Perinatal Infections


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Perinatal Infections

  1. 1. Perinatal Infections <ul><li>Objectives of the talk: </li></ul><ul><li>1. Review current concepts in perinatal infections </li></ul><ul><li>2. Review major perinatal pathogens and clinical problems </li></ul><ul><li>3. Discuss examples of successful practices in prevention </li></ul><ul><li>4. Discuss areas of possible intervention in settings with limited resources </li></ul>dr shabeel pn
  2. 2. Spectrum of infant infections from maternal sources
  3. 3. Mechanism of perinatal infections <ul><li>Infants can be infected by direct contact with: </li></ul><ul><li>1. Infected maternal secretions and mucous membranes: </li></ul><ul><li>Examples: Bacterial sexually transmitted infections </li></ul><ul><li>Genital herpes and papilloma viruses </li></ul><ul><li>Enteric or urinary pathogens </li></ul><ul><li>Mother may be asymptomatic, or clinically ill ( with vaginitis, amnionitis, or urinary tract infection) </li></ul><ul><li>2. Infected blood and cellular elements: </li></ul><ul><li>Examples: Hepatitis B and C viruses, HIV </li></ul>
  4. 4. Infant health is a continuum of maternal health <ul><li>Risks factors for maternal and child infections: </li></ul><ul><li>Absence of pre-natal care, or unrecognized risk factors: </li></ul><ul><li>Malnutrition, leading to immunologic deficiencies </li></ul><ul><li>Untreated infections, especially sexually transmitted infections (STIs) </li></ul><ul><li>Difficult pregnancy, toxemia, prematurity </li></ul><ul><li>Prolonged rupture of membranes </li></ul><ul><li>Traumatic birth </li></ul><ul><li>Post-partum infections related to poor hygiene </li></ul>
  5. 5. Major bacterial perinatal infections
  6. 6. Major viral perinatal infections
  7. 7. Diagnosis and Treatment of perinatal infections <ul><li>1. Identify risk factors </li></ul><ul><li>2. Evaluate clinical features and laboratory support </li></ul><ul><li>3. Empirical or specific antimicrobial agents </li></ul><ul><li>4. Share information between obstetrical and pediatric/ family medicine providers </li></ul><ul><li>5. Post-partum follow-up </li></ul>
  8. 8. Examples of some highly effective routine preventive measures for perinatal infections <ul><li>1. Neonatal tetanus </li></ul><ul><li>Maternal tetanus vaccination/booster </li></ul><ul><li>2. Neonatal ophthalmia with topical agents: </li></ul><ul><li>1% silver nitrate </li></ul><ul><li>0.5% erythromycin </li></ul><ul><li>1% tetracycline </li></ul><ul><li>2.5% povidone-iodine </li></ul><ul><li>3. Hepatitis B screening and vaccination </li></ul>
  9. 9. Results of HBV immunization in Taiwan <ul><li>Mass immunization program </li></ul><ul><ul><li>1984: Newborns of HBsAg(+) mothers </li></ul></ul><ul><ul><li>1986: All newborns </li></ul></ul><ul><ul><li>1987: All preschoolers </li></ul></ul><ul><li>Sero-prevalence of 6-years old cohort : </li></ul><ul><li>Year tested HBsAg(+) AntiHBc(+)/HbsAg(-) </li></ul><ul><li>1989 10.5 % 25 % </li></ul><ul><li>1991 6.3 % 16 % </li></ul><ul><li>1993 1.7 % 4.3 % </li></ul><ul><li>(Hsu etal:J Infect Dis 1999;179:367-70) </li></ul>
  10. 10. Incidence of hepato-cellular-carcinoma in Taiwanese children since routine HBV immunization in 1984
  11. 11. Prevention of Maternal-to-Child-Transmission of HIV/AIDS is possible <ul><li>A 1994 study in the USA showed that ZDV given during pregnancy and perinatally decreased MTCT from 22.6% to 7.6% </li></ul><ul><li>Since then, the rate of MTCT in resource-rich countries is further decreased from 9.8% to 1-3% </li></ul><ul><li>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. </li></ul>
  12. 12. Components of an effective prevention program <ul><li>1. Understanding of biology and epidemiology </li></ul><ul><li>2. Setting strategic priorities </li></ul><ul><li>3. Investing in material and human resources </li></ul><ul><li>4. Provide adequate monitoring and evaluation </li></ul>
  13. 13. Should antibiotics be used routinely for pre-term, pre-labor rupture of membranes ? <ul><li>Rationale : </li></ul><ul><li>1. Infants born prematurely and/or following prolonged rupture of membranes are at increased risk of disease and death. </li></ul><ul><li>2. Maternal infection or colonization with various genital pathogens increases the risk of maternal, fetal, and neonatal disease and mortality. </li></ul>
  14. 14. Review of the ORACLES studies <ul><li>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 ) </li></ul><ul><li>Enrolled more than 11,000 pregnant women at high risk: mean gestation = 31-32 weeks, 75% received antenatal corticosteroids. </li></ul><ul><li>Outcome measurements: Maternal infection, duration of pregnancy, fetal or neonatal death, chronic lung disease, major cerebral abnormality on ultra-sound. </li></ul><ul><li>(S Kenyon etal:the Lancet Vol 357, march21,2001:979-94) </li></ul>
  15. 15. Antibiotics for pre-term, pre-labor rupture of membrane: Results of the ORACLES I&II studies
  16. 16. Case study: Prevention of perinatal group B Streptococcal (GBS) infections <ul><li>Clinical epidemiology: </li></ul><ul><li>1. Infects mainly newborns, pregnant women and adults with underlying medical conditions, especially diabetes. </li></ul><ul><li>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. </li></ul>
  17. 17. Prevention of perinatal Group B Streptococcal (GBS) infections <ul><li>Clinical epidemiology: </li></ul><ul><li>3. Infants born to GBS carrier mothers have a 30-fold increase of infection. </li></ul><ul><li>4 . GBS in neonates: </li></ul><ul><ul><li>Early onset disease (< 7 days): 80% of cases, 5-20% mortality </li></ul></ul><ul><ul><li>Late onset disease ( > 7days): 20% of cases. </li></ul></ul><ul><ul><li>Spectrum: Sepsis, meningitis, pneumonia, focal infection (cellulitis, abcess, osteo-arthritis) </li></ul></ul>
  18. 18. Prevention of perinatal GBS infection: Setting up strategies <ul><li>1. Screening-based approach </li></ul><ul><li>Collect rectal-vaginal swab for GBS at 35-37 weeks </li></ul><ul><li>Give intrapartum Penicillin if screen (+). </li></ul><ul><li>[ Intrapartum chemoprophylaxis means administration of antibiotics after the onset of labor or rupture of membranes but before delivery] </li></ul><ul><li>2. Risk-factor approach </li></ul><ul><li>Give intrapartum Penicillin to women who have any of the following risks: </li></ul><ul><li>- Previously delivered infant with GBS </li></ul><ul><li>-GBS bacteriuria during pregnancy </li></ul><ul><li>-Delivery @ < 37 weeks-gestation </li></ul><ul><li>-Duration of rupture of membranes > 18 hours </li></ul><ul><li>-Intrapartum temperature > 38C </li></ul>
  19. 19. Prevention of perinatal GBS infection: Comparing strategies <ul><li>1. Screening-based approach </li></ul><ul><li>Advantages: </li></ul><ul><li>Treat only (+) women </li></ul><ul><li>Disadvantages: </li></ul><ul><li>- Cost, accuracy of screening </li></ul><ul><li>-Communication between providers </li></ul><ul><li>-Screening may still miss some cases </li></ul><ul><li>2. Risk-factor approach </li></ul><ul><li>Advantages: </li></ul><ul><li>Simpler, less error prone </li></ul><ul><li>May be cheaper </li></ul><ul><li>Disadvantages: </li></ul><ul><li>- Unwarranted treatment if infection is not present </li></ul><ul><li>-Overuse of antibiotics </li></ul><ul><li>-May miss some infants who have infection but do not fall in described risk categories </li></ul>
  20. 20. Evaluation of GBS prevention after implementation of national recommendations <ul><li>In 1990, the incidence of neonatal GBS infection in the US was 1.8/1,000 deliveries, or 7,600 cases/year. </li></ul><ul><li>For 1993-1998, the annual incidence dropped to 0.6 cases per 1,000. </li></ul><ul><li>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. </li></ul><ul><li>(Schrag etal: New Engl J Med 2000;342:15-20) </li></ul>
  21. 21. Components of an effective prevention program <ul><li>1. Understanding of biology and epidemiology </li></ul><ul><li>2. Setting strategic priorities </li></ul><ul><li>3. Investing in material and human resources </li></ul><ul><li>4. Provide adequate monitoring and evaluation </li></ul>
  22. 22. Importance of biology and epidemiology <ul><li>Knowledge can be obtained from: </li></ul><ul><li>- Reviewing world medical literature </li></ul><ul><li>- Monitoring local /national statistics </li></ul><ul><li>- Conducting focus studies: </li></ul><ul><li>* “At-risk+” populations </li></ul><ul><li>* Specific pathogens </li></ul><ul><li>* Special trends </li></ul>
  23. 23. Setting strategic priorities <ul><li>1. Identify “target” disease and “at-risk” populations, and prioritize urgency </li></ul><ul><li>2. Conduct cost-effectiveness analysis: </li></ul><ul><li>Burden of disease: </li></ul><ul><li>Mortality, morbidity, cost of providing care </li></ul><ul><li>Loss of productivity </li></ul><ul><li>Cost of preventive intervention </li></ul><ul><li>“ Bottom line”: Is there medical and societal cost-saving ? </li></ul>
  24. 24. Investing in resources <ul><li>Material resources: </li></ul><ul><li>Infrastructure </li></ul><ul><li>Adequate and affordable technology and therapeutics </li></ul><ul><li>Human resources: </li></ul><ul><li>Staff training and support </li></ul>
  25. 25. Conclusions: Setting up national recommendations for the prevention of perinatal infections <ul><li>Consider: </li></ul><ul><li>1. Evaluate areas of high mortality/morbidity, and conduct pilot studies : </li></ul><ul><li>in selected populations or localities; </li></ul><ul><li>use risk-based approach; </li></ul><ul><li>develop & test simple management guidelines </li></ul><ul><li>support and monitor implementation </li></ul>
  26. 26. Other considerations in the prevention of perinatal infections <ul><li>2. Focus on treatment and prevention of sexually transmitted infections (STIs) of women and their partners </li></ul><ul><li>3. Reduce risks of nosocomial infections by attending to “common sense / good hygiene “ practices: </li></ul><ul><ul><li>Hand-washing by all health care providers </li></ul></ul><ul><ul><li>Hospital infection control; clean wound care; safe infant feeding </li></ul></ul>
  27. 27. “ 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
  28. 28. Appendix 1:Prevention of perinatal infections: Suggested guidelines for prenatal care <ul><li>1. Evaluate at each visit risk-factors of mother and her sexual partner(s): </li></ul><ul><li>Sexual history, travel, occupation, recreational drug use </li></ul><ul><li>2. Depending on resources, “step-up” evaluation, from minimal to optimal :( @ first visit, then @ 34-36 weeks gestation) </li></ul><ul><li>Pelvic exam and urinalysis </li></ul><ul><li>Cervical smear: “wet prep”, Gram stain, other special stains </li></ul><ul><li>Cervical cultures or other diagnostic kit testing </li></ul><ul><li>Serologies: Syphilis, HIV </li></ul><ul><li>3. Treatment based on clinical findings, or according to laboratory findings. </li></ul>
  29. 29. Appendix 2: Prevention of Perinatal Infections: Suggested management at labor and delivery <ul><li>1. Review prenatal risk factors; complete prenatal evaluation if necessary or if feasible. </li></ul><ul><li>2. Consider empirical intra-partum antibiotic therapy if mother has any of the following risk factors: </li></ul><ul><li>History of multiple sexual partners or other risk factors </li></ul><ul><li>History of miscarriage or neonatal death due to infection </li></ul><ul><li>Pre-maturity ( <36 weeks-gestation) </li></ul><ul><li>Prolonged rupture of membranes (= or > 18 hours) </li></ul><ul><li>Fever, or obvious vaginal, pelvic or urinary tract infection </li></ul><ul><li>Toxemia; traumatic, septic delivery </li></ul><ul><li>3. Communicate clinical findings and treatment with pediatrician or family physician </li></ul>
  30. 30. Appendix 3: Intrapartum antibiotic regimens <ul><li>Intrapartum antibiotic administration means giving drugs as soon as possible during labor or after rupture of membranes and through delivery. </li></ul><ul><li>Useful drugs (IV or IM): </li></ul><ul><ul><li>Penicillin G 1-2 million units, q 4hr </li></ul></ul><ul><ul><li>Ampicillin 2gm loading, then 500mg to 1gm q 8hr </li></ul></ul><ul><ul><li>Cephalosporins ( many agents); clindamycin or erythromycin </li></ul></ul><ul><ul><li>Above drugs with or without aminoglycosides , q 24 hour dosing: </li></ul></ul><ul><ul><ul><li>kanamycin 10-15 mg/k; </li></ul></ul></ul><ul><ul><ul><li>gentamicin or tobramycin 7.5 mg/k </li></ul></ul></ul>
  31. 31. Appendix 4: Neonatal care immediately post-partum <ul><li>1. All neonates to receive eye prophylaxis; immuno-prophylaxis against HBV if available. </li></ul><ul><li>2. Infants born to mothers with risk factors should observed for at least 24-36 hours by trained personnel </li></ul><ul><li>3. Evaluate and treat at-risk infants if symptomatic . </li></ul>