Potential consequences of widespread antepartal use of ampicillin

doi:10.1016/S0002-9378(98)70182-6

American Journal of Obstetrics and Gynecology

Volume 179, Issue 4, October 1998, Pages 879-883

Presented at the Eighteenth Annual Meeting of the Society of Perinatal Obstetricians, Miami, Florida, February 2-7, 1998.

https://doi.org/10.1016/S0002-9378(98)70182-6 Get rights and content

Abstract

Objective: Recommendations for the use of antenatal antibiotics in obstetrics have increased in the past few years, especially for prophylaxis against group B streptococci, for prolongation of the latency time in patients with preterm premature rupture of the membranes, and as an adjuvant treatment in preterm labor. Our objective was to determine whether the use of antenatal ampicillin affects the incidence of and resistance of early-onset neonatal sepsis with organisms other than group B streptococci. Study Design: A prospective cohort study was performed between January 1, 1991, and December 31, 1996. Every case of blood culture–proven neonatal sepsis was prospectively surveyed. The type of bacteria isolated, drug resistance, antenatal antibiotic use and treatment indication, gestational age at delivery, and other antenatal and outcome variables were gathered. Early-onset neonatal sepsis was defined as disease onset within 7 days after birth. Results: A total of 42 cases of early-onset neonatal sepsis among 29,897 neonates delivered were found during the 6-year period. Of these, 15 cases were due to group B streptococci and 27 were the result of non–group B streptococcal organisms (21 gram-negative rods and 6 gram-positive cocci). Among the 27 non–group B streptococcal cases, 15 mothers had received antenatal ampicillin and 13 of the 15 bacterial isolates from these neonates (87%) were resistant to ampicillin, versus only 2 ampicillin-resistant isolates (17%) among the 12 cases in which no antenatal antibiotics were administered (P = .0004). Of the 15 mothers who were treated with ampicillin, 13 received more than 1 dose. In evaluating each year of the study, the overall administration of antibiotics to pregnant women in the antenatal period increased from <10% in 1991 to 16.9% in 1996. The incidence of early-onset neonatal sepsis with group B streptococci decreased during this time, whereas the incidence of early-onset sepsis with non–group B streptococcal organisms, especially Escherichia coli, increased. Conclusions: The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non–group B streptococcal organisms that are resistant to ampicillin. At this time penicillin G, rather than ampicillin, is therefore recommended for prophylaxis against group B streptococci. In addition, future studies are needed to determine whether alternate approaches, such as immunotherapy or vaginal washing, could be of benefit. (Am J Obstet Gynecol 1998;179:879-83.)

Section snippets

Material and methods

A prospective cohort study was performed from January 1, 1991, through December 31, 1996. Every case of blood culture–proven neonatal sepsis from the nursery at Long Beach Memorial Women’s Hospital was prospectively surveyed. Early-onset neonatal sepsis was defined as a positive blood culture result for a neonate with clinical symptoms at <7 days after birth. This study was reviewed and approved by the institution’s review board.

Maternal data collected included use of antenatal antibiotics,

Results

During the 6-year study period, 42 cases of documented, blood culture–proven early-onset neonatal sepsis occurred. Group B streptococci were the bacteria involved in 15 of the 42 cases; the remaining 27 cases were the result of non–group B streptococcal organisms. The basic bacterial category of the 27 non–group B streptococcal cases consisted of 21 gram-negative rods and 6 gram-positive cocci.

Among the 27 non–group B streptococcal cases, 15 mothers received antenatal ampicillin, and 13 of the

Comment

Although many different problems can develop from the use of antibiotics, 3 basic concerns are most often cited. These involve the development of resistance by the bacteria to a specific type of antibiotic, the selection of resistant organisms, and reactions, such as colitis, allergic reactions, and anaphylaxis, to the specific antibiotic employed.1, 2 In the use of antibiotics in the field of obstetrics, both the mother and the neonate may suffer consequences if the short course of antibiotic

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Cited by (171)

Prevalence and treatment of group B streptococcus colonization based on risk factors versus intrapartum culture screening
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
To estimate the prevalence of group B streptococcus at onset of labor and to compare the accuracy of intrapartum antibiotic prophylaxis based on a risk factor strategy versus an intrapartum screening.
In this cross-sectional study, 700 women referred for intended vaginal delivery were tested for group B streptococcus at onset of labor by gold standard culture in vaginal and rectal swabs. The results were blinded, and intrapartum antibiotic prophylaxis was given to women with risk factors for group B streptococcus infection: previous neonatal group B streptococcus infection, group B streptococcus in urine and/or vagina in current pregnancy, gestational age <36 + 0 weeks, temperature ≥38.0 °C or rupture of membranes ≥18 h.
Of 642 women, who delivered within three days of specimen collection, 170 (26.5%) received benzylpenicillin as intrapartum antibiotic prophylaxis based on risk factors. The prevalence of group B streptococcus at onset of labor was 17.8% (114/642), with 62 women positive for group B streptococcus in both the vagina and rectum, 12 in the vagina only and 40 in rectum only.
Intrapartum antibiotic prophylaxis was administered correctly in 31.6% (36/114) of GBS positive women at time of delivery and 78.8% (134/170) of women who received antibiotics were actually GBS negative. The positive predictive value of intrapartum antibiotic prophylaxis based on risk factors was 21.2%. The sensitivity was 31.6% and the specificity was 74.6%.
The accuracy of predicting maternal group B streptococcus infection from risk factors is low. Intrapartum group B streptococcus diagnostics is more precise and will not increase the overall use of intrapartum antibiotic prophylaxis.
Enterobacteria vaginal colonization among patients with preterm premature rupture of membranes from 24 to 34 weeks of gestation and neonatal infection risk
2019, Journal of Gynecology Obstetrics and Human Reproduction
Premature rupture of membranes (PROM) increases the neonatal morbidity and mortality, because of its association with a high risk of prematurity and infection. The group B streptococcus (GBS) prophylaxis using amoxicillin doesn’t seem to be adapted to the emergence of new bacteria found in vaginal samples (VS). Our study aim was to assess, for PROM occurring at 23–34 weeks’ gestation (WG), if the presence of ampicillin-resistant enterobacteria in the vaginal microbiome is predictive of an increased risk of early-onset neonatal infection.
We conducted a prospective, observational, single-center study at the Nice Academic Hospital (level 3 maternity ward), between March 16, 2014 and May 3, 2015, that evaluated patients with preterm PROM (24–34 WG). Two groups were constituted according to the VS bacteria isolates and the amoxycillin-resistant enterobacteria found. Two groups of newborns were constituted depending on the suspicion of perinatal maternal-fetal bacterial infection (MFI). An intent-to-treat analysis was performed.
Among the 67 patients included, 12 newborns presented a strong MFI suspicion, 83% of which were associated to the group of patients with untreated or amoxycillin-resistant enterobacteria VS isolates.
Our study showed that vaginal colonization of untreated or amoxycillin-resistant enterobacteria constitutes a major risk factor of neonatal infection.
Management of preterm labor
2016, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Définir la prise en charge de la menace d’accouchement prématuré (MAP).
La recherche bibliographique a été effectuée à l’aide des bases de données informatiques Medline et de la Cochrane Library sur une période allant de 1969 à mars 2016.
La NFS peut être utile pour dépister une hyperleucocytose en cas d’hospitalisation pour MAP. Son utilisation n’est pas systématique (accord professionnel). Le dépistage de l’infection urinaire par un examen cytobactériologique des urines doit être systématique et un traitement antibiotique doit être réalisé en cas de colonisation bactérienne ou d’infection urinaire pour une durée de 4 à 7 jours (grade A). Le prélèvement vaginal est utile pour dépister un streptocoque B et fait prescrire un traitement antibiotique pendant le travail en cas de positivité (grade A). L’antibiothérapie systématique n’est pas recommandée en cas de MAP (grade A). L’hospitalisation prolongée ne réduit pas le risque d’accouchement prématuré (NP3) et n’est pas recommandée (grade B). Le repos au lit strict ne réduit pas le risque d’accouchement prématuré (NP3), majore le risque thromboembolique (NP3), et n’est pas recommandé (grade C). Après une hospitalisation pour MAP, une visite régulière par un soignant à domicile pourrait être utile lorsque les patientes appartiennent à un milieu précaire ou sont en situation de vulnérabilité psychologique (accord professionnel). Le bénéfice de la réalisation répétée d’une tocographie externe dans les suites d’une hospitalisation pour MAP n’est pas démontré (NP3). Sa réalisation n’est pas recommandée à titre systématique en surveillance à domicile au décours d’une MAP (grade C).
La prise en charge de la MAP doit être individualisée, faire rechercher et traiter une infection et éviter les hospitalisations ou repos en décubitus prolongés.
To define the management of preterm labor (MAP).
The literature search was conducted using computer databases Medline and the Cochrane Library for a period from 1969 to March 2016.
Leukocytosis screening may be useful in case of hospitalization for Preterm labor (PTL). Its use is not routine (professional consensus). Screening for urinary tract infection by urine culture should be systematic and antibiotic treatment should be performed in cases of bacterial colonization or urinary tract infection for a period of 7 days (grade A). The vaginal swab is useful to detect a strep B and was prescribed antibiotics during labor if positive (grade A). Routine antibiotic therapy is not recommended in case of PTL (grade A). Prolonged hospitalization does not reduce the risk of preterm delivery (NP3) and is not recommended (grade B). Bed rest does not reduce the risk of PTL (NP3), increases the risk of thromboembolism (NP3), and is not recommended (grade C). After hospitalization for PTL, a regular visit by a caregiver at home may be helpful when patients belong to a precarious environment or are psychologically vulnerable (Professional consensus). The benefit of monitoring home uterine activity repeated in the aftermath of hospitalization for PTL is not shown (NP3). It is not recommended to follow-up uterine activity systematically after hospitalization for PTL (grade C).
The management of PTL should be individualized, include searching and treatment of infection and avoid prolonged hospitalization or bed rest.
Alarming regional differences in prevalence and antimicrobial susceptibility of group B streptococci in pregnant women: A systematic review and meta-analysis
2016, Journal of Global Antimicrobial Resistance
Group B streptococcus (GBS) is a leading cause of morbidity and mortality in infants. This study aimed to estimate the prevalence, antimicrobial susceptibility and serotype distribution of GBS isolates in pregnant women worldwide. Studies were identified by searching several English and Chinese electronic databases and reviewing relevant articles. Effect estimates were pooled using fixed- or random-effects models. Twenty-eight studies were included in this systematic review. The pooled prevalence of GBS carriage in pregnant women was 10%, being significantly lower in Asia (7%) compared with non-Asian countries (19%). Most of the GBS isolates were susceptible to penicillin, ampicillin and vancomycin. The pooled rates of resistance to erythromycin and clindamycin were 25% and 27%, respectively, and were notably higher in Asia compared with non-Asian countries. The pooled rate of resistance to tetracycline was 73%, with similar high levels in Asia and non-Asian countries. The most prevalent serotypes of GBS isolates were serotypes III, V and Ia. These findings suggest that penicillin is still the first choice for intrapartum prophylaxis of GBS diseases and support growing concern about antibiotic use (especially erythromycin and clindamycin) in Asia.
Premature Rupture of the Membranes
2016, Obstetrics: Normal and Problem Pregnancies
A case study regarding the use of antibiotic therapies for the treatment of preterm premature rupture of fetal membranes, and emergence of antibiotic resistant bacteria
2015, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Cette étude a comparé deux protocoles de prise en charge des ruptures prématurées des membranes (RPMAT) différant sur le type et la durée d’antibiothérapie.
L’antibiothérapie de la RPMAT à Fort-de-France (céphalosporine de 1^re génération pendant 7 jours) et à Pointe-à-Pitre (amoxicilline jusqu’à l’accouchement) a été comparée rétrospectivement pendant cinq ans. L’issue principale était l’apparition de bacilles Gram négatif (BGN) dans les prélèvements bactériologiques maternels ou néonataux chez les RPMAT ayant une latence ≥ quatre jours.
Nous avons comparé 38 cas de RPMAT en Martinique à 52 cas en Guadeloupe. Nous avons observé une sélection des BGN résistants au cours du suivi dans chaque centre. Elle est liée à la durée de latence dans les deux centres. L’apparition d’un BGN apparaît aussi liée à la durée d’antibiothérapie en cas de traitement long. Les durées de latences, les termes d’accouchement et la morbi-mortalité néonatale ou maternelle sont identiques.
Nous avons observé une apparition importante de BGN lors du traitement des RPMAT, d’autant plus que la latence rupture–accouchement et que le traitement sont longs.
The objective of this retrospective study is to compare two types of antimicrobial management used to treat premature rupture of membranes in pregnancy. This study evaluates both duration and the type of antibiotic therapy used for treatment.
The antimicrobials used to treat premature rupture of membranes include a first generation cephalosporin in one group and amoxicillin in the other group. Cephalosporin was used over a 7-day period to treat 38 cases, whereas amoxicillin was used through delivery in 52 cases. Emergence of multidrug-resistant Gram negative bacteria (GNB) on maternal of neonatal sampling was the primary outcome.
Emergence of antibiotic resistant GNB can be seen under both antibiotic regimens and appears to be linked to the duration of latency, and to duration of antibiotic treatment. Other outcomes (duration of latency period, gestational age at delivery, maternal and neonatal complications) were similar in both groups.
Antibiotic treatment in PPROM favors a selection of GNB. This emergence is positively linked with the duration of latency between rupture of membranes and delivery and with the length of antibiotic administration. The extension of antibiotherapy does not alter other maternal or neonatal parameters.

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^☆: From University of California, Irvine,^a Long Beach Memorial Women’s Hospital,^b St Joseph’s Hospital,^c the Department of Obstetrics and Gynecology, Medical College of Wisconsin,^d Long Beach Memorial Miller Children’s Hospital.^e

^☆☆: Supported in part by the Memorial Medical Center Foundation, Long Beach, California. Research performed at Long Beach Memorial Women’s Hospital, Long Beach, California.

^★: Reprint requests: Craig V. Towers, MD, PO Box 8400, Huntington Beach, CA 92615-8400.

^★★: 0002-9378/98 $5.00 + 0 6/6/92025

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Potential consequences of widespread antepartal use of ampicillin☆,☆☆,★,★★

Abstract

Section snippets

Material and methods

Results

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Prevention of perinatal group B streptococcal disease: a public health perspective

MMWR Morb Mortal Wkly Rep