Compared perinatal outcomes of two prophylactic antibiotic regimens for preterm premature rupture of membranes: a randomized controlled trial

Antibiotic Regimens for the Management of Preterm Prelabour Rupture of Membranes: A Multicenter Retrospective Cohort Study

OBJECTIVE

Evolving bacterial ecology and resistance warrant re-evaluation of traditional antibiotic regimens for prelabour premature rupture of membranes (PPROM). This study aimed to compare delivery within 7 days of PPROM and overall latency according to different antibiotic regimens. Secondary objectives were to compare adverse maternal and neonatal outcomes.

METHODS

This multicenter retrospective study utilized data from five Canadian hospitals from 2016-2022. Singleton pregnancies with PPROM at 18-34 weeks of gestation were included. Cases were divided into four groups based on antibiotic regimen administered, and outcomes were compared using logistic and linear regression analyses, controlling for gestational age at PPROM.

RESULTS

Of 669 PPROM cases, 50% received ampicillin/amoxicillin and macrolide, and the remainder received macrolide only (30%), macrolide and other (3%), and non-macrolide (17%) regimens. "Macrolide-only" was associated with a significantly shorter latency compared to "ampicillin/amoxicillin with macrolide" [adjusted odds ratio (aOR) for latency ≤7 days 1.9, 95% confidence interval (CI) (1.3, 2.8); and adjusted relative mean overall latency -6.7 days, 95% CI (-9.3, -4.1)]. Compared to other regimens, "macrolide-only" was associated with higher rates of maternal clinical and histological chorioamnionitis (37% vs. 14%-25%, P = 0.001, and 74% vs. 52%-61%, P < 0.001, respectively) and neonatal intraventricular hemorrhage (23% vs. 11%-13%, P = 0.009). Among cases of neonatal bacteremia, ampicillin resistance was frequent (11/19; 58%).

CONCLUSION

Macrolide alone is inferior to ampicillin/amoxicillin with a macrolide in prolonging pregnancy and preventing adverse outcomes; therefore, its use should be strongly reconsidered in women with penicillin allergy. Broader-spectrum regimens warrant further clinical investigation.

OBJECTIF

L'évolution de l'écologie bactérienne et de la résistance aux antibiotiques justifie la réévaluation des antibiothérapies traditionnelles pour la rupture prématurée des membranes avant terme (RPMAT). Cette étude visait à comparer l'accouchement dans les 7 jours suivant la RPMAT et la période de latence globale en fonction de différentes antibiothérapies. Les objectifs secondaires étaient de comparer les issues maternelles et néonatales défavorables. MéTHODES: Cette étude rétrospective multicentrique a utilisé les données de 5 hôpitaux canadiens pour la période de 2016 à 2022. Les grossesses monofœtales avec une RPMAT à un âge gestationnel entre 18 et 34 semaines ont été incluses. Les cas ont été divisés en quatre groupes en fonction de l'antibiothérapie administrée, puis les résultats ont été comparés à l'aide d'analyses de régression logistique et linéaire, en tenant compte de l'âge gestationnel au moment de la RPMAT. RéSULTATS: Sur 669 cas de RPMAT, 50 % des patientes ont reçu une combinaison d'ampicilline-amoxicilline et d'un macrolide et les autres ont reçu un macrolide seul (30 %), un macrolide combiné à un autre agent (3 %) ou une antibiothérapie sans macrolide (17 %). L'option « macrolide seul » a été associée à une période de latence significativement plus courte que l'option « combinaison d'ampicilline-amoxicilline et d'un macrolide » (rapport de cotes ajusté [RCa] pour une période de latence ≤ 7 jours : 1,9; intervalle de confiance [IC] à 95 % : 1,3-2,8; et durée de latence globale moyenne relative ajustée de -6,7 jours; IC à 95 % : -9,3 à -4,1). Par rapport aux autres antibiothérapies, l'option « macrolide seul » a été associée à des taux plus élevés de chorioamnionite clinique ou histologique maternelle (clinique : 37 % p/r à 14-25 %, p = 0,001; histologique : 74 % p/r à 52-61 %, p < 0,001) et d'hémorragie intraventriculaire néonatale (23 % p/r à 11-13 %, p = 0,009). Dans les cas de bactériémie néonatale, la résistance à l'ampicilline était fréquente (11/19; 58 %).

CONCLUSION

Le macrolide seul est inférieur à la combinaison d'ampicilline-amoxicilline et d'un macrolide pour ce qui est de la prolongation de la grossesse et de la prévention des issues défavorables; par conséquent, son utilisation doit être fortement reconsidérée chez les femmes allergiques à la pénicilline. Des analyses cliniques supplémentaires sur les antibiothérapies à large spectre seraient justifiées.

Significance of cervical secretion culture in predicting maternal and fetal outcome in pregnant women with premature rupture of membranes: a retrospective cohort study

Background: To investigate the clinical value of cervical secretion culture in pregnant women with premature rupture of membranes (PROM) in predicting maternal and fetal outcomes. Methods: We retrospectively reviewed clinical records of pregnant women who underwent obstetric examination and delivered in Fujian Maternal and Child Healthcare from December 2013 to December 2016. Pregnant women with a clear diagnosis of PROM, who underwent cervical secretion culture immediately after hospital admission were selected for the study. The primary outcome was the occurrence of chorioamnionitis. The secondary outcome was neonatal admission to the neonatal intensive care unit (NICU). Correlation between maternal and fetal outcomes and the results of the cervical secretion culture was analyzed by one-way analysis and multifactorial analysis, respectively. The predictive efficacy of cervical secretion culture was evaluated using receiver operating characteristic curve (ROC), area under the curve (AUC) and the integrated discrimination improvement (IDI). Results: A total of 7,727 pregnant women with PROM were included in the study. Of them, 1812 had positive cervical secretion cultures (635 positive for mycoplasma infection, 475 for bacterial, 637 for fungal, and 65 for chlamydial infections). Pregnant women with positive mycoplasma and bacterial cultures had higher rates of developing chorioamnionitis compared to women with negative cervical secretion cultures (9%, 12% vs. 1%, respectively). Similarly, positive mycoplasma and bacterial cultures were associated with higher rate of the preterm (before 34 weeks) labor (3%, 3% vs. 1% in women with negative cultures, respectively), and neonatal admission to the NICU (9%, 11% vs. 7%, respectively). After adjusting for various confounding factors, our analysis demonstrated that a positive cervical secretion culture for mycoplasma or bacterial pathogens remained an independent risk factor for chorioamnionitis. Cervical secretion culture outcome was less effective in predicting chorioamnionitis (AUC 0.569) compared to white blood count (WBC) (AUC 0.626) and C-reactive protein (CRP) levels (AUC 0.605). The IDI of the combined predictive model incorporating WBC, CRP, maternal fever and cervical secretion culture results was 0.0029. Conclusion: Positive cervical secretion cultures, especially for mycoplasma and bacteria, are associated with higher incidence of adverse maternal and fetal outcomes. However, the predictive value of this test is poor, and cannot be efficiently used for predicting chorioamnionitis.