Examining the infectious aetiology and diagnostic criteria of maternal pyrexia in labour to improve antibiotic stewardship

Abstract

Objectives To determine the infectious aetiology of peripartum maternal pyrexia and to assess the diagnostic accuracy of obstetric systemic inflammatory response syndrome criteria and cardiotocography as predictors of peripartum infection, in order to guide appropriate antibiotic management of mother and neonate. Study Design This study was carried out in a tertiary referral maternity hospital in Dublin, Ireland. A prospective cohort analysis was performed of 175 mother-newborn pairs with maternal pyrexia (≥38 °C) that developed after labour onset or within four hours postnatal. Infection was confirmed microbiologically in the case of sterile site infection, urinary tract infection (UTI) or growth of a significant perinatal pathogen from a placental swab. Infection was confirmed histologically by gross and microscopic examination of placentas in cases where there was growth of potentially pathogenic micro-organisms at a non-sterile site. Systemic inflammatory response syndrome criteria and cardiotocography in patients with confirmed infection versus those without evidence of infection were compared using independent samples t-test for continuous data and pearson chi-square test for nominal data. Diagnostic accuracy of obstetric systemic inflammatory response syndrome criteria (elevated maternal heart rate, elevated respiratory rate, decreased systolic blood pressure and elevated white cell count) for the identification of infection among women with peripartum pyrexia was determined using receiver operating characteristic curves. Results The infection rate was 17.1% (30/175). The rate was 22% (22/100) for pyrexia that occurred during labour and 10.7% (8/75) if it occurred within four hours after delivery. Obstetric systemic inflammatory response syndrome criteria and cardiotocography were not predictive of infection in women with peripartum pyrexia. No significant differences were observed in mean temperature, heart rate, respiratory rate, systolic blood pressure or white cell count between those with infections and those with no evidence of infection. Conclusions Peripartum pyrexia is predominantly of non-infectious origin. Improved diagnostic criteria are needed to identify infection for this indication. Early discontinuation of antibiotic treatment is appropriate in the majority of patients who develop term peripartum pyrexia after onset of labour.

Maternal sepsis update: current management and controversies

“…10,40,45 As a result, many patients for whom the sepsis bundle has been initiated may not have an infectious aetiology. Fitzgerald et al, 52 in a prospective study of 175 intrapartum women with pyrexia >38°C, showed that no patients developed sepsis or required admission to ICU. 52 They argue that de-escalation of antibiotics could be considered if sterile site cultures are negative at 48 hours and the patient is clinically well, 52 along the lines of current national guidance for the neonate.…”

“…Fitzgerald et al, 52 in a prospective study of 175 intrapartum women with pyrexia >38°C, showed that no patients developed sepsis or required admission to ICU. 52 They argue that de-escalation of antibiotics could be considered if sterile site cultures are negative at 48 hours and the patient is clinically well, 52 along the lines of current national guidance for the neonate. 53 However, given the poor sensitivity/specificity of current microbiological culture techniques and in the absence of a more sensitive tool, de-escalation should be determined with microbiological guidance.…”

Impact of NICE clinical guidelines for prevention and treatment of neonatal infections on antibiotic use in very preterm infants in England and Wales: an interrupted time series analysis

“…Preterm birth after spontaneous labour with prolonged preterm rupture of membranes necessitated antibiotic use, meaning many premature babies receive antibiotics as default. Additionally, in practice a low threshold is used to manage maternal perinatal fever as sepsis 14 which obligated neonatal antibiotic prescribing. Clinical indicators of neonatal sepsis were non-specific, 1 based on low-quality evidence 2 and risked subjective interpretation.…”