patient's postpartum clinical presentation with the implementation of an intradisciplinary approach should be utilized.

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.

Proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a referral Hospital in Bahir Dar, Northwest Ethiopia.

Background: Puerperal sepsis is any bacterial infection of the genital tract that occurs after childbirth. It is among the leading causes of maternal morbidity and mortality especially in low-income countries including Ethiopia. The aim of this study was to determine the proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a Referral Hospital in Bahir Dar, Northwest Ethiopia. Methods: A cross sectional study was conducted from January to May 2017 among 166 post-partum/aborted women admitted to Felege Hiwot Referral Hospital for medical services and suspected for puerperal sepsis.. Socio-demographic data and associated factors were collected using structured questionnaire. Bacteria were isolated and identified from blood samples on Trypton soya broth, blood, Chocolate and MacConkey agars following standard bacteriological procedures. The VITEK 2 identification and susceptibility testing system was used to determine the antimicrobial susceptibility profiles of bacterial isolates. Data were entered and analyzed using SPSS version 20. Factors associated with puerperal sepsis were considered statistically significant at P-value < 0.05. Results: The overall proportion of bacterial isolates among post-partum/aborted women was 33.7% (56/166); of which 55.4% was caused by Gram-negative and 44.6% was by Gram-positive bacteria. The most frequently isolated bacteria were Escherichia coli (32.1%) from Gram-negatives and Staphylococcus aureus (33.9%) from Gram-positives. The proportion of other isolates was (7.2%) for Coagulase Negative Staphylococci (CoNS), (12.5%) for Klebsiella pneumoniae, (10.7%) for Acinetobacter baumanni and (3.6%) for Raoultella ornithinolytica. All isolates of Gram-positive and Gram-negative bacteria were resistant to tetracycline (100%). The gram negatives show resistance to Cefazolin (72.7%), Tetracycline (93.9%) and Ampicillin (100%). The overall prevalence of multidrug resistance (MDR) was 84%. Women having multiparous parity were more likely to develop puerperal sepsis than primiparous parity (AOR 4.045; 95% CI: 1.479-11.061; P < 0.05). Other socio-demographic and clinical factors had no significant association with puerperal sepsis. Conclusion: About one third of post-partum/aborted women suspected for puerperal sepsis were infected with one or more bacterial isolates. Significant proportion of bacterial isolates showed mono and multi-drug resistance for the commonly prescribed antibiotics. Women with multiparous parity were more likely to develop puerperal sepsis than primiparous parity.

Risk factors, changes in serum inflammatory factors, and clinical prevention and control measures for puerperal infection.

BACKGROUND: To investigate the risk factors and changes in serum inflammatory factors in puerperal infection, and propose clinical prevention measures. METHODS: A total of 240 subjects with suspected puerperal infection treated in our hospital from January 2017 to December 2017 were collected, among which puerperal infection was definitely diagnosed in 40 cases, and it was excluded in 40 cases. Levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and high-sensitivity C-reactive protein (hs-CRP) were compared between the two groups, and the change trends of IL-6 and hs-CRP were recorded. RESULTS: Levels of IL-6, hs-CRP, and TNF-α in puerperal infection group were higher than those in non-infection group (P < .05). Levels of IL-6 and hs-CRP at enrollment and 1-3 days after enrollment in infection group were higher than those in non-infection group (P < .05). The body mass index >25, placenta previa, placenta accreta, postpartum hemorrhage, premature rupture of membrane, gestational diabetes mellitus, and anemia during pregnancy were relevant and independent risk factors for puerperal infection. Puerperal infection occurred in uterine cavity, vagina, pelvic peritoneum, pelvic tissue, incision, urinary system, etc, and gram-negative (G+) bacteria were dominated in pathogens. CONCLUSION: The inflammatory response of patients with puerperal infection is significantly enhanced.

Screening asymptomatic households for Streptococcus pyogenes pharyngeal carriage as a part of in-hospital investigation of puerperal sepsis.

BACKGROUND: Invasive group A streptococcal (iGAS) infection in the peripartum setting is a rare but devastating disease occasionally occurring as a health care-associated infection (HAI). Current guidelines suggest enhanced surveillance and streptococcal isolate storage after a single case of iGAS, as well as a full epidemiological investigation that includes screening health care workers (HCWs) from several sites after 2 cases. Current guidelines do not recommend routine screening of household members of a patient with iGAS. METHODS: We conducted studies of 3 patients with iGAS puerperal sepsis and related epidemiologic and molecular investigations. RESULTS: Identical GAS emm gene types were found in pharyngeal cultures of 3 asymptomatic spouses of patients with iGAS puerperal sepsis. HCWs screened negative for GAS, and emm typing indicated that other iGAS cases from this hospital were sporadic and not related to the puerperal cases. CONCLUSIONS: The concurrent presence of the same emm type in a household member practically excludes the option of an inadvertent HAI or facility outbreak. Hence, we suggest that screening close family members for asymptomatic GAS carriage should be performed early as a part of infection prevention measures, as doing so would have significant utility in saving time and resources related to a full epidemiological inquiry.

A Mobile Genetic Element Promotes the Association Between Serotype M28 Group A Streptococcus Isolates and Cases of Puerperal Sepsis.

BACKGROUND: Bacterial infections following childbirth-so-called puerperal infections-cause morbidity in 5%-10% of all new mothers. At low frequency, the infection can spread to the blood, resulting in life-threatening sepsis known as puerperal sepsis. Pathogens causing puerperal sepsis include group A Streptococcus (GAS), and epidemiological analyses have identified isolates of a single serotype, M28, as being nonrandomly associated with cases of puerperal sepsis. The genomes of serotype M28 GAS isolates harbor a 36.3-kb mobile genetic element of apparent group B Streptococcus origin, termed region of difference 2 (RD2). METHODS: The phenotypic (determined via tissue culture and a vaginal colonization model) and regulatory (determined via RNA sequencing analysis) contributions of RD2 were assessed by comparing parental, RD2 deletion mutant, and complemented mutant serotype M28 GAS strains. RESULTS: RD2 affords serotype M28 isolates an enhanced ability to adhere to human vaginal epithelial cells and to colonize the female reproductive tract in a mouse model of infection. In addition, RD2 influences the abundance of messenger RNAs from >100 core chromosomal GAS genes. CONCLUSIONS: The data are consistent with RD2 directly, via encoded virulence factors, and indirectly, via encoded regulatory proteins, modifying the virulence potential of GAS and contributing to the decades-old association of serotype M28 isolates with cases of puerperal sepsis.

The association of puerperal sepsis with HIV infection at two tertiary hospitals in Zimbabwe.

OBJECTIVE: To evaluate the association between HIV infection and puerperal sepsis among women in Zimbabwe. METHODS: A subanalysis was performed using data from a prospective cohort study conducted between September 2, 2014, and July 1, 2015, at two tertiary hospitals in Zimbabwe. Eligible participants were consecutive women who met the WHO criteria for puerperal sepsis. Variables assessed included HIV-infection status and the use of antiretroviral therapy. Severity of immunosuppression was defined by the number of T cells that expressed cluster of differentiation 4 (CD4). Endocervical swabs and blood samples were collected for microbial culture and susceptibility testing. RESULTS: In all, 33 (21.9%) of the 151 women included in the present analysis had HIV. Among women with HIV, severe immunosuppression (CD4-positive T cell count <200/mm3 ) was associated with a mean hospital stay of 19.0 days versus 10.2 days for mild-advanced immunosuppression (CD4-positive T cell count 200-500/mm3 ) and insignificant immunosuppression (CD4-positive T cell count >500/mm3 ; P=0.030). Use of antiretroviral therapy did not independently influence clinical outcomes. Furthermore, infection with HIV did not influence the microorganisms isolated from blood or endocervical samples. CONCLUSION: Severe immunosuppression was associated with increased length of hospitalization among women with HIV who had puerperal sepsis.

Recurrent group A streptococcal severe sepsis in the postpartum period.

This report presents the relapse and treatment of streptococcal infection in the postpartum period in a patient with severe group A streptococcal sepsis.