Vaginal cleansing before unscheduled cesarean delivery to reduce infection: a randomized clinical trial.

BACKGROUND: Cesarean delivery is the most performed major surgery among women, and surgical-site infections following a cesarean delivery are a significant source of postoperative morbidity. It is unclear if vaginal cleansing before a cesarean delivery decreases post-cesarean delivery infectious morbidity. OBJECTIVE: This study aimed to evaluate if preoperative vaginal cleansing with povidone-iodine among women undergoing a cesarean delivery after labor decreases postoperative infectious morbidity. STUDY DESIGN: This randomized clinical trial was conducted from August 3, 2015 to January 28, 2021, with 30 days of follow-up and the final follow-up completed on February 27, 2021. Patients met the inclusion criteria if they underwent a cesarean delivery after regular contractions with cervical dilation, rupture of membranes, or any cesarean delivery performed at >4 cm dilation. Participants were randomly assigned in a 1:1 ratio to either abdominal cleansing plus vaginal cleansing with 1% povidone-iodine or abdominal cleansing alone. The primary outcome was composite infectious morbidity including surgical-site infection, fever, endometritis, and wound complications within 30 days after the cesarean delivery. Secondary outcomes included individual components of the composite, length of hospital stay, postoperative hospitalization or outpatient treatment related to infectious morbidity, and empirical treatment for neonatal sepsis. RESULTS: A total of 608 subjects (304 vaginal cleansing group, 304 control group) were included in the intention-to-treat analysis. Patient characteristics were similar between groups. There was no significant difference in the primary composite outcome between the 2 groups (11.8% vs 11.5%; P=.90; relative risk, 1.0; 95% confidence interval, 0.7-1.6). Individual components of the composite and secondary outcomes were also not significantly different between the groups. Similar findings were observed in the as-treated analysis (11.3% vs 11.8%; P=.9; relative risk, 1.0; 95% confidence interval, 0.7-1.6). CONCLUSION: Vaginal cleansing with povidone-iodine before an unscheduled cesarean delivery occurring after labor did not reduce the postoperative infectious morbidity. These findings do not support the routine use of vaginal cleansing for women undergoing a cesarean delivery after labor.

Maternal condyloma acuminata infection in pregnancy and offspring long-term respiratory and infectious outcome.

BACKGROUND: Maternal condyloma acuminata infection may be vertically transmitted to the offspring during pregnancy and childbirth. Our study aimed to investigate the possible impact of maternal condyloma acuminata infection in pregnancy on offspring respiratory and infectious morbidity. METHODS: A population-based cohort analysis including all singleton deliveries occurring between 1991 and 2014 at a tertiary medical center. Long-term infectious and respiratory morbidities were compared between children with and without exposure to maternal condyloma infection during pregnancy. A Kaplan-Meier survival curve was used to compare cumulative hospitalization rate and a Cox regression analyses to control for confounders. RESULTS: No significant differences were found in total respiratory and infectious related hospitalizations between the study groups. The survival curves demonstrated no difference in the cumulative incidence between the two groups in both respiratory hospitalizations (log-rank, p = 0.18) and infectious hospitalizations (log-rank, p = 0.95). Cox multivariable analyses demonstrated that exposure to maternal condyloma infection during pregnancy is not a risk factor for neither infectious (aHR 0.91, [CI] 0.49-1.69) nor respiratory (aHR 0.37, [CI] 0.09-1.51) morbidity during childhood and adolescence. CONCLUSION: Exposure to maternal condyloma infection during pregnancy does not appear to be an independent risk factor for later respiratory or infectious morbidity throughout childhood and adolescence.

Pre-Caesarean Section Vaginal Preparation with Chlorhexidine Solution in Preventing Puerperal Infectious Morbidities: A Randomized Controlled Trial.

BACKGROUND: Globally, peripartum or puerperal infections account for about one tenth of maternal mortality, most of which occur in low income countries. Therefore, vaginal preparation with an antiseptic prior to a caesarean delivery could be considered an additional measure to prevent subsequent infectious morbidities. OBJECTIVES: To evaluate vaginal preparation with 0.3% chlorhexidine solution in the prevention of endometritis, surgical site infection and post-operative fever following emergency caesarean section. METHODS: This prospective randomized controlled trial (RCT) was conducted among 240 participants planned for emergency caesarean sections (CS) at term in the University of Medical Sciences Teaching Hospital Complex, Ondo State, Nigeria. Participants were randomised into either group "A" (study) or "B" (control). The former had vaginal preparation with 0.3% chlorhexidine gluconate immediately after anaesthesia while the latter received normal saline. Participants were followed up post-operatively during which clinical features of puerperal infectious morbidities were observed for each during admission as well as 8th and 14th days after delivery. RESULTS: The rate and risk of endometritis were significantly lower in the study group compared to the control; 5.0% versus 13.3%, respectively (chi squared =5.004; p=0.042, RR = 0.38; 95% CI = 0.15-0.94; p = 0.042; RRR = 0.62). Post-operative fever and surgical site infection, were also lower in the study group compared to the controls, but the difference was not statistically significant. CONCLUSION: When compared to placebo, pre-caesarean section vaginal preparation with 0.3% chlorhexidine solution significantly reduced only the rate and risk of post-operative endometritis among infectious morbidities.

CONTEXTE: À l'échelle mondiale, infections péripartum ou puerpérales représentent environ un dixième de la mortalité maternelle, dont la plupart se produisent dans les pays à faible revenu. Par conséquent, la préparation vaginale avec un antiseptique avant un accouchement par césarienne pourrait être considéré comme un mesure supplémentaire pour prévenir les morbidités infectieuses subséquentes. OBJECTIFS: Évaluer la préparation vaginale avec 0.3%solution de chlorhexidine dans la prévention de l'endométrite, site chirurgical infection et fièvre postopératoire après une césarienne d'urgence section. MÉTHODES: Cet essai prospectif randomisé contrôlé (ECR)a été menée auprès de 240 participants prévus pour une urgence césariennes (CS) à terme à l'Université des sciences médicales Complexe hospitalier universitaire, État d'Ondo, Nigéria. Les participants étaient randomisé dans le groupe "A" (étude) ou "B" (témoin). Celui-là avait une préparation vaginale avec 0.3 % de gluconate de chlorhexidine immédiatement après l'anesthésie alors que ce dernier a reçu une solution saline normale. Les participants ont été suivis postopératoirement au cours desquels des caractéristiques de morbidité infectieuse puerpérale ont été observées pour chaquelors de l'admission ainsi que les 8ème et 14ème jours après la livraison. RÉSULTATS: Le taux et le risque d'endométrite étaient significativement plus faibles dans le groupe d'étude par rapport au groupe témoin; 5.0 % contre 13.3 %, respectivement (chi carré =5.004; p=0.042, RR = 0.38; 95% CI = 0.15­0.94; p = 0.042; RRR = 0.62). Fièvre postopératoire et infection du site chirurgical, étaient également plus faibles dans le groupe d'étude par rapport aux témoins, mais lela différence n'était pas statistiquement significative. CONCLUSION: Par rapport au placebo, pré-césarienne préparation vaginale avec une solution de chlorhexidine à 0.3% significativement réduit uniquement le taux et le risque d'endométrite postopératoire chez morbidités infectieuses. Mots-clés: Chlorhexidine, Préparation Vaginale, Infection Puerpéral emorbidité, Césarienne, Endométrite, Fièvre Postopératoire, Infection Du Site Chirurgical.

Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis.

BACKGROUND: Antiseptic vaginal preparation is recommended before gynecologic surgery; however, there is a lack of data regarding the effectiveness of different agents. OBJECTIVE: To compare rates of postoperative infectious complications and hospital utilization with preoperative vaginal preparation using povidone-iodine or chlorhexidine before hysterectomy. STUDY DESIGN: This was a retrospective analysis of patients who underwent hysterectomy for gynecologic indications at 70 hospitals in a statewide surgical collaborative between January 2017 and December 2019. The primary outcome was postoperative infectious complications (including urinary tract infection, surgical site infections involving superficial, deep, or organ space tissues, or cellulitis) within 30 days of surgery. To adjust for confounding, propensity score matching, 1:1 without replacement and with a caliper of.005 was performed to create cohorts that had vaginal preparation with either povidone-iodine or chlorhexidine and did not differ in observable characteristics. We compared the rates of infectious morbidity and hospital utilization (emergency department visits, readmission, reoperation) in the matched cohorts. RESULTS: In the statewide collaborative, there were 18,184 patients who received povidone-iodine and 3018 who received chlorhexidine. After propensity score matching of 2935 pairs, the povidone-iodine and chlorhexidine groups did not differ in demographics, comorbidities, choice of preoperative antibiotics, benign vs malignant surgical indication, and surgical approach. Povidone-iodine was associated with a lower rate of infectious morbidity (3.0% vs 4.3%; P=.01), urinary tract infection (1.1% vs 1.7%; P=.03) and emergency department visits (7.9% vs 9.7%; P=.01) than with chlorhexidine. There were nonsignificant trends of lower rates of surgical site infection (2.0% vs 2.7%; P=.07) and reoperation (1.6% vs 2.1%; P=.18). CONCLUSION: This propensity score matched analysis provides evidence that povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative.

Maternal hepatitis B or hepatitis C virus carrier status and long-term infectious morbidity of the offspring: A population-based cohort study.

The objective of the study was to investigate the long-term effects of maternal hepatitis B virus (HBV) or hepatitis C virus (HCV) carrier status on the long-term infectious morbidity of their offspring. A population-based cohort study was conducted, including all singleton deliveries between the years 1991 and 2014 at a tertiary medical centre. The mothers were subdivided into three groups: HBV carriers, HCV carriers and non-carriers. Data on demographics, maternal, perinatal and long-term hospitalization for infectious morbidity were compared between the groups. During the study period, 242 905 (99.7%) non-carrier mothers, 591 (0.2%) HBV carriers and 186 (0.1%) HCV carriers were observed. Hospitalizations related to infectious morbidity was significantly higher in the offspring of HBV carriers compared with HCV and non-carriers (15.6% vs 11.3% vs 11.0%; P = .002, respectively; Kaplan-Meier, log-rank P < .001). Specifically, a significantly higher rate of hospitalizations gastrointestinal infectious morbidity was noted among the offspring of HBV carrier mothers (3.6% in the HBV carrier group, 1.6% in the HCV carrier group and 1.6% in the non-carrier group [P = .001]). There was a respiratory infectious morbidity of 8.1% among the offspring of HBV carriers, 8.6% among HCV carriers and 5.5% in non-carriers (P = .005). Using a Cox multivariable model, controlling for confounding variables, maternal HBV carrier status was associated with a significantly increased long-term infectious morbidity of the offspring, with an adjusted HR of 1.7 (95% CI, 1.388-2.077, P < .001). Maternal HBV carrier status is an independent risk factor for long-term infectious morbidity of the offspring, particularly for gastrointestinal and respiratory infections.

Delivery mode and future infectious morbidity of the offspring: a sibling analysis.

PURPOSE: Cesarean delivery (CD) has been recently suggested to be associated with offspring's long-term health implications. We aimed to investigate the association between delivery mode and long-term infectious morbidity of the offspring while employing sibling matched analysis to maximize confounder control. METHODS: A retrospective population-based cohort study was performed, which included all sibling deliveries occurring between 1991 and 2014 at a regional tertiary medical center. Offsprings were followed up until the age of 18 years. The study included 13,516 individuals (6758 sibling pairs): the first born was via vaginal delivery and the second via CD. Each siblings pair was considered a matched set, with the aim to perform a within-family analysis. A Kaplan-Meier survival curve was used to compare the cumulative infectious morbidity incidence and a multivariable Cox survival hazards regression model to control for confounders. RESULTS: Crude rates of total infectious hospitalizations were found to be significantly higher in the CD group (OR 1.25; 95% CI 1.12-1.40). Specifically, bronchiolitis (OR 2.02, 95% CI 1.56-2.63), otitis (OR 1.52, 95% CI 1.21-1.9), and gastroenteritis (OR 1.41, 95% CI 1.05-1.9) were all found to be significantly more common in the CD group. The survival curve demonstrated significantly higher cumulative infection-related hospitalization rates in the CD group (log-rank p < 0.001). The Cox model, adjusted for several confounders, confirmed the significant association between CD and offspring's infection-related morbidity (adjusted HR 1.25; 95% CI 1.02-1.53). CONCLUSION: CD appears to be independently associated with later offspring infection-related morbidity, even while rigorously adjusting for confounders.

Maternal morbidity following caesarean deliveries with barbed suture for uterine closure.

PURPOSE: Information regarding the use of barbed suture in gynecologic surgery is limited. Our aim was to compare maternal morbidity following caesarean deliveries performed with barbed compared with non-barbed suture for uterine closure. METHODS: A historical cohort study from a single tertiary institution. The study group composed of all women that underwent term, uncomplicated singleton caesarean deliveries, where uterine closure was performed with ETHICON's Stratafix®, a polydioxanone barbed suture, compared with caesarean deliveries where uterine closure was performed with ETHICON's VICRYL®, a Polyglactin 910 non-barbed suture. The primary outcomes were the rate of maternal morbidity including the rate of red packed cells transfusion and a composite of infectious morbidity. Operation duration was also evaluated. An analysis restricted to elective caesarean deliveries was performed comparing the suture types. RESULTS: Three thousand and sixty patients were included in the study; 1337 in the study group and 1723 in the control group. There was no significant difference in the rate of the primary outcomes (red packed cells transfusion: 2.5% in the barbed suture vs. 2.1% in the non-barbed suture groups; p = 0.47; composite maternal morbidity: 3.8% vs. 4.8%, respectively; p = 0.18). Barbed suture was associated with reduced risk of postoperative ileus compared with the non-barbed suture (0.3% vs. 1.0%, respectively; p = 0.02) and a longer operation time (31 vs. 29 min, respectively; p < 0.001). In the analysis restricted to elective caesarean deliveries only the duration of operation remained significantly different between the groups. CONCLUSIONS: The rate of short term maternal morbidities among patients undergoing uterine closure with barbed suture during caesarean delivery is similar to the non-barbed suture.

Prophylactic antibiotics before cord clamping in cesarean delivery: a systematic review.

INTRODUCTION: The number of clinical trials investigating the optimal timing of prophylactic antibiotics in cesarean section has increased rapidly over the last few years. We conducted a systematic review to inform up-to-date evidence-based guidelines to prevent postpartum infectious morbidity in the mother and rule out any safety issues related to antepartum antibiotic exposure in infants. MATERIAL AND METHODS: Four bibliographic databases were searched for published reports of trials. Ongoing or unpublished studies were searched in Clinicaltrials.gov and the World Health Organization registry platform. Randomized controlled trials comparing antibiotic prophylaxis before and after cord clamping in cesarean section were eligible. Maternal and neonatal outcomes were assessed, and certainty of evidence graded. RESULTS: In total, 18 randomized controlled trials met the inclusion criteria. Those women who received antibiotics preoperatively were 28% (relative risk 0.72, 95% confidence interval 0.56-0.92, nine studies, 4342 women, high quality of evidence) less likely to show infectious morbidity as compared with those who received antibiotics after cord clamping. The risk of endomyometritis and/or endometritis was reduced by 43% (relative risk 0.57, 95% confidence interval 0.40-0.82, 13 studies, 6250 women, high quality of evidence) and the risk of wound infection by 38% (relative risk 0.62, 95% confidence interval 0.47-0.81, 14 studies, 6450 women, high quality of evidence) in those who received antibiotics preoperatively as compared to those who received antibiotics after cord clamping. For other maternal infections no significant differences were identified. The risk for neonatal outcomes, such as deaths attributed to infection, sepsis, neonatal antibiotic treatment, intensive care unit admission or antibiotic-related adverse events, was not found to be different, either clinically or statistically, when antibiotics were given before or after cord clamping (moderate to low quality of evidence). CONCLUSIONS: The evidence in favor of prophylactic antibiotic administration before, in comparison with after, cord clamping for major maternal infections was of high quality, meaning that further research would be unlikely to change the confidence in these findings. However, we recommend additional research reflecting the precision of the effect estimates for neonatal outcomes.

Co-trimoxazole Prophylaxis, Asymptomatic Malaria Parasitemia, and Infectious Morbidity in Human Immunodeficiency Virus-Exposed, Uninfected Infants in Malawi: The BAN Study.

Background: Human immunodeficiency virus (HIV)-exposed infants are disproportionately at risk of morbidity and mortality compared with their HIV-unexposed counterparts. The role of co-trimoxazole preventive therapy (CPT) in reducing leading causes of infectious morbidity is unclear. Methods: We used data from the Breastfeeding, Antiretrovirals and Nutrition (BAN) clinical trial (conducted 2004-2010, Malawi) to assess the association of (1) CPT and (2) asymptomatic malaria parasitemia with respiratory and diarrheal morbidity in infants. In June 2006, all HIV-exposed infants in BAN began receiving CPT (240 mg) from 6 to 36 weeks of age, or until weaning occurred and HIV infection was ruled out. All HIV-exposed, uninfected infants (HEIs) at 8 weeks of age (n = 1984) were included when CPT was the exposure. A subset of HEIs (n = 471) were tested for malarial parasitemia using dried blood spots from 12, 24, and 36 weeks of age. Cox proportional hazards models for recurrent gap-time data were used to examine the association of time-varying exposures on morbidity. Results: CPT was associated with a 36% reduction in respiratory morbidity (hazard ratio [HR], 0.64 [95% confidence interval {CI}, .60-.69]) and a 41% reduction in diarrheal morbidity (HR, 0.59 [95% CI, .54-.65]). Having asymptomatic malaria parasitemia was associated with a 40% increase in respiratory morbidity (HR, 1.40 [95% CI, 1.13-1.74]) and a 50% increase in diarrheal morbidity (HR, 1.50 [95% CI, 1.09-2.06]), after adjusting for CPT. Conclusions: CPT may have an important role to play in reducing the leading global causes of morbidity and mortality in the growing population of HEIs in malaria-endemic resource-limited settings.

Single dose versus multiple dose of antibiotic prophylaxis in caesarean section: a systematic review and meta-analysis.

BACKGROUND: Prophylactic antibiotics are traditionally given as a single dose for caesarean section. However, inconsistent application of recommendations and recent evidence prompted a literature review. OBJECTIVES: To assess the optimal regimen for antibiotic prophylaxis in caesarean section by comparing single versus multiple doses of the same intervention. SEARCH STRATEGY: MEDLINE, Web of Knowledge, SCOPUS, CENTRAL and ongoing trials databases were searched. Reference lists were reviewed and international groups contacted. SELECTION CRITERIA: Randomised controlled trials (RCT) comparing single with multiple dose regimens of the same antibiotic prophylaxis. Quasi-RCT and abstracts were suitable for inclusion. DATA COLLECTION AND ANALYSIS: Reviewers independently extracted data and assessed quality of evidence. A random-effects model was used and results presented as risk ratio (RR) with 95% confidence intervals (CI). MAIN RESULTS: Sixteen studies were included, involving 2695 women. Nonsignificant differences were observed between single dose and multiple dose antibiotic prophylaxis in the incidence of postpartum infectious morbidity (RR 0.95, 95% CI 0.75-1.20, I2 = 25%), endometritis (RR 1.03, 95% CI 0.74-1.42, I2 = 0%) and wound infection (RR 1.22, 95% CI 0.72-2.08, I2 = 0%). A trend towards lower risk of urinary tract infection was seen with multiple dose (RR 0.65, 95% CI 0.34-1.24, I2 = 0%). CONCLUSIONS: There was insufficient evidence to determine whether there is a difference between single and multiple dose regimens in reducing the incidence of infectious morbidity after caesarean section. The quality of evidence was very low and well-designed RCTs are needed. TWEETABLE ABSTRACT: Insufficient evidence of difference between dosage regimens of antibiotic prophylaxis in caesarean section.

Infectious morbidity and resource use in children under 2 years old at childcare centres.

AIM: To analyse the associations between childcare centres and infectious morbidity and resource consumption. METHODS: Cohort study from birth to 2 years. OUTCOME VARIABLE: number and types of infections, drug consumption and medical visits. Exposure variable: attending or not attending a childcare centre. School age: 6-12, >12-18, >18-24 months. RESULTS: The initial cohort comprised 445 children, and the final cohort comprised 419 children. The mean number of recurrent infections and wheezing was higher in children attending childcare centres in all age groups with significant differences. Recurrent acute otitis media was observed in the 12- to 18-month group with an odds ratio of 6.04 (95% confidence interval, 1.3-27.6; P = 0.001) in the children attending childcare centres. In children older than 6 months, there was greater consumption of antibiotics, inhaled bronchodilators, oral and inhaled corticosteroids and montelukast. CONCLUSIONS: Attending a childcare is associated with an increased frequency of recurrent infections and wheezing, as well as the consumption of antibiotics, bronchodilators, corticosteroids and montelukast.

Preoperative vaginal cleansing with chlorhexidine and cetrimide solution for reduction of postoperative infectious morbidity at a tertiary care center in North India: A prospective cohort study.

OBJECTIVE: To determine the effect of preoperative vaginal cleansing with chlorhexidine and cetrimide solution on postoperative infectious morbidity. METHODS: This prospective cohort study was conducted over a period of 18 months in the Department of Obstetrics and Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India. Women undergoing cesarean section were alternately allotted to study and control groups. Women with chorioamnionitis, antepartum hemorrhage, rupture of membranes for more than 24 h, and fever in the preoperative period were excluded. The study group received preoperative vaginal cleansing with antiseptic solution (7.5% chlorhexidine w/v and 15% cetrimide w/v); the control group did not receive vaginal cleansing. Both groups were followed for the presence of any infectious morbidity until they were discharged from the hospital. RESULTS: Age, body mass index (calculated as weight in kilograms divided by the square of height in meters), gestational age, and the parity of the women in the study and control groups were comparable (n = 760). The rate of endometritis was lower in the study group, but the difference was not statistically significant (P = 0.054). Post-cesarean febrile morbidity and wound sepsis were significantly lower in the study group (P = 0.017 and P = 0.02, respectively). On subgroup analysis, women in the study group with rupture of the membranes before cesarean delivery had lower wound sepsis and a reduced duration of hospital stay. Women in the study group with emergency cesarean delivery showed a significant reduction in wound sepsis, febrile morbidity, and length of hospital stay. CONCLUSION: Preoperative vaginal cleansing with chlorhexidine and cetrimide solution before a cesarean section reduces postoperative infectious morbidity.

The Association between Term Chorioamnionitis during Labor and Long-Term Infectious Morbidity of the Offspring.

Background: Chorioamnionitis during labor exposes the fetus to an intrauterine state that may alter the future immune response and may expose the offspring to future susceptibility to infectious disease. We evaluated the long-term pediatric infectious morbidity of children born at term to mothers who have chorioamnionitis during labor. Methods: This was a population-based cohort analysis including only term singleton deliveries at a regional tertiary hospital between the years 1991 and 2021. Offspring to mothers with and without a diagnosis of chorioamnionitis during labor were compared. Offspring hospitalizations up to the age of 18 years involving infectious morbidity were evaluated using the Kaplan-Meier survival curve and a Cox regression model to control possible confounders. Results: A total of 331,598 deliveries were included, 988 (0.3%) of which were of mothers diagnosed with chorioamnionitis during labor. All infectious morbidity rates included in the analysis were comparable between groups. The Kaplan-Meier survival curves were similar for both groups (log-rank = 0.881) and the multivariable analysis ascertained that chorioamnionitis during labor was not a risk factor for offspring's long-term infectious morbidity (HR 0.929, 95%CI 0.818-1.054, p = 0.254). Conclusions: In our cohort, term chorioamnionitis during labor was not associated with a higher risk of pediatric hospitalization due to infections. The infectious/inflammatory state during labor did not expose nor increase the susceptibility of the term offspring to future infectious morbidity.

Compared perinatal outcomes of two prophylactic antibiotic regimens for preterm premature rupture of membranes: a randomized controlled trial.

BACKGROUND: Prophylactic antibiotic use in preterm premature rupture of membranes is associated with significantly reduced intra-amniotic infection and improved neonatal outcome, although data are insufficient to determine the optimal antibiotic regimen. Ampicillin resistance has changed the epidemiology of neonatal sepsis. OBJECTIVE: This study aimed to determine the efficacy of two antibiotic regimens in prolonging the latency period in women with preterm premature rupture of membranes. STUDY DESIGN: This randomized-controlled trial was conducted in 3 tertiary university-affiliated hospitals. A total of 124 women with preterm premature rupture of membranes at <37 weeks of gestation were randomized into two antibiotic prophylactic protocols: ampicillin + roxithromycin and cefuroxime + roxithromycin. The latency period length, neonatal adverse outcomes, and maternal infectious morbidity, including intrauterine infection, intrapartum fever, postpartum antibiotic treatment, endometritis, and wound infection, were measured and compared. RESULTS: Maternal infectious morbidity was higher in the ampicillin group than in the cefuroxime group (17.7% vs 6.5%; 1-sided P value =.048). The pathogen distribution among placenta, membrane, cord, and uterine cultures differed between the groups (P=.017). Enterobacteriaceae spp. cultures were identified in 68.6% of the cultures in the ampicillin group and 43.2% in the cefuroxime group (P=.036). The composite neonatal adverse outcome was higher in the ampicillin group than in the cefuroxime group (55 [88.7%] vs 46 [74.2%]; 1-sided P value =.03). The proportion of primiparas with a latency period >4 days was significantly higher in the cefuroxime group than in the ampicillin group (odds ratio, 3.69; 95% confidence interval, 1.175-11.607; P=.025). CONCLUSION: In combination with roxithromycin, the use of cefuroxime, as a prophylactic in women with premature rupture of membranes at <37 weeks of gestation, showed longer pregnancy in primiparas and less maternal and neonatal morbidity than the use of ampicillin. Further larger studies are needed to support our results.

A randomized controlled trial to compare antibiotic prophylaxis in elective gynecological surgeries: Single dose of cefazolin versus single dose of cefazolin and tinidazole.

Objectives: To evaluate if addition of an anti-anaerobic agent to standard drug-cefazolin for antimicrobial prophylaxis would further decrease postoperative infectious morbidity or not. This is relevant as most of the infections in gynecological surgeries are anaerobic but cefazolin does not protect against anaerobes. Materials and Methods: The study design was a parallel randomized controlled trial. Two hundred patients undergoing benign gynecological surgeries were divided into two groups of 100 each. Group A received 2 g cefazolin 30-60 min before incision and Group B received 2 g cefazolin 30-60 min and 1.6 g tinidazole 60-120 min before incision. The patients were followed for any infectious morbidity for 1 month postoperatively. The analysis was done separately for abdominal, laparoscopic, and vaginal surgeries. The analysis was also done for surgeries according to the wound category, i.e. clean and clean-contaminated. Results: The two groups were comparable for age and body mass index (BMI). The two groups were comparable for the factors affecting infectious morbidity such as duration of surgery, blood loss, blood transfusions, duration of hospital stay, and need for additional antibiotics. The postoperative infectious morbidity was analyzed in terms of fever, surgical site infection (SSI), and urinary tract infection (UTI). No patient in vaginal and laparoscopic groups suffered from infectious morbidity. In abdominal surgeries group, postoperative fever occurred in 6/74 (8.1%) and 11/74 patients (14.8%) in Groups A and B, respectively (P = 0.38). SSI occurred in 1/74 (1.3%) and 2/74 (2.7%) patients in Groups A and B, respectively (P = 1.0). UTI occurred in 5/74 patients (6.7%) and 2/74 patients (2.7%) in Groups A and B, respectively (P = 0.44). The data were also analyzed for infectious morbidity for clean and clean-contaminated wound categories, and the results were nonsignificant between both groups for each type of wound category (P > 0.05). Conclusion: Cefazolin alone is a sufficient antibiotic prophylaxis for benign gynecological procedures.

Infectious morbidity of speculum versus digital examinations in preterm prelabor rupture of membranes: a systematic review and meta-analysis.

OBJECTIVE: To estimate the effect of speculum examination only versus digital cervical examination on maternal infectious morbidity in women with preterm prelabor rupture of membranes by performing a systematic review and meta-analysis. MATERIALS AND METHODS: We explored MEDLINE, Scopus, Embase, CINAHL, ClinicalTrials.gov and Cochrane Central Register of Controlled Trials for studies comparing the rate of a composite maternal infectious morbidity (either chorioamnionitis, endometritis or both) in women with preterm prelabor rupture of membranes that underwent a speculum only versus digital cervical examination at the time of diagnosis. Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of a composite maternal infectious morbidity (either chorioamnionitis, endometritis or both) were compared and odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. RESULTS: Four cohort studies, reporting on 1213 women were identified. The median point prevalence of the composite maternal infectious morbidity was 26% (interquartile range 15-35%) in women who had a speculum examination only compared to 33% (interquartile range 22-42%) in women who underwent a digital examination. The overall maternal composite infectious morbidity rate in women that had a speculum examination only was less compared to women that had undergone a digital examination (pooled OR 0.75, 95% CI 0.58-0.98, I2 17%). The weighted mean length of latency in women with preterm prelabor rupture of membranes was longer in individuals evaluated by speculum only versus digital examination, 6.6 d versus 2.9 d (mean difference 4.5 d, 95% CI 1.4 to 7.8, I2 99%). CONCLUSION: Speculum examination only in women with preterm prelabor rupture of membranes is associated with less maternal infectious morbidity and longer latency periods.

The maternal leukocyte count at admission for labor is indicative of early maternal postpartum infectious morbidity and adverse neonatal outcome.

OBJECTIVES: Investigate the association between maternal leukocyte count at admission for labor and postpartum infectious maternal morbidity (PPIM) following vaginal delivery. STUDY DESIGN: Retrospective cohort study, 2005-2017. Afebrile women, term, singleton, vaginal delivery included. Maternal leukocyte/differential at admission for labor and 24 h postpartum were analyzed as continuous values and quintiles. Pre/postpartum difference (Δleukocyte) was calculated. The primary outcome was maternal PPIM, early and late. The secondary outcome was adverse neonatal outcomes (ANO). RESULTS: 58,174 eligible deliveries out of168,979 (34.4 %); 1068 (1.8 %) women with PPIM. The rate rose linearly from 1.4 % for the lowest admission for labor leukocyte quantile to 2.7 % for the highest quantile, p for trend <0.001. The women with early PPIM had significantly higher admission levels of leukocytes (mean): 12.04 ± 3.43 vs. 11.18 ± 2.86 × 10^3/µl; neutrophils, 9.48 ± 3.46 vs. 8.40 ± 2.67 × 10^3/µl; and monocytes 0.76 ± 0.25 vs. 0.72 ± 0.23 × 10^3/µl); p < 0.001 for all. The mean leukocyte count for women with PPIM diagnosis, including only postpartum fever, was 12.06 ± 2.64; significantly higher than in the non-PPIM group, p = 0.014. A Δleukocyte value of >3.7 × 10^3/µl is significantly associated with PPIM, aOR 2.10 [1.82-2.41]. No significant association between leukocyte count or Δleukocyte and maternal readmission rate due to infectious complications. 386 neonates (0.7 %) had records of ANO and 64 neonates (0.1 %) had records of neonatal sepsis, positive linear association; p for trend < 0.001. The maternal Δleukocyte value of >3.7 × 10^3/µl was found to be significantly associated with the risk for ANO, aOR 1.5[1.19-1.90]. CONCLUSION: In healthy women, an elevated level of the leukocyte count at admission for labor and the Δleukocyte are significant risk predictors of PPIM and ANO.

Maternal celiac disease and the risk for long-term infectious morbidity of the offspring.

PROBLEM: Celiac disease is an autoimmune disease, patients with celiac have increased risk for infections, and offspring of celiac mothers have increased morbidity. The aim of the study was to assess long-term infectious morbidity among offspring of pregnant women with celiac disease. METHOD OF STUDY: A population-based cohort study was conducted, including all singleton deliveries between the years 1991-2014 at a tertiary medical center. The offsprings were subdivided into two groups: offsprings of mothers with and without celiac disease. Data on demographics, maternal, perinatal, and long-term hospitalizations for infectious morbidity were compared between the two groups. RESULTS: During the study period there were 210 (0.09%) deliveries of mothers with celiac, and they were compared to 242170 (99.91%) deliveries of non-celiac mothers. Cumulative infectious morbidity was significantly higher in offspring of mothers with celiac compared to offspring of mothers without celiac (Kaplan-Meier, log-rank p = .004). Specifically, among the offspring of mothers with celiac significantly higher rates of bacteremia was noted (1.0% vs. 0.1%; p = .001), and infections of the central nervous system (1% vs. 0.2%; p = .028). In the Cox multivariable model which accounted for confounding variables, being born to mothers with celiac disease was associated with significantly increased risk for long-term infectious morbidity of the offspring (adjusted HR = 1.6, 95% CI 1.165-2.357, p = .005). CONCLUSIONS: Maternal celiac disease is an independent risk factor for long-term infectious morbidity for the offspring.

Maternal preeclampsia and long-term infectious morbidity in the offspring - A population based cohort analysis.

OBJECTIVE: We evaluated the association between maternal preeclampsia and long-term infectious morbidity of the offspring. STUDY DESIGN: A retrospective cohort analysis was performed, evaluating risk of long-term infectious morbidity in children born to women with and without preeclampsia between the years 1991-2014. Infectious morbidity included hospitalizations of offspring during childhood. Infants were followed until age 18 years or until hospitalization. Multiple gestations, newborns with congenital malformations and perinatal deaths were excluded. Cumulative incidence rates of infectious morbidity were compared. A Cox proportional hazards model was employed to control for various confounders including gestational age and cesarean delivery (CD). RESULTS: During the study period 239,725 newborns were included: 96% (n = 230,217) without preeclampsia, 3% (n = 7280) with mild preeclampsia and 0.9% (n = 2228) with severe preeclampsia, defined mostly by evidence of maternal organ dysfunction. Hospitalization rate due to infectious morbidity was significantly higher for offspring to mothers with severe preeclampsia in comparison to those with no preeclampsia (13.1% vs 11%, P = 0.008), specifically respiratory and bacterial infections. The Kaplan-Meier survival curve demonstrated that offspring born to mothers with severe preeclampsia had a significantly higher cumulative incidence of hospitalization (Log-rank test P value = 0.026). However, while controlling for confounders in the Cox regression model, severe preeclampsia was not found as an independent risk factor (adjusted hazard ratio 0.95, 95% confidence interval 0.8-1.1, P = 0.36). CONCLUSION: While severe preeclampsia is associated with higher risk for long-term infectious morbidity of the offspring, it seems that the association is due to prematurity and CD, but not the preeclampsia per-se.