RIVERSIDE PROTOCOL Ampicillin & Azithromycin Protocol CULTURE FOR GBS 1 ST
IV Ampicillin (2-g dose every 6 hours) for 48 hours
IV Azithromycin ( 500 mg dose every 24 hours ) for 48 hours
Followed by ORAL Amoxicillin (500-mg dose every 8 hours) to complete a 7 day course
Followed by a single daily ORAL dose of Azithromycin 250 mg to complete a 7-day course of therapy.
MANAGEMENT Perform GBS Culture
24 – 32 WEEKS
1)BMS course + Antibiotics + MgSo4 Neuroprotection when delivery imminent. GBS prophylaxis @ delivery for + GBS cultures. Consider repeat BMS if criteria met.
1) Antibiotics for ALL
2) Neuroprotection when delivery imminent or indicated
3) Attempt to collect vaginal pool fluid for (FLM/PG ) ONLY If immature administer BMS
4) If mature @ 32-34 (FLM/PG) deliver AFTER MgSO4
5) GBS prophylaxis @ delivery for + GBS cultures
34 WEEKS ALL DELIVERED
GBS prophylaxis @ delivery for + GBS cultures
Neuroprotection INTERIM GUIDELINES
Neuroprotection INITIATED for imminent delivery FROM 24- 32 weeks (BEAM & ACTOMgSO4)
6 gram MgSo4 LOAD followed by 2 grams / hour for 12-24 hours.
Discontinue if Delivery is not imminent ( minimum 12hrs Mg )
When subsequently delivery again appears imminent ( ie onset of labor or delivery indicated) if more than 6 hours elapsed since discontinuation of MgSO4 RELOAD with 6 grams and continue with 2 grams / hour. If 6 hours has not elapsed reload not recommended.
Re initiation of MgSO4 is indicated up to 34 0/7 weeks.
Neuroprotection is indicated if : Delivery is imminent ( within estimated ~ 24 hours ) as a result of preterm labor with advanced cervical dilation ( 3-4 cm ) with either preterm premature rupture of membranes or intact membranes OR before an indicated preterm delivery.
Exclude patients anticipated to deliver in < 1 hour or CI to MgSO4 ( myasthenia gravis)
Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev 2003;(2):CD001058 .
INCREASED LATENCY PERIOD
Significant reduction in
1) Chorioamnionitis (RR 0.57)
2) Babies born within 48 hours (RR 0.71) and seven days (RR 0.80 )
RIVERSIDE PROTOCOL RECOMMENDS AZITHROMYCIN AS A SUBSTITUTE FOR ERYTHROMYCIN
Oral Azithromycin MUCH better tolerated vs E-Mycin with significant reduction in nausea/emesis and significantly increased ability to complete the recommended 5 day PO course vs E - mycin.
Azithromycin is (FDA) pregnancy category B drug ( no evidence of risk in pregnant humans) the same category as Erythromycin
ORIGINAL NICHD PROTOCOL Antibiotic therapy for reduction of infant morbidity after preterm premature rupture of the membranes. Randomized controlled trial NICHD MFM Network 1997
Intravenous ampicillin (2-g dose every 6 hours) 48 hours
Intavenous erythromycin (250-mg dose every 6 hours) for 48 hours
Followed by oral amoxicillin (250-mg dose every 8 hours) and erythromycin base (333-mg dose every 8 hours) for 5 days.
Total of 7 days of antibiotic therapy
Azithromycin vs E- mycin
Azithromycin is a derivative of the older macrolide antibiotic, erythromycin. The structural modifications made to erythromycin to create azithromycin result in a change in the spectrum of activity, dosing, and GI tolerance.
The mechanism of action of the macrolide, azithromycin is similar to that of erythromycin. They both bind to the 50S subunit of bacterial ribosomes, leading to inhibition of translocation, chain elongation and, ultimately, bacterial protein synthesis
Azithromycin vs E- mycin
Structural changes make newer macrolides such as azithromycin more acid-stable than erythromycin, providing improved oral absorption, tolerance, and pharmacokinetic properties. Azithromycin also has a longer serum half-life, and better tissue and intracellular penetration than erythromycin.
Azithromycin is stable at gastric pH. As a result the bioavailability is better than that of erythromycin base and enteric coating is not required. Azithromycin also has significantly fewer GI side effects
Azithromycin vs E- mycin
The newer macrolides such as Azithromycin have a broader spectrum of antibacterial activity than erythromycin
Azithromycin has enhanced gram-negative activity compared to Erythromycin.
Antibiotics for preterm rupture of membranes. Cochrane Database Syst Rev 2003;(2):CD001058
There were inadequate data to determine whether any antibiotic regimen (drug, dose, duration) was better than any other other
However macrolide antibiotics (erythromycin/ azithromycin ) appeared to be safer than beta-lactam antibiotics (amoxicillin-clavulanate), as the latter were associated with an increased risk of necrotizing enterocolitis.
Impact of a rescue course of antenatal corticosteroids: Multicenter randomized placebo-controlled trial Thomas J. Garite, MD; et al for the Obstetrix Collaborative Research Network STUDY DESIGN : A multicenter randomized double-blind placebo-controlled trial was performed with singletons or twins @ 33weeks or less who had completed a single course of ACS before 30 weeks and at least 14 days before inclusion, and were judged to have a recurring threat of preterm delivery in the coming week, were included. Patients were randomized to receive a single rescue course of Betamethasone, 2 12-mg doses 24 hours a part, or placebo. RESULTS: In all, 437 patients were randomized (223 rescue steroid group and 214 placebo group). There was a significant reduction in the primary outcome of composite neonatal morbidity 34 weeks in the rescue steroid group vs placebo (43.9%vs 63.6%) P .002and significantly decreased respiratory distress syndrome, ventilator support, and surfactant use. CONCLUSION: Administration of a single rescue course of ACS before 33 weeks improves neonatal outcome without apparent increased short-term risk.