Maternal Bacteremia Research Articles

Associations between maternal bacteremia during the peripartum period and early-onset neonatal sepsis: a retrospective cohort study

IntroductionEarly-onset neonatal sepsis (EONS) significantly impacts neonatal morbidity and mortality, with maternal bacteremia during the peripartum period being a potential risk factor. This study aims to explore the association between peripartum maternal bacteremia and EONS.MethodsA retrospective cohort study at the Women's Wellness and Research Center in Doha, Qatar (2015–2019) compared women with and without bacteremia, based on blood cultures taken from up to seven days before to 48 h after delivery, examining the association with EONS.ResultsAmong the 536 maternal blood cultures analyzed, 102 (19.0%) were positive. The most prevalent organisms were Group B streptococcus (GBS) (39.2%), followed by Escherichia coli (14.7%) and anaerobes (10.8%). Neonates from bacteremic mothers had lower birth weights (2913 ± 86 g vs. 3140 ± 745 g; MD 227.63 g; 95% CI 61.72 − 393.55; p = 0.007), required more resuscitation (27.5% vs. 13.2%; OR 2.48; 95% CI 1.48 − 4.17; p < 0.001), and received antibiotics for ≥ 7 days more frequently (41.2% vs. 16.6%; OR 3.51; 95% CI 2.20 − 5.62; p < 0.001) compared to those from non-bacteremic mothers. Maternal Gram-positive (GP) organisms were more commonly isolated in term gestation (67.9%) compared to Gram-negative (GN) (22.2%) and anaerobic bacteremias (9.9%). During intrapartum, GP bacteremia was predominant (67.1%) vs. GN (21.4%) and Anaerobes (11.4%), with GN bacteremia being more common in postpartum samples. Culture-proven EONS occurred in 0.75% of the cohort, affecting 3.9% of infants from bacteremic mothers vs. none in controls (OR 2.34; 95% CI 1.27 − 4.31; p < 0.001). Culture-negative EONS appeared in 14.7% of infants from bacteremic mothers vs. 7.8% in controls (OR 2.02; 95% CI, 1.05 − 3.88; p = 0.03). Among 40 cases of maternal GBS bacteremia, culture-proven GBS EONS occurred in 3 neonates (7.5%), all from mothers with negative GBS screening, compared to none in the control group. A strong association was found between EONS and maternal bacteremia due to any organism (aOR 2.34; 95% CI, 1.24 − 4.41; p = 0.009), GP bacteremia (aOR 3.66; 95% CI, 1.82 − 7.34; p < 0.001), or GBS (aOR 5.74; 95% CI, 2.57 − 12.81; p < 0.001). Bacteremia due to GN and Anaerobic organisms were not associated with EONS. Chorioamnionitis and antepartum fever were independent predictors for EONS associated with significant bacterial isolates.ConclusionThis study underscores the significant impact of maternal GP bacteremia, particularly from GBS, on EONS. The strong association highlights the need for vigilant monitoring and interventions in pregnancies complicated by bacteremia to reduce adverse neonatal outcomes.

Intrapartum fever complicated with maternal bacteremia: prevalence, bacteriology, and risk factors

PurposeTo assess the prevalence, microbial profile, and clinical risk factors of maternal bacteremia associated with intrapartum fever (IPF).MethodsA retrospective cohort study, in a single tertiary university-affiliated medical center between 2012 and 2018. Demographic and labor characteristics of women, who delivered at term (37+0/7–41+6/7) and developed bacteremia following IPF were compared to a control group of women with IPF but without bacteremia.ResultsDuring the study period there were 86,590 deliveries in our center. Of them, 2074 women (2.4%) were diagnosed with IPF, of them, for 2052 women (98.93%) the blood maternal cultures were available. In 26 patients (1.25%) maternal bacteremia was diagnosed. A lower rate of epidural anesthesia (84.6% vs 95.9%, p = 0.02) and a higher rate of antibiotics prophylaxis treatment prior to the onset of fever (30.8%.vs 12.1%, p = 0.006) were observed in patients who developed maternal bacteremia in comparison to those who have not. Maternal hyperpyrexia developed after initiation of antibiotics or without epidural anesthesia remained significantly associated with maternal bacteremia after applying a multivariate analysis, (Odds Ratio 3.14 95% CI 1.27–7.14, p = 0.009; 4.76 95% CI 1.35–12.5, p = 0.006; respectively).ConclusionMaternal fever developing after initiation of antibiotics or without epidural is associated with maternal bacteremia.

Evaluation of microbiological epidemiology and clinical characteristics of maternal bloodstream infection: a 10 years retrospective study.

Although the incidence of bloodstream infection (BSI) during pregnancy is relatively low, it can lead to unfavorable outcomes. The aim of our study was to analyze the clinical and microbiological characteristics of maternal bacteremia and to assess maternal and fetal outcomes. Our study was a retrospective study conducted in a tertiary women and children's hospital in Guangzhou, China, from 2013 to 2022. Data were extracted from medical records and the laboratory information system. The participants were divided into groups, and the difference between the groups was analyzed. The incidence of maternal BSI during the 10 years study period was 10.2 cases/10,000 maternities, with a peak found from 2014 to 2016. Escherichia coli (48%) was the predominant causative pathogen, followed by Streptococcus agalactiae (13%). Gestational diabetes mellitus (GDM) (15%) was the most common underlying condition among maternal BSI episodes. Urinary tract (13%) and genital tract (28%) were the predominant source of BSI. About 14% of neonates were infected, and BSI was the most common type of infection. E. coli was the predominant pathogen in mother-neonate pairs with concurrent BSI. Premature rupture of membranes (PROM, OR:4.68) and preterm birth (OR:3.98) were the risk factors predicting neonatal infection. More than 85% of the E. coli were resistant to ampicillin (AMP) and 50% of the E. coli were extended-spectrum β-lactamase (ESBL)-producing bacteria. Maternal BSI is a rare event, but continuous monitoring on the aspects of pathogen composition, antimicrobial resistance characteristics, and risk factors for adverse outcomes remains necessary to further reduce poor outcomes and mitigate bacterial resistance.

Genome Characterisation of Invasive Haemophilus influenzae in Pregnancy: The Noticeable Placental Tissue Tropism Is Distributed across the Species Rather Than Linked with Capsulation or Particular Clones.

Pregnancy is associated with a 5-26 times increased risk of invasive Haemophilus influenzae infection and subsequent adverse pregnancy outcomes. Incidence rate and outcome are published in some regions, but the characterisation of bacterial isolates is limited. We performed comparative genomic analyses of isolates from 12 pregnancy-associated cases, cultured from maternal bacteraemia in pregnancy (nine), postpartum bacteraemia (one), neonatal bacteraemia (one), and placental tissue (one). In two bacteraemia cases, identical isolates were also cultured from cervical swabs. Eight cases occurred early in pregnancy (gestational week 7-26), and seven of them resulted in miscarriage or neonatal death. All bacterial genomes were devoid of capsule loci, and they were evenly distributed in the major phylogenetic group I of the species. The conspicuous tropism of H. influenzae for pregnancy and placental tissue is associated with the species rather than specific clonal subtypes.

The association between maternal colonization with Group B Streptococcus and infectious morbidity following transcervical Foley catheter-assisted labor induction.

To determine whether maternal colonization with Group B Streptococcus increases the risk for infectious morbidity following transcervical Foley catheter-assisted cervical ripening. A retrospective cohort study comparing infectious morbidity and other clinical outcomes by Group B Streptococcus colonization status between all women with singleton pregnancies who underwent Foley catheter-assisted cervical ripening labor induction at a single tertiary medical center during 2011-2021. Multivariable logistic regression explored the relationship between Group B Streptococcus colonization to adverse outcomes while adjusting for relevant clinical variables. A total of 4,409 women were included of whom 886 (20.1 %) were considered Group B Streptococcus carriers and 3,523 (79.9 %) were not. Suspected neonatal sepsis rate was similar between Group B Streptococcus carriers and non-carriers (5.2 vs. 5.0 %, respectively, p=0.78). Neonatal sepsis was confirmed in 7 (0.02 %) cases, all born to non-carriers. Group B Streptococcus carriers had a higher rate of maternal bacteremia compared to non-carriers (1.2 vs. 0.5 %, respectively, p=0.01). Group B Streptococcus colonization was independently associated with maternal bacteremia (adjusted odds ratio 3.05; 95 %CI 1.39, 6.66). Group B Streptococcus colonization among women undergoing Foley catheter-assisted cervical ripening does not seem to increase the risk for neonatal infection. However, higher rates of maternal bacteremia were detected.

Time to reconsider antibiotic prophylaxis in women with prolonged rupture of membranes: The trend of Enterobacteriaceae in peripartum infections.

The proportion of neonatal early-onset sepsis (EOS) by gram-negative bacteria has increased. The authors examined bacterial distribution in the amniotic membrane cultures of women with peripartum fever (PPF) and related perinatal outcomes. This retrospective study covered the period 2011 to 2019. The primary outcomes were Enterobacteriaceae-positive birth culture rates in women with PPF and the trend of ampicillin resistance. Maternal and neonatal outcomes were compared between women with group B Streptococcus (GBS) and Enterobacteriaceae-positive isolates. Bacterial distribution was also compared according to rupture of membrane (ROM) duration. Among 621 women with PPF, the positive birth culture rate was 52%. Increasing prevalences of ampicillin-resistant Enterobacteriaceae (81%) were noted. Positive birth cultures were associated with maternal bacteremia (P = 0.017) and neonatal EOS (P = 0.003). Prolonged ROM ≥18 h was associated with increased risk for Enterobacteriaceae-positive cultures, while intrapartum ampicillin and gentamicin were associated with lower risk. Enterobacteriaceae-positive compared with GBS-positive birth cultures were associated with adverse maternal and neonatal outcomes. Positive birth cultures were related to maternal bacteremia and neonatal sepsis. Adverse outcomes were more prevalent among women with Enterobacteriaceae-positive versus GBS-positive birth cultures. Prolonged ROM is a risk factor for Enterobacteriaceae-positive birth cultures among women with PPF. Antibiotic prophylaxis treatment for prolonged ROM should be reconsidered.

5613393 PREGNANCY OUTCOMES IN WOMEN WITH SICKLE CELL DISEASE IN IRELAND: A RETROSPECTIVE REVIEW

Background: Sickle cell disease (SCD) is one of the most common single gene disorders worldwide and is characterised by significant morbidity and early mortality.[1] Pregnancy in SCD is associated with an increased risk of maternal and foetal complications.[2,3] The 2011 RCOG and the 2021 BSH guidelines[5,6] on the management of pregnancy in SCD have provided the basis for best practice care in the UK over the past decade and is the guidance which we follow in Ireland. To date, there is no published data on outcomes for pregnant women with SCD in Ireland. The number of Irish patients with SCD has risen over the past 20 years. Without a national database, the exact prevalence is not known but currently there are at least 600 adults and children with SCD in Ireland, whose population is just over 5 million.[4] Aims: Our study assesses outcomes of pregnant patients with SCD from 2015 to 2022. Our aims were to: Assess adherence to current guidelines Assess pregnancy outcomes and maternal complications Assess transfusion rates amongst our patient cohort. Method: This is a retrospective cohort study. We do not have a directly matched cohort, but have compared our findings to published data on Irish pregnancy outcomes from the Irish Maternity Indicator System National Report and have correlated our findings with studies of women with SCD who were managed in UK centres.[8,9,10] Results: We reviewed outcomes of 29 pregnancies in 19 women over a 7-year period. The median age was 29 (range 20-41) and the predominant maternal sickle genotype was HbSS (65.5%). Before conception, 55.2% of cases had pre-existing complications of SCD, including acute chest syndrome (ACS), pulmonary hypertension (PHTN) and prior stroke. In accordance with current guidelines, 100% of women (n=29) were prescribed folic acid, penicillin, and aspirin prophylaxis. 51.7% (n=15) of women had documented maternal complications during pregnancy, including ACS (34%), vaso-occlusive crisis (34%), gestational diabetes (10%), VTE (3%) and UTI (3%). Two women (7%) developed Covid-19 pneumonitis despite vaccination. There was one case of maternal bacteraemia (3%). 65.5% of cases (n=19) required blood transfusion during pregnancy. One woman was already on a blood transfusion programme for disease modification prior to pregnancy. In 6 cases (20.6%), a transfusion programme was commenced during pregnancy due to prior pregnancy complications or intrauterine growth restriction. During pregnancy, 27.6% (n=8) of women required emergency red cell exchange for ACS. Prior studies have suggested that between 30% and 70% of pregnant women with SCD require at least one blood transfusion during pregnancy.[8,9,10] By comparison, only 2.6% of the Irish general obstetric population required transfusion during pregnancy.[7] 20.6% (n=6) of births were preterm at <37 weeks’ gestation. There was one live preterm birth (3%) at <34 weeks and one intrauterine death (3%) at 23 weeks’ gestation. Similar to UK data[9], 31% of women required critical care stay (n=9) during pregnancy, in comparison with 1.44% nationwide in 2020.[7] Conclusion: It is well established that pregnancy in SCD is high risk, and despite adherence to current guidelines, we have shown very high rates of critical care admission, significant transfusion requirement and hospital admissions. Our findings are comparable to published UK outcomes and they further support the need for a comprehensive specialist care setting for this patient cohort.

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate

Early Preterm meconium stained amniotic fluid is an independent risk factor for peripartum maternal bacteremia

ObjectiveTo investigate the association of maternal peripartum bacteremia and meconium stained amniotic fluid in early preterm deliveries. MethodsWe conducted a single center retrospective study, in a tertiary university affiliated medical center. The study cohort included women with culture proven maternal bacteremia who had a preterm delivery between 24–34 weeks of gestation. The control group composed of women with similar gestational age at delivery without bacteremia. Maternal characteristics were compared between the groups. ResultsDuring the six-years study period there were 86,590 deliveries in our center. 2625 (3.03 %) women had early preterm deliveries (24–34 weeks), of them 22 (0.84 %) were diagnosed with peripartum bacteremia.The groups were similar with regard to obstetric and demographic characteristics. In the peripartum maternal bacteremia group, we found significantly higher rates of MSAF (6.86 % vs 22.73 %, p = 0.036).Logistic regression of multivariable analysis demonstrated that MSAF is an independent risk factor for maternal bacteremia adjusted for gestational age, intrapartum fever and leukocytosis (Odd Ratio 4.29, 95 % CI 1.26–12.56, p = 0.012) ConclusionPreterm MSAF is an independent risk factor for maternal bacteremia among women with early preterm delivery. More studies are needed to determine the need for broad spectrum antibiotic prophylaxis therapy in preterm deliveries complicated by MSAF.

Antimicrobial susceptibility and serotype distribution of Streptococcus agalactiae rectovaginal colonising isolates from pregnant women at a tertiary hospital in Pretoria, South Africa: An observational descriptive study.

Streptococcus agalactiae or group B streptococcus (GBS) is a significant cause of neonatal sepsis. Intrapartum antibiotic prophylaxis is recommended for pregnant women identified to be rectovaginally colonised between 34 and 37 weeks' gestational age to decrease the risk of invasive disease in their newborns. An effective multivalent GBS vaccine may prevent a broader scope of GBS-associated diseases, such as GBS early-onset disease, GBS late-onset disease, spontaneous abortion, stillbirth and maternal bacteraemia. Serotype distribution of GBS isolates is essential to determine the efficacy of such a vaccine. To investigate serotype distribution and antimicrobial susceptibility patterns of GBS isolates cultured from rectovaginal specimens during pregnancy. Sixty-nine archived maternal colonising isolates were tested against penicillin, erythromycin, clindamycin, vancomycin and levofloxacin. Minimum inhibitory concentration testing was performed using the ETEST method. Serotyping was performed by the latex agglutination method. The most common serotypes detected were Ia (54%), III (20%), V (16%), II (6%), IV (2%) and Ib (1%). All isolates were fully susceptible to penicillin, vancomycin and levofloxacin. Eight (11%) and 50 (56%) isolates showed intermediate resistance to erythromycin and clindamycin, respectively, and 1 isolate was resistant to erythromycin. The macrolide-lincosamide-streptogramin B (MLSB) phenomenon was noted in 3 (4%) of the isolates. GBS-colonising isolates remain susceptible to penicillin, which remains the drug of choice for intrapartum antibiotic prophylaxis and treatment of invasive disease in newborns. Macrolides should only be used if clinically indicated due to the high prevalence of intermediate resistance. A pentavalent GBS vaccine currently in phase I trials should provide coverage for 97% of the isolates identified in this study.

Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis.

BackgroundSepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period.MethodsThis was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission.ResultsTwenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25–33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23–34) weeks’ gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications.ConclusionsInjection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

Clinical Risk Factors Associated With Peripartum Maternal Bacteremia

(Obstet Gynecol. 2017;130(4):710–717) Maternal sepsis remains an important contributor to severe maternal morbidity. However, consensus guidelines conflict with evidence-based recommendations encouraging early diagnosis and treatment of febrile peripartum women, and there is no gold standard for the diagnosis of sepsis in pregnancy. In the present study, authors identified exposures associated with bacteremia in febrile women in the peripartum period (primary outcome) and examined associations between adverse outcomes and bacteremia. The degree of initial fever as a clinical predictor was also evaluated.

Clinical Risk Factors Associated With Peripartum Maternal Bacteremia.

To evaluate risk factors associated with maternal bacteremia in febrile peripartum women. We performed a case-control study of women with fevers occurring between 7 days before and up to 42 days after delivery of viable neonates at two academic hospitals. Women with positive blood cultures were matched with the next two febrile women meeting inclusion criteria with negative blood cultures in the microbiology data without other matching parameters. We compared maternal and neonatal characteristics and outcomes between women in the case group and those in the control group with univariate analysis. We then used logistic regression to examine the association between clinical characteristics and maternal bacteremia. After excluding blood cultures positive only for contaminants, we compared 115 women in the case group with 285 in the control group. Bacteremic women were more likely to experience their initial fever during labor (40.9% compared with 22.8%, P<.01) and more likely to have fever at or above 102°F (62.6% compared with 31.6%, P<.01). These associations persisted in the adjusted analysis: multiparity (adjusted odds ratio [OR] 1.75, 95% CI 1.07-2.87), initial fever during labor (adjusted OR 2.82, 95% CI 1.70-4.70), and fever at or above 102°F (adjusted OR 3.83, 95% CI 2.37-6.19). In an analysis restricted to neonates whose mothers had initial fevers before or in the immediate 24 hours after delivery, neonates born to women in the case group had higher rates of bacteremia compared with those born to women in the control group (9.0% compared with 1.3%, P<.01). Eight of the nine bacteremic neonates born to bacteremic mothers (89%) grew the same organism as his or her mother in blood culture. Maternal bacteremia is associated with multiparity, initial fever during labor, and fever at or above 102°F; however, 37.5% of cases of bacteremia occurred in women with maximum fevers below this threshold. Obstetricians should maintain a heightened suspicion for an infectious source of fever in women with these clinical characteristics.

Intrapartum fever and the risk for perinatal complications – the effect of fever duration and positive cultures

Objective: To estimate the association between intrapartum fever and adverse perinatal outcome.Methods: A retrospective cohort study of women attempting vaginal delivery at term in a tertiary hospital (2012–2015). Perinatal outcome of deliveries complicated by intrapartum fever (≥38.0 °C) were compared to women with no intrapartum fever matched by parity and gestational age at delivery in a 1:2 ratio. Maternal outcome included cesarean section (CS), operative vaginal delivery (OVD), retained placenta or post-partum hemorrhage. Neonatal outcome included 5-minute Apgar score <7, umbilical artery pH <7.1, meconium aspiration syndrome, need for mechanical ventilation or hypoxic ischemic encephalopathy.Results: Overall, 309 women had intrapartum fever and 618 served as controls. Women with intrapartum fever had higher rates of OVD (34.3 versus 19.6%, p < .001) and CS (20.7 versus 8.7%, p < .001). In multivariate analysis, intrapartum fever was independently associated with adverse maternal (3.75, 95%CI 2.65–5.30, p < .001) and neonatal outcome (3.39, 95%CI 1.78–6.45, p < .001). In febrile women, fever duration was related to maternal complications, specifically to CS. In addition, maternal bacteremia and positive placental cultures were risk factors for neonatal complications compared to those with negative cultures (23.3 versus 9.8%, p = .01).Conclusions: Intrapartum fever was associated with adverse perinatal complications. The duration of intrapartum fever, maternal bacteremia, and positive cultures further increase this risk.

Acute Fetal Demise with First Trimester Maternal Infection Resulting from Listeria monocytogenes in a Nonhuman Primate Model

ABSTRACTInfection with Listeria monocytogenes during pregnancy is associated with miscarriage, preterm birth, and neonatal complications, including sepsis and meningitis. While the risk of these conditions is thought to be greatest during the third trimester of pregnancy, the determinants of fetoplacental susceptibility to infection, the contribution of gestational age, and the in vivo progression of disease at the maternal-fetal interface are poorly understood. We developed a nonhuman primate model of listeriosis to better understand antecedents of adverse pregnancy outcomes in early pregnancy. Four pregnant cynomolgus macaques (Macaca fascicularis) received a single intragastric inoculation between days 36 and 46 of gestation with 107 CFU of an L. monocytogenes strain isolated from a previous cluster of human listeriosis cases that resulted in adverse pregnancy outcomes. Fecal shedding, maternal bacteremia, and fetal demise were consistently noted within 7 to 13 days. Biopsy specimens of maternal liver, spleen, and lymph node displayed variable inflammation and relatively low bacterial burden. In comparison, we observed greater bacterial burden in the decidua and placenta and the highest burden in fetal tissues. Histopathology indicated vasculitis, fibrinoid necrosis, and thrombosis of the decidual spiral arteries, acute chorioamnionitis and villitis in the placenta, and hematogenous infection of the fetus. Vascular pathology suggests early impact of L. monocytogenes infection on spiral arteries in the decidua, which we hypothesize precipitates subsequent placentitis and fetal demise. These results demonstrate that L. monocytogenes tropism for the maternal reproductive tract results in infection of the decidua, placenta, and the fetus itself during the first trimester of pregnancy.

Evaluation of the Systemic Inflammatory Response Syndrome Criteria for the Diagnosis of Sepsis Due to Maternal Bacteremia

(Int J Gynaecol Obstet. 2016;133(1):116–119) Sepsis is defined as the systemic inflammatory response syndrome (SIRS) with an infectious etiology, including but not limited to bacteremia. Recent studies have confirmed that there is overlap between standard SIRS criteria and the normal physiology of pregnancy. In 2014, a customized obstetric sepsis screening tool was implemented for pregnant and postpartum women in Irish hospitals. These obstetric sepsis screening criteria differed from standard criteria in heart rate (≥100 beats/min, obstetric vs. &gt;90 beats/minute, standard) and leukocyte count (&lt;4.0 or &gt;16.9×109/L, obstetric vs. &lt;4.0 or &gt;12.0×109/L, standard). The authors of the present study evaluated this customized obstetric SIRS screening tool and compared its effectiveness with that of the standard SIRS screening tool, for the diagnosis of maternal sepsis in the presence of maternal bacteremia.

Maternal Sepsis Incidence, Etiology, and Outcome for Mother and Fetus

(BJOG. 2015;122(5):663–671) Although maternal sepsis is uncommon in developed countries due to the availability of antibiotic therapy, bacterial sepsis and fulminant sepsis can occur and result in maternal death. This prospective study aimed to determine the incidence of maternal bacteremia during pregnancy and 6 weeks’ postpartum, characterize the gestation or postpartum period at which sepsis occurs, identify the causative organisms, examine antibiotic resistance, and review maternal, fetal, and neonatal outcomes.

Evaluation of the systemic inflammatory response syndrome criteria for the diagnosis of sepsis due to maternal bacteremia.

To examine, in the setting of maternal bacteremia, the implications for the diagnosis of maternal sepsis of customizing the systemic inflammatory response syndrome (SIRS) criteria for physiologic changes of pregnancy. Women with maternal bacteremia in a tertiary maternity hospital during 2009-2014 were identified. Records were retrospectively reviewed to determine whether they fulfilled the criteria for diagnosis of sepsis based on either the standard SIRS parameters derived from the Surviving Sepsis Campaign or SIRS parameters customized for pregnancy. Diagnosis of sepsis was based on the presence of two or more SIRS criteria, in conjunction with infection, during the hour before and the 6 hours after phlebotomy for blood culture. Of 93 women with bacteremia, 61 (66%) would have been diagnosed with sepsis based on standard criteria compared with 52 (56%) based on customized criteria (P=0.18). Seventeen women had a diagnosis of sepsis based on the standard but not the customized criteria, while eight women had sepsis based on the customized but not the standard criteria. In maternal bacteremia, customized SIRS criteria do not increase the rate of diagnosis of sepsis. Prospective studies should investigate whether the introduction of customized SIRS criteria can improve clinical outcomes.

Expression of Toll-Like Receptors in Chronic Histiocytic Intervillositis of the Placenta

Chronic histiocytic intervillositis of the placenta (CHI) shows monocytic/histiocytic infiltration of the intervillous space. Placental malaria has a CHI-like histopathology and induces an aberrant expression of Toll-like receptors (TLR) 3, 7–9. We hypothesized that, similar to placental malaria, CHI could be associated with increased TLR expression. TLR1-10 and other inflammation-associated factors were analyzed by real-time PCR and immunohistochemistry. A total of 31 formalin-fixed and paraffin–embedded placenta samples were evaluated: CHI (n = 9), and for control purposes, villitis of unknown etiology (VUE, n = 8) and placentas without inflammation (n = 14). CHI shows increased expression of monocytic TLR1, a receptor which is involved in bacterial lipopolysaccharide (LPS)-induced inflammation. This could indicate a TLR1-mediated immune mechanism in the placenta (e.g. triggered by transient, clinically inapparent maternal bacteraemia) which leads to massive monocytic/histiocytic accumulation in the intervillous space. The increased expression of TLR1 with no increased expression of TLR3 and TLR7-9 is different from that in malaria.

Defining Physiological Predictors of Peripartum Maternal Bacteremia.

This study aims to examine physiological and laboratory parameters associated with peripartum maternal bacteremia. This case-control study matched 115 cases (women with fever and bacteremia during the peripartum period) to 285 controls (defined as the next two febrile women with negative blood cultures at the same institution) from two academic medical centers from 2009 to 2013. Conditional logistic regression models were used to evaluate the association of physiological and laboratory parameters with maternal bacteremia at the time of initial and maximum fever. At the time of initial fever, temperature > 103°F (adjusted odds ratio [aOR]: 5.58, 95% confidence interval [CI]: 2.05-15.19) and respiratory rate (RR) > 20 respirations per minute (aOR: 5.27, 95% CI: 2.32-11.96) were associated with bacteremia. At the time of maximum fever, temperature (> 102°F, aOR: 3.37, 95% CI: 1.61-7.06; > 103°F, aOR: 7.96, 95% CI: 3.56-17.82), heart rate > 110 beats per minute (aOR: 2.20, 95% CI: 1.21-3.99), and RR > 20 (aOR: 3.65, 95% CI: 1.65-8.08) were associated with bacteremia. Bandemia > 10% (aOR: 2.44, 95% CI: 1.07-5.54) was associated with bacteremia. Physiological and laboratory parameters associated with maternal bacteremia differed from those reported with sepsis in the adult critical care population. Further studies of objective markers are needed to improve detection and treatment of peripartum bacteremia.