The document discusses strategies for preventing perinatal infections. It reviews major bacterial and viral infections, risk factors, diagnostic and treatment approaches, and examples of effective prevention measures. Key prevention strategies include prenatal screening and treatment, vaccination programs, and guidelines for managing at-risk pregnancies and deliveries. National recommendations and monitoring have significantly reduced rates of certain infections.

1. 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

2. Spectrum of infant infections from maternal sources

3. 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

4. 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

5. Major bacterial perinatal infections

6. Major viral perinatal infections

7. 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

8. 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

9. 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)

10. Incidence of hepato-cellular-carcinoma in Taiwanese children since routine HBV immunization in 1984

11. 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.

12. 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

13. 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.

14. 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)

15. Antibiotics for pre-term, pre-labor rupture of membrane: Results of the ORACLES I&II studies

16. 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.

17. 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)

18. 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

19. 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

20. 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)

21. 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

22. 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

23. 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 ?

24. Investing in resources Material resources: Infrastructure Adequate and affordable technology and therapeutics Human resources: Staff training and support

25. 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

26. 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

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. 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.

29. 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

30. 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

31. 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 .