Perinatal Infections
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Perinatal Infections

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Perinatal Infections Perinatal Infections Presentation Transcript

  • Perinatal Infections
    • Objectives of the talk:
    • 1. Review current concepts in perinatal infections
    • 2. Review major perinatal pathogens and clinical problems
    • 3. Discuss examples of successful practices in prevention
    • 4. Discuss areas of possible intervention in settings with limited resources
    dr shabeel pn www.hi-dentfinishingschool.blogspot.com
  • Spectrum of infant infections from maternal sources
  • Mechanism of perinatal infections
    • Infants can be infected by direct contact with:
    • 1. Infected maternal secretions and mucous membranes:
    • Examples: Bacterial sexually transmitted infections
    • Genital herpes and papilloma viruses
    • Enteric or urinary pathogens
    • Mother may be asymptomatic, or clinically ill ( with vaginitis, amnionitis, or urinary tract infection)
    • 2. Infected blood and cellular elements:
    • Examples: Hepatitis B and C viruses, HIV
    View slide
  • Infant health is a continuum of maternal health
    • Risks factors for maternal and child infections:
    • Absence of pre-natal care, or unrecognized risk factors:
    • Malnutrition, leading to immunologic deficiencies
    • Untreated infections, especially sexually transmitted infections (STIs)
    • Difficult pregnancy, toxemia, prematurity
    • Prolonged rupture of membranes
    • Traumatic birth
    • Post-partum infections related to poor hygiene
    View slide
  • Major bacterial perinatal infections
  • Major viral perinatal infections
  • Diagnosis and Treatment of perinatal infections
    • 1. Identify risk factors
    • 2. Evaluate clinical features and laboratory support
    • 3. Empirical or specific antimicrobial agents
    • 4. Share information between obstetrical and pediatric/ family medicine providers
    • 5. Post-partum follow-up
  • Examples of some highly effective routine preventive measures for perinatal infections
    • 1. Neonatal tetanus
    • Maternal tetanus vaccination/booster
    • 2. Neonatal ophthalmia with topical agents:
    • 1% silver nitrate
    • 0.5% erythromycin
    • 1% tetracycline
    • 2.5% povidone-iodine
    • 3. Hepatitis B screening and vaccination
  • Results of HBV immunization in Taiwan
    • Mass immunization program
      • 1984: Newborns of HBsAg(+) mothers
      • 1986: All newborns
      • 1987: All preschoolers
    • Sero-prevalence of 6-years old cohort :
    • Year tested HBsAg(+) AntiHBc(+)/HbsAg(-)
    • 1989 10.5 % 25 %
    • 1991 6.3 % 16 %
    • 1993 1.7 % 4.3 %
    • (Hsu etal:J Infect Dis 1999;179:367-70)
  • Incidence of hepato-cellular-carcinoma in Taiwanese children since routine HBV immunization in 1984
  • Prevention of Maternal-to-Child-Transmission of HIV/AIDS is possible
    • A 1994 study in the USA showed that ZDV given during pregnancy and perinatally decreased MTCT from 22.6% to 7.6%
    • Since then, the rate of MTCT in resource-rich countries is further decreased from 9.8% to 1-3%
    • Even in developing countries, anti-retroviral therapy can decrease the rate of transmission by 30-50%, to as low as 6.5% in one study.
  • Components of an effective prevention program
    • 1. Understanding of biology and epidemiology
    • 2. Setting strategic priorities
    • 3. Investing in material and human resources
    • 4. Provide adequate monitoring and evaluation
  • Should antibiotics be used routinely for pre-term, pre-labor rupture of membranes ?
    • Rationale :
    • 1. Infants born prematurely and/or following prolonged rupture of membranes are at increased risk of disease and death.
    • 2. Maternal infection or colonization with various genital pathogens increases the risk of maternal, fetal, and neonatal disease and mortality.
  • Review of the ORACLES studies
    • Two randomized, controlled studies evaluating the risk/benefits of broad spectrum antibiotics for pre-term, pre-labor rupture of membranes. ( erythromycin, amoxicillin+clavulanate, both drugs, or placebo, for 10 days or until delivery )
    • Enrolled more than 11,000 pregnant women at high risk: mean gestation = 31-32 weeks, 75% received antenatal corticosteroids.
    • Outcome measurements: Maternal infection, duration of pregnancy, fetal or neonatal death, chronic lung disease, major cerebral abnormality on ultra-sound.
    • (S Kenyon etal:the Lancet Vol 357, march21,2001:979-94)
  • Antibiotics for pre-term, pre-labor rupture of membrane: Results of the ORACLES I&II studies
  • Case study: Prevention of perinatal group B Streptococcal (GBS) infections
    • Clinical epidemiology:
    • 1. Infects mainly newborns, pregnant women and adults with underlying medical conditions, especially diabetes.
    • 2. 10-30% of pregnant women are asymptomatic carriers in the rectal-vaginal areas. A few develop urinary tract infection, amnionitis, endometritis, wound infections, still births and premature delivery.
  • Prevention of perinatal Group B Streptococcal (GBS) infections
    • Clinical epidemiology:
    • 3. Infants born to GBS carrier mothers have a 30-fold increase of infection.
    • 4 . GBS in neonates:
      • Early onset disease (< 7 days): 80% of cases, 5-20% mortality
      • Late onset disease ( > 7days): 20% of cases.
      • Spectrum: Sepsis, meningitis, pneumonia, focal infection (cellulitis, abcess, osteo-arthritis)
  • Prevention of perinatal GBS infection: Setting up strategies
    • 1. Screening-based approach
    • Collect rectal-vaginal swab for GBS at 35-37 weeks
    • Give intrapartum Penicillin if screen (+).
    • [ Intrapartum chemoprophylaxis means administration of antibiotics after the onset of labor or rupture of membranes but before delivery]
    • 2. Risk-factor approach
    • Give intrapartum Penicillin to women who have any of the following risks:
    • - Previously delivered infant with GBS
    • -GBS bacteriuria during pregnancy
    • -Delivery @ < 37 weeks-gestation
    • -Duration of rupture of membranes > 18 hours
    • -Intrapartum temperature > 38C
  • Prevention of perinatal GBS infection: Comparing strategies
    • 1. Screening-based approach
    • Advantages:
    • Treat only (+) women
    • Disadvantages:
    • - Cost, accuracy of screening
    • -Communication between providers
    • -Screening may still miss some cases
    • 2. Risk-factor approach
    • Advantages:
    • Simpler, less error prone
    • May be cheaper
    • Disadvantages:
    • - Unwarranted treatment if infection is not present
    • -Overuse of antibiotics
    • -May miss some infants who have infection but do not fall in described risk categories
  • Evaluation of GBS prevention after implementation of national recommendations
    • In 1990, the incidence of neonatal GBS infection in the US was 1.8/1,000 deliveries, or 7,600 cases/year.
    • For 1993-1998, the annual incidence dropped to 0.6 cases per 1,000.
    • Thus, intrapartum penicillin given to cases selected by the protocol decreased the incidence of disease by 65% and prevented 3,900 cases and 200 neonatal deaths due to GBS per year.
    • (Schrag etal: New Engl J Med 2000;342:15-20)
  • Components of an effective prevention program
    • 1. Understanding of biology and epidemiology
    • 2. Setting strategic priorities
    • 3. Investing in material and human resources
    • 4. Provide adequate monitoring and evaluation
  • Importance of biology and epidemiology
    • Knowledge can be obtained from:
    • - Reviewing world medical literature
    • - Monitoring local /national statistics
    • - Conducting focus studies:
    • * “At-risk+” populations
    • * Specific pathogens
    • * Special trends
  • Setting strategic priorities
    • 1. Identify “target” disease and “at-risk” populations, and prioritize urgency
    • 2. Conduct cost-effectiveness analysis:
    • Burden of disease:
    • Mortality, morbidity, cost of providing care
    • Loss of productivity
    • Cost of preventive intervention
    • “ Bottom line”: Is there medical and societal cost-saving ?
  • Investing in resources
    • Material resources:
    • Infrastructure
    • Adequate and affordable technology and therapeutics
    • Human resources:
    • Staff training and support
  • Conclusions: Setting up national recommendations for the prevention of perinatal infections
    • Consider:
    • 1. Evaluate areas of high mortality/morbidity, and conduct pilot studies :
    • in selected populations or localities;
    • use risk-based approach;
    • develop & test simple management guidelines
    • support and monitor implementation
  • Other considerations in the prevention of perinatal infections
    • 2. Focus on treatment and prevention of sexually transmitted infections (STIs) of women and their partners
    • 3. Reduce risks of nosocomial infections by attending to “common sense / good hygiene “ practices:
      • Hand-washing by all health care providers
      • Hospital infection control; clean wound care; safe infant feeding
  • “ The measure of success is not whether you have a tough problem to deal with, but whether it is the same problem you had last year.” John Foster Dulles
  • Appendix 1:Prevention of perinatal infections: Suggested guidelines for prenatal care
    • 1. Evaluate at each visit risk-factors of mother and her sexual partner(s):
    • Sexual history, travel, occupation, recreational drug use
    • 2. Depending on resources, “step-up” evaluation, from minimal to optimal :( @ first visit, then @ 34-36 weeks gestation)
    • Pelvic exam and urinalysis
    • Cervical smear: “wet prep”, Gram stain, other special stains
    • Cervical cultures or other diagnostic kit testing
    • Serologies: Syphilis, HIV
    • 3. Treatment based on clinical findings, or according to laboratory findings.
  • Appendix 2: Prevention of Perinatal Infections: Suggested management at labor and delivery
    • 1. Review prenatal risk factors; complete prenatal evaluation if necessary or if feasible.
    • 2. Consider empirical intra-partum antibiotic therapy if mother has any of the following risk factors:
    • History of multiple sexual partners or other risk factors
    • History of miscarriage or neonatal death due to infection
    • Pre-maturity ( <36 weeks-gestation)
    • Prolonged rupture of membranes (= or > 18 hours)
    • Fever, or obvious vaginal, pelvic or urinary tract infection
    • Toxemia; traumatic, septic delivery
    • 3. Communicate clinical findings and treatment with pediatrician or family physician
  • Appendix 3: Intrapartum antibiotic regimens
    • Intrapartum antibiotic administration means giving drugs as soon as possible during labor or after rupture of membranes and through delivery.
    • Useful drugs (IV or IM):
      • Penicillin G 1-2 million units, q 4hr
      • Ampicillin 2gm loading, then 500mg to 1gm q 8hr
      • Cephalosporins ( many agents); clindamycin or erythromycin
      • Above drugs with or without aminoglycosides , q 24 hour dosing:
        • kanamycin 10-15 mg/k;
        • gentamicin or tobramycin 7.5 mg/k
  • Appendix 4: Neonatal care immediately post-partum
    • 1. All neonates to receive eye prophylaxis; immuno-prophylaxis against HBV if available.
    • 2. Infants born to mothers with risk factors should observed for at least 24-36 hours by trained personnel
    • 3. Evaluate and treat at-risk infants if symptomatic .