Infections/Sepsis in Pregnancy - including GBS GT36, Bacterial Sepsis in/following pregnancy GT64a, b Flashcards
What is the incidence of Early Onset GBS disease in the UK?
0.5/1000 Births
If GBS was detected in a previous pregnancy what is the likelihood of carriage in a subsequent pregnancy?
50%
If GBS was detected in a previous pregnancy - what is the risk estimate of disease (EOGBS) in this pregnancy?
1/700-1/800
If has third trimester screening and swab is positive for GBS then risk is 1/400
If swab negative then risk is 1/5000
If a woman has pyrexia in labour, and an unknown GBS carrier status, what is the risk of EOGBS?
5.3/1000
What is the risk of EOGBS in preterm deliveries?
What is the mortality rate?
2-3/1000
Mortality rate is 20-30%
What is the antibiotic recommendation for intrapartum antibiotics to prevent EOGBS?
Benzylpenicillin 3g then 1.5g 4 hourly
If penicillin allergic then cefuroxime (1.5g loading dose followed by 750mg 8hourly)
OR Vancomycin 1g every 12hours
(Clindamycin no longer recommended due to resistance rate in UK of 16%).
What % of EOGBS were identified on day 1?
89-94%
How do babies with EOGBS present?
80% sepsis
12% meningitis
8% pneumonia
1% focal
How should well babies at risk of EOGBS whose mothers did not receive adequate IAP be observed?
Assessed for clinical indicators of neonatal infection and have vital signs checked @ 0,2,4,6,8,10,12 hours
In which triennium was sepsis the leading cause of direct maternal deaths in the UK? And which microbe was responsible for death in 13 women?
2006-8
GAS
What is the mortality rate of severe sepsis with acute organ dysfunction?
And if septic shock develops?
Severe sepsis - 20-40%
Septic shock - 60%
What is the definition of sepsis?
Infection plus systemic manifestations of infection
What is the definition of severe sepsis?
Sepsis + sepsis-induced organ dysfunction or tissue hypoperfusion
What is the definition of septic shock?
Persistence of hypoperfusion despite adequate fluid replacement therapy
What are the risk factors for maternal sepsis in pregnancy?
Obesity DM/impaired glucose tolerance Impaired immunity/medication Anaemia Vaginal discharge History of pelvic infection History of group B streptococcal infection Amniocentesis and other invasive procedures Cervical cerclage Prolonged SROM GAS in close contacts Black/minority ethnic
When should lactate be measured in suspicion of severe sepsis and at what level is indicative of tissue hypoperfusion?
Within 6 hours
Lactate >=4
Within what time scale should IVAbx be administered when there is recognition of severe sepsis?
1 hour
What are the parameters for fluid resuscitation in severe sepsis/septic shock if lactate =>4 or there is hypotension?
Crystalloid 20ml/kg initially
If does not respond vasopressors to maintain MAP >65mmHg
If septic shock: CVP >8mmHg
Central venous SpO2 >=70%
Mixed venous SpO2 >= 65%
What are the indications for transfer to ICU?
CV - Hypotension or raised lactate despite fluid resus (ie
need vasopressors)
Resp - Pulmonary oedema, ventilation, airway support
Renal - Dialysis
Neuro - Decreased GCS
Other - Multiorgan failure, uncorrected acidosis,
hypothermia
What are the most commonly identified organisms implicated in maternal death?
- Lancefield group A beta-haemolytic Streptococcus
- E Coli (esp urosepsis, PPROM, cerclage)
Less commonly anaerobes -
- Peptostreptococcus
- Bacteroides spp
(Clostridium perfringens)
What are the limitations of co-amoxiclav when treating sepsis in pregnancy?
No MRSA or Pseudomonas cover
Risk of NEC to neonates
What are the limitations of metronidazole when treating sepsis in pregnancy?
Only covers anaerobes
What are the actions of clindamycin?
Covers most strep and staph including many MRSA
Switches off exotoxin production
Not nephrotoxic/renally excreted
What are the limitations of Tazocin/carbapenems when treating sepsis in pregnancy?
Covers all except MRSA
Renal sparing compared to aminoglycosides
How does IVIG work in treatment of severe sepsis?
which bacteria is it effective against?
When is it contraindicated?
Immunomodulatory
Neutralises superantigen effect of exotoxins in staph/strep
Inhibits production of TNF and interleukins
Contraindicatied in congenital deficiency of IgA
What prophylaxis should be considered when a mother is found to have invasive group A streptococcal infection peripartum?
What is the antibiotic regime as per the HPA?
- Notifiable disease!
- Baby administered with prophylactic abx
- Close household contacts - seek advice if symptoms devlop
- Healthcare workers exposed to respiratory secretions consider for prophylaxis
- Penicillin V qds 10/7 or azithromycin 500mg OD 5/7
What are the 5 clinical findings in staphylococcal toxic shock?
- Temp >= 39.9
- Diffuse macular erythroderma
- Desquamation 10-14 days after onset (palms/soles)
- BP <90mmHg systolic
- > =3 systems affected: GI, muscular, mucous membranes, renal, hepatic, haematological, CNS
What are the common pathogens causing sepsis in the purperium?
- GAS (Streptococcus pyogenes)
- Escherichia coli
- Staphylococcus aureus
- Streptococcus pneumoniae
- Meticillin-resistant S. aureus (MRSA)
- Clostridium septicum
- Morganella morganii
What are the rates of MRSA carriage and infection in mothers in the puerperium in the US?
2.1%
What % of coliform bacteria are ESBL-producing in the UK?
12%
Cause many co-amoxiclav and cephalosporin resistant UTIs - may need carbapenems
What are the other sources of puerperial sepsis outside of the genital tract?
- Mastitis (can become necrotising!)
- UTI
- Pneumonia
- Skin/soft tissue infection
- Gastroenteritis (may be 2dry to TSS if diarrhoea..)
- Pharyngitis (10% GAS)
- Spinal abscess (regional anaesthetic)
- Usu Staph aureus (Strep, gram neg rods, sterile
specimens in 15% each)
- Usu Staph aureus (Strep, gram neg rods, sterile
Which analgesics should be avoided in sepsis and why?
NSAIDs
Impede ability of polymorphs to fight GAS infection
What organism is found by contact with aborting sheep or infected birds, or washing contaminated clothing?
Chlamydophila psittaci
What causes Q fever?
Coxielli burnetti
Inhaling particles from birthing animals or infected dust
What are the likely orgaisms and suggested empirical treatment in:
Mastitis
MSSA, Strep
Flucloxacillin + clindamycin
(Vanc and clinda if allergic or if MRSA; also teic and clinda)
What are the likely orgaisms and suggested empirical treatment in:
C-section wound/cannula site infection
MSSA, Strep
Flucloxacillin + clindamycin
(Vanc and clinda if allergic or if MRSA; also teic and clinda)
What are the likely organisms and suggested empirical treatment in:
Endometritis
Gram neg anaerobes, Strep
Shot of gent, Cefotaxime + Metronidazole
(Gent + Clinda + Cipro if allergic)
What are the likely orgaisms and suggested empirical organisms in:
Acute Pyelonephritis
Gram neg bacteria, some Staph/Strep occasionally
Cefotaxime and shot of gent
(Gent and cipro if allergic)
If ESBL-producing - Gent and meropenem
What are the likely orgaisms and suggested empirical organisms in:
Toxic Shock Syndrome
Staph, Strep
Fluclox (Vanc if MRSA), clinda, gent (shot)
Any regime must have clinda or linezolid (antitoxin)
What are the likely orgaisms and suggested empirical organisms in:
Severe sepsis, no focus
MRSA, Strep, Gram negs (ESBL, pseudomonas, anaerobes)
Meropenem + Clinda + gent (shot
If allergy to penicillin, no meropenem)
- Clinda + Gent + metronidazole + cipro
What is the NNT with intrapartum antibiotics to prevent 1 case of neonatal death secondary to GBS?
5882
what type of infections are associated with coliform bacteria?
urinary sepsis, PPROM, cerclage
what is the clinical case definition of streptococcal sepsis?
hypotension + 2 or more of following:
- renal impairment (Cr>176)
- coagulopathy- plts <100
- Liver involvement
- ARDS
- generalised erythematous rash
- soft tissue necrosis
which bacterial infections merit antibiotic prophylaxis for family/staff that have come into close contact with the infected?
- meningococcus (neisseria meningitides)
2. Group A Strep
