Microbiology and clinical outcomes of puerperal sepsis: a prospective cohort study

Abstract

The objectives of this study were to determine the identity and antibacterial susceptibility profiles of bacteria colonising the female genital tract and blood stream and their association with clinical outcomes in women with puerperal sepsis. A prospective descriptive cohort study was conducted at two tertiary hospitals in Zimbabwe. Endocervical swabs and blood were collected for culture and susceptibility testing from 151 consecutive women who met the World Health Organisation criteria for puerperal sepsis. Medical records were reviewed for assessment of clinical outcomes. The commonest bacterial isolates were Escherichia coli (30.6%) and Klebsiella pneumoniae (15.3%). Multidrug-resistant organisms (MDRO) accounted for 10.9% of all isolates. MDRO were associated with prolonged hospital stay, 23.0 days compared to 10.5 days in women without MDRO (p = .009). Puerperal sepsis case fatality rate was 7.3%. Clinical culture surveillance to monitor epidemiologic trends, identify MDRO, robust infection control strategies and emphasis on rational drug use are recommended. Impact statement What is already known? Puerperal sepsis is often a polymicrobial infection. Escherichia coli has been reported as a common cause of severe maternal sepsis originating from the genital tract. Other bacteria include Group A Streptococcus, S. aureus, Streptococcus spp. Klebsiellae spp, Pseudomonas spp. and anaerobes. What does this study add? This study confirms Escherichia coli as the commonest cause of sepsis in Harare. There is high level resistance to first-line antibiotic regimens on most Gram-negative isolates from the endocervix among women with puerperal sepsis. Emerging resistance to carbapenems is demonstrated. MDRO significantly increased length of hospital stay, and there was a clinically important trend towards higher rates of pelvic abscess, septic shock, death, need for laparotomy and ICU admission specific to puerperal sepsis. What are the implications for clinical practice and further research? Clinical culture surveillance to monitor epidemiologic trends in conjunction with robust infection control strategies and rational drug use may assist in prevention of community acquired and nosocomial multidrug-resistant infections.

Determinants and aetiologies of postpartum pyrexia; a retrospective analysis in a tertiary health facility in the Littoral Region of Cameroon

“…Approximately 77.5% of culture results reviewed in this study were positive, with the most isolated germ being E. coli. This finding is similar to those revealed in other studies [21,22] which identified E. coli as the most commonly isolated organism from high vaginal swabs obtained from women with puerperal sepsis. However, these studies were limited to high vaginal swab cultures among women with puerperal sepsis and so may not reflect the true microbiological spectrum of postpartum pyrexia, compared to our study which reviewed culture results from different specimen.…”

Effectiveness of preoperative bath using Chloroxylenol antiseptic soap on the incidence of post emergency Cesarean section surgical site infection at Mbarara Regional Referral hospital, Uganda: a Randomized Controlled trial

“…These infections contribute significantly to adverse maternal outcomes (Wendmagegn et al, 2018). Data from one of our previous studies and many others have shown that puerperal sepsis is the leading cause of maternal mortality in the hospital (Ngonzi et al, 2016, Majangara et al, 2018. Finding such a high incidence of SSI among post emergency Cesarean section mothers only confirms the burden as being huge, and one that needs extra attention.…”

The association of puerperal sepsis with HIV infection at two tertiary hospitals in Zimbabwe

“…A subanalysis was performed using data from a prospective cohort study that had been conducted between September 2, 2014, and July 1, 2015, among women with puerperal sepsis who were admitted to either Parirenyatwa Hospital or Harare Central Hospital in Harare, Zimbabwe. 8 Demographic data were collected using an interviewer-administered questionnaire. An endocervical swab and a blood sample were collected for microbial culture and susceptibility testing at the time of hospital admission, preferably before administration of antibiotics.…”

“…9 Information regarding any prior antibiotic administration before sample collection was captured using a case investigation form. 8 Microbial culture and susceptibility testing were performed as described previously. 8 Testing for HIV infection is routine standard of care among Zimbabwean women during the prenatal period and breastfeeding, with such testing offered using an opt-out approach.…”

“…8 Microbial culture and susceptibility testing were performed as described previously. 8 Testing for HIV infection is routine standard of care among Zimbabwean women during the prenatal period and breastfeeding, with such testing offered using an opt-out approach. 10 Both the HIVinfection status and the number of T cells expressing cluster of differentiation 4 (CD4) were obtained from a primary source document if testing was performed within 3 and 6 months of presentation for puerperal sepsis, respectively.…”