Intrapartum Antibiotics Research Articles

Increasing Incidence of Late-onset Neonatal Invasive Group B Streptococcal Infections in Iceland

Group B streptococci (GBS) may cause life-threatening invasive infections in infants. The incidence of these infections has been increasing during the last decades. The aim of the study was to determine the epidemiology of neonatal GBS infections to be able to implement therapeutic and preventive measures more effectively. A retrospective case study was conducted in Iceland that included all neonates with positive GBS cultures from blood or cerebrospinal fluid during the period 1975 to 2006. Serotyping of all available GBS isolates was performed. A total of 87 children with 89 infections were included in the study. In all, 53 infants had early-onset (EO) GBS infections (occurring <7 days after birth) and 34 had late-onset (LO) infections (occurring on days 7-90). EO infections increased during the first 3 quartiles of the study period but decreased during the last quartile. LO infections increased throughout the entire study period. GBS was cultured from cerebrospinal fluid in 21 patients; 9 with EO and 12 with LO infections. Premature infants comprised 15 with EO and 14 with LO infections. Eight children died of GBS infection, 7 with EO and 1 with LO infections; no correlation with serotypes was found. Serotype III was most common for both EO (34%) and LO infections (62%). The number of GBS infections increased during the study period. The decrease in EO infections in recent years could be attributed to intrapartum antibiotic treatment. The increasing number of LO infections is a concern.

Streptococcus agalactiae increase in resistance to erythromycin and clindamycin in vaginal-anal colonization in third quarter of pregnancy in one decade of universal screening

Streptococcus agalactiae (GBS) is the main causative agent of early perinatal sepsis. The acquisition of prevention policies has led to frequent use of intrapartum antibiotics. Surveillance of antimicrobial resistance is indispensable for defining drugs of choice and alternatives for such prophylaxis. To determine the evolution of antimicrobial resistance of GBS from maternal colonization to drugs used in the prevention of neonatal sepsis, between 2002 and 2008. We studied 100 GBS positive vaginal and anal samples from pregnant women. Disc diffussion susceptibility method was performed for penicillin, ampicillin, cefazolin, erythromycin and clindamycin according to the Clinical and Laboratory Standards Institute (CLSI). We analyzed the susceptibility of 99 strains. Seventeen were resistant to erythromycin (17.1%) and 13 were resistant to clindamycin (13.1%). Thirteen of the 17 strains resistant to erythromycin had the MLS phenotype (resistance to erythromycin and clindamycin) and 4 had the M phenotype (resistance to erythromycin only). Within the MLS phenotype, resistance was constitutive in 9 strains, and induced in 4 strains (positive D test). Compared with 2002 there was a significant increase in resistance to clindamycin (from 3.27% to 13.1% p < 0.002) and erythromycin (1.09% to 17% p < 0.001). 100% GSB remained sensitive to penicillin and ampicillin. GBS remains highly susceptible to drugs of choice for prevention of perinatal sepsis. There is a significant increase in antimicrobial resistance to clindamycin and erythromycin. Therefore, it is necessary to request susceptibility testing in GBS from third trimester of pregnancy screening in patients allergic to penicillin.

Aumento de resistencia de Streptococcus agalactiae vaginal-anal en el tercer trimestre de gestación a eritromicina y clindamicina al cabo de una década de tamizaje universal

Streptococcus agalactiae (GBS) is the main causative agent of early perinatal sepsis. The acquisition of prevention policies has led to frequent use of intrapartum antibiotics. Surveillance of antimicrobial resistance is indispensable for defining drugs of choice and alternatives for such prophylaxis.To determine the evolution of antimicrobial resistance of GBS from maternal colonization to drugs used in the prevention of neonatal sepsis, between 2002 and 2008.We studied 100 GBS positive vaginal and anal samples from pregnant women. Disc diffussion susceptibility method was performed for penicillin, ampicillin, cefazolin, erythromycin and clindamycin according to the Clinical and Laboratory Standards Institute (CLSI).We analyzed the susceptibility of 99 strains. Seventeen were resistant to erythromycin (17.1%) and 13 were resistant to clindamycin (13.1%). Thirteen of the 17 strains resistant to erythromycin had the MLS phenotype (resistance to erythromycin and clindamycin) and 4 had the M phenotype (resistance to erythromycin only). Within the MLS phenotype, resistance was constitutive in 9 strains, and induced in 4 strains (positive D test). Compared with 2002 there was a significant increase in resistance to clindamycin (from 3.27% to 13.1% p < 0.002) and erythromycin (1.09% to 17% p < 0.001). 100% GSB remained sensitive to penicillin and ampicillin.GBS remains highly susceptible to drugs of choice for prevention of perinatal sepsis. There is a significant increase in antimicrobial resistance to clindamycin and erythromycin. Therefore, it is necessary to request susceptibility testing in GBS from third trimester of pregnancy screening in patients allergic to penicillin.

Evaluation of a rapid, real-time intrapartum group B streptococcus assay

We sought to evaluate an intrapartum nucleic acid amplification test (NAAT) for group B streptococcus (GBS). This was a prospective cohort study of 559 women comparing intrapartum GBS culture with antepartum culture and intrapartum NAAT. GBS prevalence was 19.5% by antepartum culture and 23.8% by intrapartum culture. Compared with intrapartum culture, antepartum culture had 69.2% sensitivity (60.6-76.9%) and 96.0% specificity (93.7-97.7%). The NAAT demonstrated sensitivity of 90.8% (84.6-95.2%), specificity of 97.6% (95.6-98.8%), and predictive values >92%. The incidence of discordant cultures was 10.4%. Of the women with negative antepartum and positive intrapartum cultures, only 1 (2.4%) received intrapartum antibiotics. Compared with white women, black (P = .02) and Hispanic (P = .02) women were more likely to have discordant cultures. This intrapartum NAAT has excellent characteristics. It may be superior to antepartum culture for detecting intrapartum GBS-allowing more accurate management of laboring mothers and reducing neonatal GBS sepsis.

Universal Antenatal Screening for Group B Streptococcus in Emilia-romagna

Group B streptococcus (GBS) is a leading cause of severe infections in newborns. Intrapartum antibiotic chemoprophylaxis (IAP) reduces the rate of early-onset disease. The aim of this study is to determine the degree of clinicians' compliance with the suggested protocol for GBS prevention in Emilia-Romagna (Italy). Characteristics of each delivery were prospectively recorded in the period between October 2005 to December 2005. Standardized pro-forma were used to collect data. Among 5118 babies, 7.2% (369) were preterm and 92.3% were born at term (4749). Antenatal screening was performed in 86.6% of women who delivered at term, of which 18.1% were GBS culture-positive. Information regarding culture site was available in 93.2% of women screened and recto-vaginal cultures were documented in 42.7%. IAP was administered to 28.7% of 3937 women at term who had either spontaneous delivery or emergency caesarean section. In this cohort, 15.9% were diagnosed GBS culture-positive, of which 92.6% received IAP. Prophylaxis was also administered to 8.4% (331) of women for no apparent reason. Compared with tertiary level hospitals, women delivering in primary/secondary hospitals were more likely to be both GBS screened (P < 0.0001; OR 3.04; CI 2.33-3.97) and to receive prophylaxis ≥4 hours before delivery (P = 0.0025; OR 1.57; CI 1.17-2.12). GBS screening was performed in >85% of women and >90% of culture-positive women received prophylaxis. However, there is a need to educate clinicians about protocol adherence, as most cultures were suboptimal and cases of unnecessary IAP were administered. The screening was more effective in hospitals with fewer deliveries.

Bactériurie maternelle à streptocoque B et endocardite néonatale : à propos d’un cas

Bacterial endocarditis is rare in children. We report the case of streptococcal B endocarditis in a newborn whose mother had asymptomatic bacteriuria during pregnancy. This report emphasizes the importance of maternal intrapartum antibiotic therapy when there is a major risk of neonatal infection and underlines the diagnostic value of echocardiography in case of prolonged fever.

A quantitative descriptive study of the prevalence of carriage (colonisation) of haemolytic streptococci groups A, B, C and G in pregnancy

Invasive group B streptococcus (GBS) disease is a leading cause of neonatal death. There is no UK national screening programme for GBS in pregnancy, hence colonisation rates are unknown. Intrapartum antibiotic prophylaxis is given during labour to colonised women to reduce neonatal GBS transmission and subsequent invasive infection. Data about prevalence of other haemolytic streptococci in pregnancy, including group A streptococcus (GAS), are uncommon despite increasing importance. This study investigated colonisation in 100 pregnant women using conventional culture methods; 19% had GBS. This suggests that GBS carriage is common in the UK. The role of other β-haemolytic streptococci remains undefined.

Low-Dose 18F-FDG PET/CT Enterography: Improving on CT Enterography Assessment of Patients with Crohn Disease

The purpose of this study was to evaluate the diagnostic efficacy of low-dose, combined (18)F-FDG PET/CT enterography (PET/CTE), compared with CT enterography (CTE) alone, in the assessment of patients with Crohn disease. Thirteen patients with Crohn disease were prospectively enrolled in this pilot study and underwent abdominal-pelvic (18)F-FDG PET/CTE using neutral oral and intravenous contrast medium. The effective dose from PET/CTE was 17.7 mSv for the first 4 patients and 8.31 mSv for the last 9 patients. Six patients underwent surgical resection of the bowel, and 7 patients underwent colonoscopy with biopsies within 27 d (mean, 12 d) of PET/CTE. PET/CTE and CTE images were each visually assessed for Crohn disease involvement in 54 bowel segments with pathology correlation. Extraintestinal findings were recorded. A CTE severity score, maximum standardized uptake value (SUVmax), SUVmax ratio, simplified endoscopic score, and clinical parameters were correlated with pathology inflammation grade, on a per-patient basis and on a per-bowel-segment basis, using Spearman correlation. In 3 (23.1%) of 13 patients, (18)F-FDG uptake using PET/CTE revealed active inflammation in a bowel segment not evident using CTE (n = 2) or revealed an enterocolic fistula missed with CTE (n = 1). Visual interpretation of both PET/CTE and CTE images detected the presence of disease in all bowel segments with more than mild inflammation (sensitivity, 100%; specificity, 89.7%; positive predictive value, 78.9%; and negative predictive value, 100%). Correlation to inflammation grade per patient was the strongest for the SUVmax ratio (0.735, P = 0.004) and SUVmax (0.67, P = 0.013), as compared with the CTE score (0.62, P = 0.024). Correlation with inflammation per bowel segment was higher for the CTE score (0.79, P < 0.0001) than the SUVmax ratio (0.62, P < 0.0001) or SUVmax (0.48, P < 0.0001). SUVmax correlated strongly with serum C-reactive protein (0.82, P = 0.023), but CTE score did not. Low-dose (18)F-FDG PET/CTE, compared with CTE, may improve the detection and grading of active inflammation in patients with Crohn disease. PET/CTE also may reveal clinically significant findings, such as enterocolic fistula, not evident on PET or CTE alone.

Development of a Rapid PCR Assay for Screening of Maternal Colonization by Group B Streptococcus and Neonatal Invasive Escherichia coli during Labor

Objective: Group B Streptococcus (GBS) and Escherichiacoli(E. coli) are the leading causes of early-onset neonatal disease (EOD). Intrapartum antibiotic prophylaxis of GBS-colonized women decreases vertical transmission and EOD due to GBS. Nevertheless, no intervention has been developed to reduce the risk of EOD related to E. coli. Timely and accurate identification of colonized mothers is necessary to implement preventive strategies against neonatal sepsis. To screen for colonization during labor, we developed a real-time PCR assay for the simultaneous detection of GBS and neonatal invasive strains of E. coli. Study Design: Specific DNA targets for GBS are publicly available. For neonatal invasive E. coli, we analyzed candidate DNA targets by DNA hybridization on microarrays of invasive strains isolated from neonatal E. coli sepsis or meningitis (K1 and not K1 ‘invasive’ serotypes). Specificity of DNA probes was tested against a panel of bacteria and by simulating clinical conditions (spiking vaginal samples from pregnant women). Then, the characteristics of the selected probes were evaluated in a pilot study including 200 women in labor. Results: Prevalence of rectovaginal GBS and of vaginal and cervical E. coliserotype K1 colonization were 16.0, 3.5 and 3.5% by culture and 27, 10 and 8.5% by PCR, respectively. The prevalence of other invasive E. coli in the vagina and in the cervix, detected by PCR, was around 10%. Compared to the culture, considered as the gold standard, the sensitivities of the PCRs for the GBS and E. coli K1 were 97 and 71%, respectively. Specificities were 86 and 92%, respectively. Specificity is difficult to interpret, as a false-positive PCR result may in fact be a false-negative result of the culture. The turnaround time needed for PCR analysis was 2.5 h, compared to a minimum of 48 h for the culture. Conclusion: Our rapid PCR is reliable in detecting GBS in women in labor. Optimization of the PCR for invasive E. coli is needed before its implementation in clinical practice. More efforts to fight against main causes of neonatal sepsis need to be undertaken to prevent this terrible medical complication.

Prévention des infections maternofœtales à streptocoque B. 1. Application des recommandations de l’Anaes

To examine adherence to the Anaes guidelines for early-onset infections prophylaxis, based on a systematic prenatal vaginal swab aiming group B Streptococcus and/or infection risk factors during delivery. Retrospective study of 6125 consecutive deliveries through a 28-month period. Data were collected from the patients files recorded in a computer database. Overall, a vaginal swab was performed on 88.3% of the patients. Among these, 79.1% were performed according to the guidelines. Among the patients, 90.2% with a positive swab received intrapartum antibiotics. In accordance to the national guidelines, we noticed a 40% increase in the consumption of antibiotics, without any severe complication during the study. Certain points must be improved though: time of the sampling, antibiotic therapy in case of quick delivery, management of patients with allergy to penicillin. Concordance with the national guidelines is feasible in a department with a high obstetrical activity.

An Outbreak of Necrotizing Enterocolitis Associated With Norovirus Genotype GII.3

Necrotizing enterocolitis (NEC) is an acute abdominal emergency of unknown etiology predominantly affecting preterm infants. We describe a cluster of NEC in a level III NICU involving 15 infants over a6-month period. Cohorting and stringent infection control measures were associated with termination of the cluster. A case-control study was used to investigate potential risk factors associated with development of NEC. Stool samples were collected from 55 infants (10 of 15 NEC and 45 non-NEC controls). Enteric pathogens were identified by culture and/or molecular diagnostic techniques. For the case-control study, controls were selected from admitted neonates during the same time and in the preceding 6-month period, matched for gestation and birthweight. Forty percent (4/10) of NEC infants had norovirus RNA detected compared with 9% (4/45) of non-NEC infants (OR: 6.83, 95% CI: 1.3-34.9,P = 0.021). A lower rate of prolonged rupture of membranes and a higher rate of maternal smoking was also observed in NEC infants than in controls. No significant differences in incidences of chorioamnionitis, intrapartum antibiotics,volume of feedings, time of first formula feeding, and rates of patent ductus arteriosus or intrauterine growth retardation were detected. Infants who developed NEC had an increased incidence of norovirus detection in their stool following diagnosis. This further strengthens the case for an etiologic role of norovirus in the pathogenesis of NEC.

Real-Time PCR Assay Provides Reliable Assessment of Intrapartum Carriage of Group B Streptococcus

The objective of this study was to determine the reliability of the real-time PCR assay for determining the group B Streptococcus (GBS) status of women in labor. In this prospective study we compared the results of culture and PCR testing of vaginal and rectal samples collected by nursing staff when women were in labor. Patients' charts were also reviewed to obtain relevant information about pregnancy risk factors. Our results demonstrated a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 90.5%, 96.1%, 86.4%, and 97.4%, respectively, for rapid PCR. Of the 196 women evaluated, 29 (14.8%) presented with unknown GBS status, 11 (37.9%) of whom received unnecessary intrapartum antibiotics. The rapid real-time PCR test was robust and was able to reliably detect the presence of GBS in women in labor within 1 h of specimen submission to the laboratory. We recommend that the rapid PCR test be targeted to women who present in labor with unknown GBS status. In cases where the laboratory does not offer 24-h availability of testing, sample collection followed by PCR testing the next morning is still valuable and provides reliable results 24 to 48 h faster than culture and will aid appropriate decision-making regarding continuing or stopping antibiotics for neonates of women with unknown GBS status.

Group B Streptococcus Early-Onset Disease in Emilia-Romagna: Review After Introduction of a Screening-Based Approach

Group B Streptococcus (GBS) is a leading cause of neonatal bacterial infections. Early-onset infections have decreased in recent years but, despite considerable efforts poured into prevention, cases continue to occur. To analyze trends and identify determining factors for the persistence of the GBS infections. To evaluate the impact of antenatal screening and intrapartum chemoprophylaxis on the clinical presentation of the infection. A prospective cohort, population-based study has been ongoing in Emilia-Romagna (Italy) since 2003. Invasive GBS infections, observed between 2003 and 2008 in infants aged < 7 days were analyzed. Among 214,120 live births, 61 early-infections were observed. Fourteen infants (23.0%) were born preterm. Among 47 infants who were delivered at term, 28 were born to mothers who had no risk factors and 7 were born to mothers who had none other than GBS colonization. Forty-one women at term had been screened prenatally; among them, only 10 were documented as GBS culture-positive.Disease severity was highest in infants at lower gestational ages, but most meningitis cases were observed in term infants born to mothers who were GBS culture-negative at screening.Nine newborns had culture-proven infection despite having received intrapartum antibiotics. They were born to mothers with > or =1 obstetrical risk factors and 5 mothers had been treated during labor with macrolides. Most infections presented in infants whose mothers had been screened as GBS culture-negative. Missed opportunities for prevention contributed more than prophylaxis failures to the early-onset disease burden.

WITHDRAWN. Intrapartum antibiotics for Group B streptococcal colonisation.

Group B streptococcal infection is common in pregnant women without causing harm. However it is also a significant cause of neonatal morbidity and mortality. The objective of this review was to assess the effects of intrapartum administration of antibiotics to women on infant colonization with group B streptococcus, early onset neonatal group B streptococcus sepsis and neonatal death from infection. The Cochrane Pregnancy and Childbirth Group trials register was searched. Controlled trials of pregnant women colonized with group B streptococcus comparing intrapartum antibiotic administration with no treatment, and providing data on infant colonization with group B streptococcus and/or neonatal infection. Eligibility and trial quality assessment were done by one reviewer. Five trials were included. Overall quality was poor, with potential selection bias in all the identified studies. Intrapartum antibiotic treatment reduced the rate of infant colonization (odds ratio 0.10, 95% confidence interval 0.07 to 0.14) and early onset neonatal infection with group B streptococcus (odds ratio 0.17, 95% confidence interval 0.07 to 0.39). A difference in neonatal mortality was not seen (odds ratio 0.12, 95% confidence interval 0.01 to 2.00). Intrapartum antibiotic treatment of women colonized with group B streptococcus appears to reduce neonatal infection. Effective strategies to detect maternal colonization with group B streptococcus and better data on maternal risk factors for neonatal group B streptococcus infection in different populations are required.

Treatment of trichomoniasis in pregnancy in sub-Saharan Africa does not appear to be associated with low birth weight or preterm birth.

To determine whether treatment of trichomoniasis increases the risk of prematurity. Sub-analysis of a randomised trial. We analysed data from HPTN trial of antenatal and intrapartum antibiotics to reduce chorioamnionitis-related perinatal HIV transmission. Pregnant women from four sites in Africa. Gestational age at the time of delivery or mean birth weight. Of 2,428 women-infant pairs included, 428 (18%) had trichomoniasis at enrolment. There were no differences in infant age or birth weight between women with or without trichomoniasis. By randomisation group, there were no differences in gestational age at birth or birth weight. Of the 428 women diagnosed with trichomoniasis, 365 (83%) received antibiotics and 63 (15%) did not. In analysis of actual use of antibiotics, women with trichomoniasis who received no treatment were more likely to deliver a preterm infant when the symphysis-fundal height was used to estimate gestational age (36% v. 23%; p=0.03), but not when the Ballard score was used (16% v. 21%; p=0.41). There were no differences in mean birth weight between groups. In pregnant women in sub-Saharan Africa, most of whom were HIV-infected, neither trichomoniasis nor its treatment appears to influence the risk of preterm birth or a low-birth-weight infant.

Intrapartum antibiotics and risk factors for early onset sepsis

ObjectiveTo determine the independent risk factors for early onset neonatal sepsis (EONS) in a setting where the policy is to use intrapartum antibiotic prophylaxis (IAP) for known risk factors.DesignProspective cohort...

Evaluation of a novel real-time PCR test based on the ssrAgene for the identification of group B streptococci in vaginal swabs

BackgroundDespite the implementation of prevention guidelines, early-onset group B streptococci (GBS) disease remains a cause of neonatal morbidity and mortality worldwide. Strategies to identify women who are at risk of transmitting GBS to their infant and the administration of intrapartum antibiotics have greatly reduced the incidence of neonatal GBS disease. However, there is a requirement for a rapid diagnostic test for GBS that can be carried out in a labour ward setting especially for women whose GBS colonisation status is unknown at the time of delivery. We report the design and evaluation of a real-time PCR test (RiboSEQ GBS test) for the identification of GBS in vaginal swabs from pregnant women.MethodsThe qualitative real-time PCR RiboSEQ GBS test was designed based on the bacterial ssrA gene and incorporates a competitive internal standard control. The analytical sensitivity of the test was established using crude lysate extracted from serial dilutions of overnight GBS culture using the IDI Lysis kit. Specificity studies were performed using DNA prepared from a panel of GBS strains, related streptococci and other species found in the genital tract environment. The RiboSEQ GBS test was evaluated on 159 vaginal swabs from pregnant women and compared with the GeneOhm™ StrepB Assay and culture for the identification of GBS.ResultsThe RiboSEQ GBS test is specific and has an analytical sensitivity of 1-10 cell equivalents. The RiboSEQ GBS test was 96.4% sensitive and 95.8% specific compared to "gold standard" culture for the identification of GBS in vaginal swabs from pregnant women. In this study, the RiboSEQ GBS test performed slightly better than the commercial BD GeneOhm™ StrepB Assay which gave a sensitivity of 94.6% and a specificity of 89.6% compared to culture.ConclusionThe RiboSEQ GBS test is a valuable method for the rapid, sensitive and specific detection of GBS in pregnant women. This study also validates the ssrA gene as a suitable and versatile target for nucleic acid-based diagnostic tests for bacterial pathogens.

Diagnostic Accuracy of a Rapid Real‐Time Polymerase Chain Reaction Assay for Universal Intrapartum Group B Streptococcus Screening

Intrapartum antibiotic prophylaxis is currently given to mothers who test positive for group B streptococcus (GBS) by antenatal culture-based screening, with a risk-based approach for cases with an unknown GBS status. A rapid real-time polymerase chain reaction (PCR) assay for the detection of GBS became available recently, making intrapartum screening possible. We aimed to assess its diagnostic accuracy and to compare it with antenatal screening. We conducted a prospective study in a French hospital. All pregnant women giving birth at the maternity ward were considered for inclusion, except those with planned cesarean delivery, with delivery at <35 weeks gestation, and who received antibiotic therapy before admission. We performed GBS culture (the reference standard) and a molecular GBS test (Xpert GBS; Cepheid) on intrapartum specimens. Decisions about intrapartum antibiotic prophylaxis were based on the current GBS screening by culture at 35-37 weeks gestation. We prospectively enrolled 968 pregnant women from April 2007 through March 2008. The overall molecular GBS test yield was 89.2%. Among the 863 women with available results, the molecular GBS test had a sensitivity of 98.5%, specificity of 99.6%, positive predictive value of 97.8%, and negative predictive value of 99.7%. The positive predictive value of antenatal culture for identifying colonization status at delivery was low (58.3%), whereas the negative predictive value was imperfect (92.1%). This real-time PCR assay is a highly accurate test to identify intrapartum GBS carriers at point of care. This new tool could enhance the exact identification of candidates for intrapartum antibiotic prophylaxis, including women with preterm rupture of membranes or preterm labor.

A randomised trial of home energy efficiency improvement in the homes of elderly COPD patients

A randomised trial of 178 patients in Aberdeen, UK with a previous hospital admission for chronic obstructive pulmonary disease (COPD) was carried out in order to determine whether improving home energy efficiency improves health-related quality of life in COPD patients. 118 patients were randomised and 60 agreed to monitoring only. Energy efficiency upgrading was carried out in 42% of homes randomised to intervention. Independent energy efficiency action was taken by 15% of control participants and 18% in the monitoring group. The main outcome measures were respiratory and general health status, home energy efficiency and hospital admissions. Intention-to-treat analysis found no difference in outcomes between the two groups. In 45 patients, who had energy efficiency action independent of original randomisation, there were significant improvements in respiratory symptom scores (adjusted mean 9.0, 95% CI 2.5-15.5), decreases in estimated annual fuel costs (- pound65.3, 95% CI - pound31.9- - pound98.7) and improved home energy efficiency rating (1.1, 95% CI 0-1.4). COPD patients are unlikely to take up home energy efficiency upgrading, if offered. Secondary "pragmatic" analysis suggests that those who do take action may achieve clinically significant improvement in respiratory health, which is not associated with an increase in indoor warmth.

Intrapartum antibiotic exposure and early neonatal, morbidity, and mortality in Africa.

Infants born to women who receive intrapartum antibiotics may have higher rates of infectious morbidity and mortality than unexposed infants. Our goal was to determine the association of maternal intrapartum antibiotics and early neonatal morbidity and mortality. We performed secondary analysis of data from a multisite randomized, placebo-controlled clinical trial of antibiotics to prevent chorioamnionitis-associated mother-to-child transmission of HIV-1 and preterm birth in sub-Saharan Africa. Early neonatal morbidity and mortality were analyzed. In an intention-to-treat (ITT) analysis, infants born to women randomly assigned to antibiotics or placebo were compared. In addition, non-ITT analysis was performed because some women received nonstudy antibiotics for various clinical indications. Overall, 2659 pregnant women were randomly assigned. Of these, 2466 HIV-1-infected and HIV-1-uninfected women delivered 2413 live born and 84 stillborn infants. In the ITT analysis, there were no significant associations between exposure to antibiotics and early neonatal outcomes. Non-ITT analyses showed more illness at birth (11.2% vs 8.6%, P = .03) and more admissions to the special care infant unit (12.6% vs 9.8%, P = .04) among infants exposed to maternal intrapartum antibiotics than among unexposed infants. Additional analyses revealed greater early neonatal morbidity and mortality among infants of mothers who received nonstudy antibiotics than of mothers who received study antibiotics. There is no association between intrapartum exposure to antibiotics and early neonatal morbidity or mortality. The associations observed in non-ITT analyses are most likely the result of women with peripartum illnesses being more likely to receive nonstudy antibiotics.