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Bladon S, Ashiru-Oredope D, Cunningham N, Pate A, Martin GP, Zhong X, Gilham EL, Brown CS, Mirfenderesky M, Palin V, van Staa TP. Rapid systematic review on risks and outcomes of sepsis: the influence of risk factors associated with health inequalities. Int J Equity Health 2024; 23:34. [PMID: 38383380 PMCID: PMC10882893 DOI: 10.1186/s12939-024-02114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND AND AIMS Sepsis is a serious and life-threatening condition caused by a dysregulated immune response to an infection. Recent guidance issued in the UK gave recommendations around recognition and antibiotic treatment of sepsis, but did not consider factors relating to health inequalities. The aim of this study was to summarise the literature investigating associations between health inequalities and sepsis. METHODS Searches were conducted in Embase for peer-reviewed articles published since 2010 that included sepsis in combination with one of the following five areas: socioeconomic status, race/ethnicity, community factors, medical needs and pregnancy/maternity. RESULTS Five searches identified 1,402 studies, with 50 unique studies included in the review after screening (13 sociodemographic, 14 race/ethnicity, 3 community, 3 care/medical needs and 20 pregnancy/maternity; 3 papers examined multiple health inequalities). Most of the studies were conducted in the USA (31/50), with only four studies using UK data (all pregnancy related). Socioeconomic factors associated with increased sepsis incidence included lower socioeconomic status, unemployment and lower education level, although findings were not consistent across studies. For ethnicity, mixed results were reported. Living in a medically underserved area or being resident in a nursing home increased risk of sepsis. Mortality rates after sepsis were found to be higher in people living in rural areas or in those discharged to skilled nursing facilities while associations with ethnicity were mixed. Complications during delivery, caesarean-section delivery, increased deprivation and black and other ethnic minority race were associated with post-partum sepsis. CONCLUSION There are clear correlations between sepsis morbidity and mortality and the presence of factors associated with health inequalities. To inform local guidance and drive public health measures, there is a need for studies conducted across more diverse setting and countries.
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Affiliation(s)
- Siân Bladon
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Alexander Pate
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Glen P Martin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Xiaomin Zhong
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Ellie L Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester, M13 9WL, UK
| | - Tjeerd P van Staa
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
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Kinoshita T, Espino F, Bunagan R, Lim D, Daga C, Parungao S, Balderian A, Micu K, Laborera R, Basilio R, Inobaya M, Baquilod M, Dy M, Chiba H, Matsumoto T, Nakayama T, Kita K, Hirayama K. First malaria in pregnancy followed in Philippine real-world setting: proof-of-concept of probabilistic record linkage between disease surveillance and hospital administrative data. Trop Med Health 2024; 52:17. [PMID: 38331887 PMCID: PMC10851569 DOI: 10.1186/s41182-024-00583-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/20/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Although the Philippines targets malaria elimination by 2030, it remains to be a disease that causes considerable morbidity in provinces that report malaria. Pregnant women residing in endemic areas are a vulnerable population, because in addition to the risk of developing severe malaria, their pregnancy is not followed through, and the outcome of their pregnancy is unknown. This study determined the utility of real-world data integrated with disease surveillance data set as real-world evidence of pregnancy and delivery outcomes in areas endemic for malaria in the Philippines. METHODS For the period of 2015 to 2019, electronic data sets of malaria surveillance data and Ospital ng Palawan hospital admission log of pregnant women residing in the four selected barangays of Rizal, Palawan were merged using probabilistic linkage. The source data for record linkage were first and last names, birth date, and address as the mutual variable. The data used for characteristics of the pregnant women from the hospital data set were admission date, discharge date, admitting and final diagnosis and body weight on admission. From the malaria surveillance data these were date of consultation, and malaria parasite species. The Levenshtein distance formula was used for a fuzzy string-matching algorithm. Chi-square test, and Mann-Whitney U test were used to compare the means of the two data sets. RESULTS The prevalence of pregnant women admitted to the tertiary referral hospital, Ospital ng Palawan, was estimated to be 8.34/100 overall, and 11.64/100 from the four study barangays; that of malaria during pregnancy patients was 3.45/100 and 2.64/100, respectively. There was only one true-positive matched case from 238 women from the hospital and 54 women from the surveillance data sets. The overall Levenshstein score was 97.7; for non-matched cases, the mean overall score was 36.6 (35.6-37.7). The matched case was a minor who was hospitalized for severe malaria. The outcome of her pregnancy was detected from neither data set but from village-based records. CONCLUSIONS This proof-of-concept study demonstrated that probabilistic record linkage could match real-world data in the Philippines with further validation required. The study underscored the need for more integrated and comprehensive database to monitor disease intervention impact on pregnancy and its outcome in the Philippines.
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Affiliation(s)
- Takuya Kinoshita
- Department of Health Informatics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Fe Espino
- Department of Parasitology, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines.
| | - Raymart Bunagan
- Department of Parasitology, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines
| | - Dodge Lim
- National Tuberculosis Reference Laboratory, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines
| | - Chona Daga
- Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines
| | - Sabrina Parungao
- Department of Parasitology, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines
| | - Aileen Balderian
- Kilusang Ligtas Malaria, Provincial Health Office, Puerto Princesa City, Palawan, Philippines
| | - Katherine Micu
- Rural Health Unit, Punta Baja, Rizal, Palawan, Philippines
| | | | - Ramon Basilio
- National Tuberculosis Reference Laboratory, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines
| | - Marianette Inobaya
- Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Department of Health, Muntinlupa City, Philippines
| | - Mario Baquilod
- Center for Health Development MIMAROPA, Quezon City, Philippines
| | - Melecio Dy
- Ospital Ng Palawan, Puerto Princesa City, Palawan, Philippines
| | - Hitoshi Chiba
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Takehiro Matsumoto
- Department of Health Informatics, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Kiyoshi Kita
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Host-Defense Biochemistry, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Kenji Hirayama
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN) and Interfaculty Initiative of Planetary Health, Nagasaki University, Nagasaki, Japan
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3
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Mohn SF, Reimer R, Mar N, Katelieva A, Paquette V, Albert AYK, Roberts A, Tilley P, McClymont E, Ting J, Boucoiran I, Elwood C. Empiric antibiotics for peripartum bacteremia: A chart review from a quaternary Canadian centre. Int J Gynaecol Obstet 2024; 164:786-792. [PMID: 37658607 DOI: 10.1002/ijgo.15048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of empiric antibiotic protocols for peripartum bacteremia at a quaternary institution by describing incidence, microbial epidemiology, clinical source of infection, susceptibility patterns, and maternal and neonatal outcomes. METHODS Retrospective chart review of peripartum patients with positive blood cultures between 2010 and 2018. RESULTS The incidence of peripartum bacteremia was 0.3%. The most cultured organisms were Escherichia coli (51, 26.7%), Streptococcus spp. (52, 27.2%), and anaerobic spp. (35, 18.3%). Of the E. coli cases, 54.9% (28), 19.6% (10), and 19.6% (10) were resistant to ampicillin, first- and third-generation cephalosporins, respectively. Clinical sources of infection included intra-amniotic infection/endometritis (115, 67.6%), upper and/or lower urinary tract infection (23, 13.5%), and soft tissue infection (8, 4.7%). Appropriate empiric antibiotics were prescribed in 137 (83.0%) cases. There were 7 ICU admissions (4.2%), 18 pregnancy losses (9.9%), 9 neonatal deaths (5.5%), and 6 cases of neonatal bacteremia (3.7%). CONCLUSION Peripartum bacteremia remains uncommon but associated with maternal morbidity and neonatal morbidity and mortality. Current empiric antimicrobial protocols at our site remain appropriate, but continuous monitoring of antimicrobial resistance patterns is critical given the presence of pathogens resistant to first-line antibiotics.
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Affiliation(s)
- Sarah F Mohn
- UBC Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Renee Reimer
- UBC Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Nicole Mar
- UBC Faculty of Medicine, Vancouver, British Columbia, Canada
| | | | - Vanessa Paquette
- BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | | | - Ashley Roberts
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Peter Tilley
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Elisabeth McClymont
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph Ting
- UBC Faculty of Medicine, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Isabelle Boucoiran
- Mother and Child Infectious Disease Centre, CHU Sainte, Justine, Montreal, Quebec, Canada
- Department of Obstetrics and Gynecology and School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Chelsea Elwood
- UBC Faculty of Medicine, Vancouver, British Columbia, Canada
- Women's Health Research Institute, Vancouver, British Columbia, Canada
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
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Shah NM, Charani E, Ming D, Cheah FC, Johnson MR. Antimicrobial stewardship and targeted therapies in the changing landscape of maternal sepsis. JOURNAL OF INTENSIVE MEDICINE 2024; 4:46-61. [PMID: 38263965 PMCID: PMC10800776 DOI: 10.1016/j.jointm.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 01/25/2024]
Abstract
Pregnant and postnatal women are a high-risk population particularly prone to rapid progression to sepsis with significant morbidity and mortality worldwide. Moreover, severe maternal infections can have a serious detrimental impact on neonates with almost 1 million neonatal deaths annually attributed to maternal infection or sepsis. In this review we discuss the susceptibility of pregnant women and their specific physiological and immunological adaptations that contribute to their vulnerability to sepsis, the implications for the neonate, as well as the issues with antimicrobial stewardship and the challenges this poses when attempting to reach a balance between clinical care and urgent treatment. Finally, we review advancements in the development of pregnancy-specific diagnostic and therapeutic approaches and how these can be used to optimize the care of pregnant women and neonates.
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Affiliation(s)
- Nishel M Shah
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Damien Ming
- Department of Infectious Diseases, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
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Radu VD, Costache RC, Onofrei P, Antohi L, Bobeica RL, Linga I, Tanase-Vasilache I, Ristescu AI, Murgu AM, Miftode IL, Stoica BA. Factors Associated with Increased Risk of Urosepsis during Pregnancy and Treatment Outcomes, in a Urology Clinic. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1972. [PMID: 38004021 PMCID: PMC10673142 DOI: 10.3390/medicina59111972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Urosepsis is a significant cause of maternal and fetal mortality. While certain risk factors for urinary tract infections (UTIs) in pregnant women are well established, those associated with an elevated risk of urosepsis in pregnant women with upper UTIs remain less defined. This study aims to identify factors linked to an increased risk of urosepsis and examine urologic treatment outcomes in such cases. Materials and Methods: We conducted a retrospective analysis on 66 pregnant women diagnosed with urosepsis over a nine-year period. A control group included 164 pregnant women with upper UTIs, excluding urosepsis, admitted during the same timeframe. This study highlights factors potentially contributing to urosepsis risk, including comorbidities like anemia, pregnancy-related hydronephrosis or secondary to reno-ureteral lithiasis, prior UTIs, coexisting urological conditions, and urologic procedures. Outcomes of urologic treatments, hospitalization duration, obstetric transfers due to fetal distress, and complications associated with double-J catheters were analyzed. Results: Pregnant women with urosepsis exhibited a higher prevalence of anemia (69.7% vs. 50.0%, p = 0.006), 2nd-3rd grade hydronephrosis (81.8% vs. 52.8%, p = 0.001), and fever over 38 °C (89.4% vs. 42.1%, p = 0.001). They also had a more intense inflammatory syndrome (leukocyte count 18,191 ± 6414 vs. 14,350 ± 3860/mmc, p = 0.001, and C-reactive protein (CRP) 142.70 ± 83.50 vs. 72.76 ± 66.37 mg/dL, p = 0.001) and higher creatinine levels (0.77 ± 0.81 vs. 0.59 ± 0.22, p = 0.017). On multivariate analysis, factors associated with increased risk for urosepsis were anemia (Odds Ratio (OR) 2.622, 95% CI 1.220-5.634), 2nd-3rd grade hydronephrosis (OR 6.581, 95% CI 2.802-15.460), and fever over 38 °C (OR 11.612, 95% CI 4.804-28.07). Regarding outcomes, the urosepsis group had a higher rate of urological maneuvers (87.9% vs. 36%, p = 0.001), a higher rate of obstetric transfers due to fetal distress (22.7% vs. 1.2%, p = 0.001), and migration of double-J catheters (6.1% vs. 0.6%, p = 0.016), but no maternal fatality was encountered. However, they experienced the same rate of total complications related to double-J catheters (19.69% vs. 12.80%, p > 0.05). The pregnant women in both groups had the infection more frequently on the right kidney, were in the second trimester and were nulliparous. Conclusions: Pregnant women at increased risk for urosepsis include those with anemia, hydronephrosis due to gestational, or reno-ureteral lithiasis, and fever over 38 °C. While the prognosis for pregnant women with urosepsis is generally favorable, urological intervention may not prevent a higher incidence of fetal distress and the need for obstetric transfers compared to pregnant women with uncomplicated upper UTIs.
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Affiliation(s)
- Viorel Dragos Radu
- Department of Urology, Faculty of Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania; (V.D.R.); (R.C.C.)
- Urological Department, “C.I. Parhon” University Hospital, 700115 Iasi, Romania; (R.L.B.); (I.L.)
| | - Radu Cristian Costache
- Department of Urology, Faculty of Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania; (V.D.R.); (R.C.C.)
- Urological Department, “C.I. Parhon” University Hospital, 700115 Iasi, Romania; (R.L.B.); (I.L.)
| | - Pavel Onofrei
- Department of Morpho-Functional Sciences II, Faculty of Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania
- Urological Department, Elytis Hope Hospital, 700010 Iasi, Romania
| | - Liviu Antohi
- Department of Anaesthesia and Intensive Care, “C.I. Parhon” University Hospital, 700115 Iasi, Romania;
| | - Razvan Lucian Bobeica
- Urological Department, “C.I. Parhon” University Hospital, 700115 Iasi, Romania; (R.L.B.); (I.L.)
| | - Iacov Linga
- Urological Department, “C.I. Parhon” University Hospital, 700115 Iasi, Romania; (R.L.B.); (I.L.)
| | - Ingrid Tanase-Vasilache
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania
| | - Anca Irina Ristescu
- Department of Anaesthesia and Intensive Care, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania;
| | - Alina-Mariela Murgu
- Department of Mother and Child Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania;
| | - Ionela-Larisa Miftode
- Department of Infectious Diseases, Faculty of Medicine, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania
- St. Parascheva Clinical Hospital of Infectious Diseases, 700116 Iasi, Romania
| | - Bogdan Alexandru Stoica
- Department of Biochemistry, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania;
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Shields AD, Plante LA, Pacheco LD, Louis JM. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis. Am J Obstet Gynecol 2023; 229:B2-B19. [PMID: 37236495 DOI: 10.1016/j.ajog.2023.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice).
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7
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Ozarslan N, Gaw SL, Cassidy AG, Caughey AB. Predictors of antepartum maternal sepsis and effects on neonatal outcomes: a population-based cohort study. J Perinatol 2023; 43:752-757. [PMID: 37217673 DOI: 10.1038/s41372-023-01696-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 04/12/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023]
Abstract
OBJECTIVE To examine the relationship between maternal sepsis, type of infection, and short-term neonatal outcomes. STUDY DESIGN We conducted a retrospective cohort study investigating pregnancies between 2005 and 2008 in California with antepartum maternal sepsis diagnosis. Comparisons were made between sepsis cases and controls, using chi-squared or Fisher's exact test. Multivariable logistic regression was performed, adjusting for maternal characteristics. RESULTS Several maternal characteristics were associated with increased odds of maternal sepsis. Both obstetric and non-obstetric infections were associated with maternal sepsis (p < 0.001). The positive predictive value of maternal sepsis for preterm delivery was 55.03%. Neonates born to maternal sepsis patients had a higher risk of developing neonatal complications including neonatal shock. CONCLUSION Maternal sepsis was associated with neonatal complications. Efforts to reduce maternal sepsis may improve neonatal outcomes. Further studies are required for a better understanding of these associations and whether prevention or more rapid diagnosis and treatment can lower these risks.
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Affiliation(s)
- Nida Ozarslan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Stephanie L Gaw
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Arianna G Cassidy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA.
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8
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Liu P, Zhang X, Wang X, Liang Y, Wei N, Xiao Z, Li T, Zhe R, Zhao W, Fan S. Maternal sepsis in pregnancy and the puerperal periods: a cross-sectional study. Front Med (Lausanne) 2023; 10:1126807. [PMID: 37261123 PMCID: PMC10228646 DOI: 10.3389/fmed.2023.1126807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/17/2023] [Indexed: 06/02/2023] Open
Abstract
Maternal sepsis is a life-threatening condition and ranks among the top five causes of maternal death in pregnancy and the postpartum period. Herein, we conducted a retrospective study on sepsis cases to explain the related risk factors by comparing them with bloodstream infection (BSI) and control maternities. In total, 76 sepsis cases were enrolled, and 31 BSI and 57 maternal cases of the same age but with neither sepsis nor BSI were set as controls. Genital tract infection (GTI) and pneumonia were the two most common infection sources in both sepsis (22 cases, 29% and 29 cases, 38%) and BSI cases (18 cases, 58% and 8 cases, 26%). Urinary tract infection (UTI)/pyelonephritis (9 cases, 12%) and digestive infection cases (11 cases, 14%) only existed in the sepsis group. Significantly different infection sources were discovered between the sepsis-death and sepsis-cure groups. A higher proportion of pneumonia and a lower proportion of GTI cases were present in the sepsis-death group (17 cases, 45% pneumonia and 9 cases, 24% GTI) than in the sepsis-cure group (12 cases, 32% pneumonia and 13 cases, 34% GTI). In addition, although gram-negative bacteria were the dominant infectious microorganisms as previously reported, lower proportion of gram-negative bacteria infectious cases in sepsis (30 cases, 50%) and even lower in sepsis-death group (14 cases, 41%) was shown in this study than previous studies. As expected, significantly greater adverse maternal and fetal outcomes, such as higher maternal mortality (26.3% vs. 0% vs. 0%), higher fetal mortality (42.2% vs. 20.8% vs. 0%), earlier gestational age at delivery (26.4 ± 9.5 vs. 32.3 ± 8.1 vs. 37.7 ± 4.0) and lower newborn weight (1,590 ± 1287.8 vs. 2859.2 ± 966.0 vs. 3214.2 ± 506.4), were observed in the sepsis group. This study offered some potential pathogenesis and mortality risk factors for sepsis, which may inspire the treatment of sepsis in the future.
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Affiliation(s)
- Ping Liu
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xiaowei Zhang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
| | - Xinxin Wang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
| | - Yiheng Liang
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Nan Wei
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Zhansong Xiao
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Ting Li
- Department of Obstetrics and Gynecology, Suzhou Municipal Hospital, Suzhou, China
| | - Ruilian Zhe
- Department of Obstetrics, Shenzhen People’s Hospital, Shenzhen, China
| | - Weihua Zhao
- Department of Obstetrics, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Shangrong Fan
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
- Shenzhen Key Laboratory of Gynecological Diagnostic Technology Research, Peking University Shenzhen Hospital, Shenzhen, China
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Stephens AJ, Lee KH, Barton JR, Chauhan SP, Baker AL, Sibai BM. Development of the Sepsis-Associated Adverse Outcomes in Pregnancy Score. Am J Perinatol 2023; 40:128-136. [PMID: 35750320 DOI: 10.1055/a-1884-1001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE This study aimed to develop and evaluate a scoring system-called the Sepsis-Associated Adverse Outcomes in Pregnancy (SAAP) Score-to identify individuals with maternal infection that have composite maternal adverse outcomes (CMAO). STUDY DESIGN Using the International Classification of Disease codes, we identified pregnant and postpartum (up to 6 weeks after birth) individuals admitted at our center with a primary diagnosis of infection. The primary outcome was CMAO which included any of the following: maternal intensive care unit admission, surgical intervention, vasopressor use, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, dialysis, organ failure, venous thromboembolism, or maternal death. Regularized logistic regression was used to identify variables that best discriminate CMAO status. Variables were chosen for inclusion following evaluation of statistical and clinical significance. Model performance was evaluated using area under the curve (AUC) with 95% confidence intervals (CIs), sensitivity, specificity, and predictive values. RESULTS Of the 23,235 deliveries during the study period, 227 (0.9%) individuals met inclusion criteria and among them CMAO occurred in 39.2% (95% CI: 33.1-45.7%). The SAAP score consisted of six variables (white blood cell count, systolic blood pressure, respiratory rate, heart rate, lactic acid, and abnormal diagnostic imaging) with scores ranging from 0 to 11 and a score of ≥7 being abnormal. An abnormal SAAP score had an AUC of 0.80 (95% CI: 0.74-0.86) for CMAO. The sensitivity and specificity of the SAAP score for CMAO was 0.71 (95% CI: 0.60-0.80) and 0.73 (95% CI: 0.64-0.80), respectively. The positive predictive value was 0.62 (95% CI: 0.52-0.72) and negative predictive value was 0.79 (95% CI: 0.71-0.86). CONCLUSION Pending external validation, the sixth variable SAAP score may permit early recognition of pregnant and postpartum individuals with infection who are likely to develop adverse maternal outcomes. KEY POINTS · Sepsis is a leading cause of maternal morbidity and mortality.. · Early recognition improves maternal sepsis outcomes.. · The SAAP score may permit early recognition of maternal adverse outcomes due to infection..
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Affiliation(s)
- Angela J Stephens
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Kyung H Lee
- Center for Clinical Research and Evidence-Based Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - John R Barton
- Division of Maternal-Fetal Medicine, Baptist Health Lexington, Lexington, Kentucky
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Andrea L Baker
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Baha M Sibai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
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Maternal Sepsis in Italy: A Prospective, Population-Based Cohort and Nested Case-Control Study. Microorganisms 2022; 11:microorganisms11010105. [PMID: 36677397 PMCID: PMC9865500 DOI: 10.3390/microorganisms11010105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023] Open
Abstract
Maternal sepsis represents a leading cause of mortality and severe morbidity worldwide. In Italy, it is the second cause of direct maternal mortality. Delay in recognition and treatment initiation are the drivers of sepsis-associated adverse outcomes. Between November 2017 and October 2019, the Italian Obstetric Surveillance System coordinated a prospective population-based study on maternal sepsis occurring before or after childbirth from 22 weeks' gestation onward and up to 42 days following the end of pregnancy. A nested 1:2 matched case-control study on postpartum sepsis was also performed. Maternal sepsis was diagnosed for the presence of suspected or confirmed infection alongside signs or symptoms of organ failure. The aim of this study was to assess maternal sepsis incidence and its associated risk factors, management, and perinatal outcomes. Six Italian regions, covering 48.2% of the national births, participated in the project. We identified an incidence rate of 5.5 per 10,000 maternities (95% CI 4.80-6.28). Seventy percent of patients had a low education level and one third were foreigners with a language barrier. Genital, respiratory, and urinary tract infections were the predominant sources of infection; the majority of cases was caused by E. coli and polymicrobial infections. The presence of vascular and indwelling bladder catheters was associated with a nine-fold increased risk of postpartum sepsis. There were no maternal deaths, but one fourth of women experienced a serious adverse event and 28.3% required intensive care; 1.8% of newborns died. Targeted interventions to increase awareness of maternal sepsis and its risk factors and management should be promoted.
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