A global perspective on management of bacterial infections in pregnancy: a systematic review of international guidelines

Abstract

Introduction: Maternal sepsis is a leading cause of maternal and neonatal mortality. Despite the availability of management protocols, there is disparity in case fatality rates for pregnancy-related sepsis compared to other maternity-related complications. The main aim of this systematic review was to assess concordance between international evidence-based guidelines for the prevention and management of childbirth-related bacterial infections. Material and methods: The PRISMA statement was followed during the conduct and reporting of this review. PubMed and G-IN were searched electronically from 2009 to November 2019 for clinical guidelines covering the topic of childbirth-related infections and speci c searches for relevant guidelines on the websites of the top 5 international professional bodies most commonly identi ed by our searches. We did not apply any language restrictions. Guidelines were included if they provided any information about the prevention or management of childbirth-related bacterial infections irrespective of whether the guideline stated a recommendation or not. Two independent reviewers undertook study selection, decisions about inclusion of selected guidelines and data extraction. Extracted information was synthesized under the following topics: Asymptomatic bacteriuria; group B streptococcal infection (GBS); preterm premature rupture of membranes (P-PROM); Intrauterine infection; Interventions and procedures; maternal sepsis; miscellaneous. Concordance was de ned as absence of contradictory information between the different guidelines with regards to a speci c topic, subtopic or recommendation. Quality of included guidelines was assessed against the AGREE II guideline reporting domains. Results: A total of 43 guidelines were selected of which 11 were excluded leaving 32 guidelines that ful lled our inclusion criteria. None of the guidelines ful lled all the quality assessment domains and 11 (34%) of the guidelines satis ed 1-2 of domains only. Two guidelines covered the topic of asymptomatic bacteriuria, nine for GBS, ve for P-PROM and three covered each of intra-amniotic infections maternal sepsis, obstetric procedures and interventions topics. The remaining guidelines covered miscellaneous topics. Conclusions: There was concordance between guidelines with regards to several aspects in the prophylaxis and treatment of bacteriological infections in pregnancy. Nevertheless, there were several areas of discordance, some of which reached the extent of contradictory information as in the case of antenatal screening for GBS.

Clinical chorioamnionitis: where do we stand now?

“…Although there is not enough evidence to support one antibiotic over another, most countries prefer a regimen that is easy to administer and follows antibiotic use principles to minimize the emergence of resistant bacterial strains ( 36 ). In a recent article, Koucky et al ( 44 ) pointed out that only three recommendations or guidelines [ACOG ( 1 ), CNGOF ( 42 ), and WHO ( 43 )] addressed this issue, and that there was agreement among them with regard to immediately initiating combination antibiotic therapy and maintaining this for the duration of labor. The guidelines recognized the weakness of evidence to make strong recommendations regarding the duration for which antibiotics should be continued after delivery ( 44 ).…”

“…In a recent article, Koucky et al ( 44 ) pointed out that only three recommendations or guidelines [ACOG ( 1 ), CNGOF ( 42 ), and WHO ( 43 )] addressed this issue, and that there was agreement among them with regard to immediately initiating combination antibiotic therapy and maintaining this for the duration of labor. The guidelines recognized the weakness of evidence to make strong recommendations regarding the duration for which antibiotics should be continued after delivery ( 44 ). Maternal GBS colonization is one of the main factors associated with the onset of chorioamnionitis and neonatal infection.…”

“…In contrast, the New Zealand Medical Association (NZMA) and the Royal College of Obstetricians and Gynaecologists (RCOG) do not support such a policy. The RCOG decision is based on the opinion of the UK National Screening Committee that clear evidence is still lacking regarding the benefits of routine screening for GBS, no fully accurate screening test is available yet, and at 35–37 weeks of gestation the GBS status does not reflect what this status will be at delivery ( 44 – 46 ). On the other hand, the American Academy of Pediatrics stated that broad adoption of the routine antenatal GBS screening policy it recommends has corresponded to an estimated 80% drop in early-onset GBS ( 44 ).…”

“…The RCOG decision is based on the opinion of the UK National Screening Committee that clear evidence is still lacking regarding the benefits of routine screening for GBS, no fully accurate screening test is available yet, and at 35–37 weeks of gestation the GBS status does not reflect what this status will be at delivery ( 44 – 46 ). On the other hand, the American Academy of Pediatrics stated that broad adoption of the routine antenatal GBS screening policy it recommends has corresponded to an estimated 80% drop in early-onset GBS ( 44 ). For example, the proportion of Slovenian pregnant women that are carriers of GBS in the intestine or vagina was determined in two studies ( 47 , 48 ) and was found to be 17 and 23%, respectively.…”

Correlation of histologic chorioamnionitis and intra-partum leukocytosis

“…However, these clinical signs and symptoms of bacterial infection demonstrate low sensitivity and low speci city in clinical setting, and a large percentage of patients with histologic evidence of acute chorioamnionitis shows no clinical signs and symptoms [3]. These patients without clinical manifestation of intraamniotic infection (acute chorioamnionitis) are undetected and untreated despite the increased risks of neonatal bacterial infection and other pregnancy related complications.…”