CPG Infectious Diseases (OB-Gyne) (POGS, 2009 ) 2 PDF

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Philippine Obstetrical and Gynecological Society (POGS), Foundation, Inc.

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C L IN I C A L P R AC T I C E G U ID E L IN E S on IN F E C T IO U S D I SE A SE S IN O B - G YN

November 2009

Task Force on Clinical Practice Guideline In the Management of Infectious Diseases in OB-GYN

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FOREWORD!

! LOURDES B. CAPITO, MD President Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009

I have envisioned and have implemented to completion the publication of a series of Clinical Practice Guidelines on the major procedures and topics of Obstetrics and Gynecology. This is in consonance with the theme of my Presidency, “Babae, Kalusugan Mo, Katungkulan Natin”. This is the Clinical Practice Guidelines on Infectious Diseases in Obstetrics and Gynecology (OB-GYN) and is the First Edition of this Publication, 2009. In the role of the POGS to provide its members with updates, current and standard practice recommendations and guidelines, this publication will fulfill the objective of continuing education and implementation of refinements in Obstetrics and Gynecology. In keeping with the highest standards of care, the Level and Grades of Clinical Practice/Recommendation have been adopted for every recommendation that is completed and decided. In the process of the formulation of the guideline/recommendation, the entire membership of the POGS was consulted. I take special effort to thank the AdHoc Committee on Clinical Practice Guidelines, headed by its Chair, Dr. Efren J. Domingo for the unceasing tireless effort to complete this publication. I also gratefully acknowledge the Chairs and Training Officers of the Residency-Accredited Hospitals, the Section of OB-GYN Infectious Diseases, PGH, and the CME Committee. It becomes easy, dignified and scientific to conduct the practice of Obstetrics and Gynecology specifically on Infectious Diseases in OB-GYN. Now, the Clinical Practice Guidelines on Infectious Diseases in OB-GYN will hope to update and make the practice current and responsive to world-class standards and make the patients under our care deserving of the trust and confidence that we, Obstetrician-Gynecologist, impart with utmost care and compassion.

LOURDES BLANCO-CAPITO, MD

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INTRODUCTION!

EFREN J. DOMINGO, MD, PhD Chair, AdHoc Committee on the Clinical Practice Guidelines, 2009

The Clinical Practice Guidelines on Infectious Diseases in Obstetrics and Gynecology (OB-GYN) is the First Edition of this Publication, 2009. The Philippine Obstetrical and Gynecological Society, (Foundation), Inc. (POGS), through the AdHoc Committee on Clinical Practice Guidelines initiated and led to completion the publication of this manual in plenary consultation with the Residency Accredited Training Hospitals’ Chairs and Training Officers, The Regional Board of Directors, The Board of Trustees, The Section of OB-GYN Infectious Diseases, PGH and the Committee on Continuing Medical Education. This publication represents the collective effort of the POGS in updating the clinical practice of Obstetrics and Gynecology, specifically on Infectious Diseases in OB-GYN, and making it responsive to the most current and acceptable standard in this procedure. A greater part of the inputs incorporated in this edition are the contributions originating from the day-today academic interactions from the faculty of the different Residency-Accredited Hospitals in Obstetrics and Gynecology in the country. This Clinical Practice Guideline on Infectious Diseases in OB-GYN is envisioned to become the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition of quality care and decision making in managing the OB-GYN patient. This is also envisioned to provide the academic institutions in the country and in Southeast Asia updated information on Infectious Diseases in OB-GYN treatments being practiced in the Philippines. Profound gratitude is extended to all the members of the POGS, the Chairs and Training Officers of the Residency-Training Accredited Institutions, the Regional Directors, The Section of OB-GYN Infectious Diseases, PGH, The CME Committee members and the 2009 POGS Board of Trustees.

EFREN J. DOMINGO, MD, PhD

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BOARD OF TRUSTEES 2009

OFFICERS Lourdes B. Capito, MD President Regta L. Pichay, MD Vice President Ma. Carmen H. Quevedo, MD Secretary Ditas Christina D. Decena, MD Treasurer Christia S. Padolina, MD Public Relations Officer

BOARD OF TRUSTEES Mayumi S. Bismarck, MD Virgilio B. Castro, MD Efren J. Domingo, MD, PhD Gil S. Gonzales, MD Diosdado V. Mariano, MD Ma. Socorro M. Solis, MD

! ! ADHOC COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON INFECTIOUS DISEASES IN OB-GYN Efren J. Domingo, MD, PhD Chair MEMBERS Jennifer T. Co, MD Lisa Teresa P. Jabson, MD Jericho Thaddeus P. Luna, MD Noel E. Raymundo, MD Josephine M. Lumitao, MD Elisa O. Tiu, MD FELLOWS Rachelle U. delos Reyes, MD Ana Victoria V. Dy Echo, MD May Nueva-Hipolito, MD Michelle R. Ong, MD Renee Vina G. Sicam, MD TECHNICAL STAFF ASSISTANTS Ms. Emiliana C. Enriquez Ms. Jhasmin G. De Guzman

TASK FORCE ON INFECTIOUS DISEASES IN OB-GYN Lourdes B. Capito, MD Ricardo M. Manalastas Jr, MD Chairs CONSULTANT STAFF Stella Marie L. Jose, MD Guadalupe N. Villanueva, MD Maria Angela R. Bandola, MD Sybil Lizanne R. Bravo, MD Lorina Q. Esteban, MD Analyn F. Fallarme, MD INVITED ALUMNI FACULTY Martha M. Aquino, MD Jennifer T. Co, MD Christine D. Dizon, MD Patricia M. Kho, MD Mary Jane Noble, MD OB-GYN INFECTIOUS DISEASE FELLOWS Sigrid A. Barinaga, MD Mary Judith Q. Clemente, MD May Gabaldon, MD Julie M. Resurreccion, MD Rojannah T. Sahagun, MD

Chairs, Training Officers of POGS Accredited Residency Training Program

Regional Directors of POGS, 2009

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DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY

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This is the Clinical Practice Guidelines (CPG) on Infectious Diseases in Obstetrics and Gynecology, First Edition, November 2009. This is the publication of the Philippine Obstetrical and Gynecological Society, (Foundation), Inc. (POGS). This is the ownership of the POGS, its officers, and its entire membership. The obstetrician-gynecologist, the general practitioner, the patient, the student, the allied medical practitioner, or for that matter, any capacity of the person or individual who may read, quote, cite, refer to, or acknowledge, any, or part, or the entirety of any topic, subject matter, diagnostic condition or idea/s willfully release and waive all the liabilities and responsibilities of the POGS, its officers and general membership, as well as the AdHoc Commiittee on the Clinical Practice Guidelines and its Editorial Staff in any or all clinical or other disputes, disagreements, conference audits/controversies, case discussions/critiquing. The reader is encouraged to deal with each clinical case as a distinct and unique clinical condition which will never fit into an exact location if reference is made into any or all part/s of this CPG. The intention and objective of this CPG is to serve as a guide, to clarify, to make clear the distinction. It is not the intention or objective of this CPG to serve as the exact and precise answer, solution and treatment for clinical conditions and situations. It is always encouraged to refer to the individual clinical case as the one and only answer to the case in question, not this CPG. It is hoped that with the CPG at hand, the clinician will find a handy guide that leads to a clue, to a valauable pathway that leads to the discovery of clinical tests leading to clinical treatments and eventually recovery. In behalf of the POGS, its Board of Trustees, the Adhoc Committee on The Clinical Practice Guidelines, 2009, this CPG is meant to make each one of us a perfect image of Christ, the Healer.

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CPG ON INFECTIOUS DISEASES IN OB-GYN TABLE OF CONTENTS / AUTHORS!

Management Guidelines of Common Obstetric Infections I. Intraamnionic Infection …………………………………………………….. Patricia Malay-Kho, MD II. Puerperal Infection …………………………………………………………. Jennifer T. Co, MD III. Surgical Site Infections a. Post-Cesarean Section Wound Infections …………………………. Mary Jane Noble, MD b. Episiotomy Site Dehiscence ……………………………………….. Lorina Quimio-Esteban, MD IV. Septic Abortion …………………………………………………………….. Analyn Fuentes-Fallarme, MD

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INTRA-AMNIOTIC INFECTION Patricia Malay-Kho, MD

DEFINITION OF TERMS Intra-amniotic Infection (IAI) • Describe the clinical syndrome of intrapartum infection of the placenta and membranes accompanied by signs and symptoms in the mother and fetus Chorioamnionitis • Denote histologic infection wherein microorganisms and polymorphonuclear leukocytes resides in the layers between the chorion and the amnion • Applied only to pregnancies in which the fetus has achieved viability; i.e., weight exceeding 500 grams, to differentiate it from infected abortion

DIAGNOSIS: CLINICAL HISTORY – IDENTIFY RISK FACTORS (A)

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First pregnancy Young age Preterm labor (10x increase risk) Premature rupture of amniotic membranes (10x increase risk) Ruptured membranes for a prolonged period (> 12 hrs) Prolonged active phase Labor o Primigravid > 12 hours o Multigravid > 8 hours Use of intrauterine monitors Frequent and numerous vaginal examinations (> 6 times) Presence of meconium in the amniotic fluid (4x increase risk) History of untreated or inadequately treated abnormal vaginal flora (Group B Streptococcus (GBS), Neisseria gonorrhea, Chlamydia trachomatis, Enterobius coli, Gardneralla vaginalis, bacteroides, etc.) o Bacterial reproduction occur in either the uterine cavity or the amniotic fluid over the course of 12 hours

DIAGNOSIS: PHYSICAL EXAMINATION (B)

• Criteria for the Diagnosis of IAI – presence of two out of three clinical signs of disease

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1 Maternal Pyrexia (nonspecific) • a confirmed oral temperature of greater than 37.8C • most significant and constant finding • considered as the hallmark for the diagnosis of IAI 2 Uterine tenderness (specific) 3 Persistent fetal tachycardia (specific) – a fetal heart rate greater than or equal to 160 beats per minute for 5 minutes Other physical examination findings: • Membrane status

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o Clinical significance: possible postpartum endometritis

DIFFERENTIAL DIAGNOSIS (C)

• Intrapartum fever in a woman with ruptured membranes and in the absence of other causes almost always signifies IAI

• It is important to determine the site of infection, and not to assume that it is intrauterine because the usual management of chorioamnionitis is to deliver the fetus, regardless of age.

ANCILLARY PROCEDURES (D) A positive result is defined as the presence of any microorganism seen on high power field (HPF) of unspun amniotic fluid, it establishes that there are > 103 bacteria/mL of amniotic fluid present Correlated with subsequent culture growth but not with GRAM STAIN clinical diagnosis of IAI > 104 cfu bacteria/mL increases probability to develop chorioamnionitis There are no data to suggest that intervention based on a positive gram stain alters perinatal morbidity S. agalactiae Gram positive cocci L. monocytogenes Gram positive bacilli Homogenous morphologic gram- E. coli negative bacilli Prevotella Pleomorphic gram-negative rods Fusobacterium Fusiform gram-negative rods Large gram-positive cocci Anaerobic streptococci Suggest an inflammatory response Specificity = 75 – 98% WHITE BLOOD CELLS (WBC) Sensitivity = 75 – 100% Considered to be of little predictive or diagnostic value < 15 mg/dL suggest phagocytic activity and infection Sensitivity to predict a positive amniotic fluid culture = 41GLUCOSE CONCENTRATION 55% Specificity in detecting those cases with positive amniotic fluid culture = 94-100% Identify aerobic, facultative, obligate anaerobic bacteria, C. trachomatis, Mycoplasma and Ureaplasma The inherent 48 hour delay limits their clinical application CULTURE Unless the amniotic fluid is foul smelling, only aerobic culture is required Do not correlate well with clinical disease

" Evaluate for presence of bacterial vaginosis – Associated with 2-fold increase incidence of IAI " Rectovaginal swab culture for GBS – No conclusion can be made on the influence of GBS on the frequency of IAI

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If > 10% of WBC are immature polymorphonuclear leukocytes, this is indicative of acute infection – By the time a significant increase in the WBC is demonstrable, other signs indicative of chorioamnionitis are usually present C-reactive protein – Nonspecific – Generally increases in conjunction with an inflammatory response – Sensitivity = 82% – Specificity = 55% – Positive predictive value (PPV) = 36% – Negative predictive value (NPV) = 9% – Become of value in guiding the duration of therapy in preterm prelabor rupture of membranes (PPROM) on antibiotic therapy challenge • Continue antibiotic therapy 24 hours beyond a negative titer Urine culture Blood culture for patients with clinically apparent chorioamnionitis Despite the presence of fever, blood cultures are of limited value

Patients not presenting with classic signs and symptoms of IAI should be evaluated as follows:

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CBC with WBC differential C-reactive protein Urine culture Amniocentesis – culture, gram stain, glucose concentration

TREATMENT (E) 1.

Antimicrobial Therapy • Antimicrobial therapy should be given at the time of diagnosis1 • Ampicillin is the drug of choice for fetal therapy3 • Aminoglycoside is added as a maternal therapy to prevent development of septic shock from Enterobacteriaceae (E. coli or K. pneumoniae)3 • If foul-smelling amniotic fluid is present, an intravenous bolus of metronidazole may be utilized for coverage of Bacteroidaceae/Prevotella species ! The relative inability of clindamycin to effectively traverse the placental barrier limits its theoretical efficacy.3 ! No recommendations can be made on the most appropriate antimicrobial regimen to choose to treat IAI4

Antibiotic (Trade Name) COMBINATION THERAPIES Ampicillin and gentamicin *

Piperacillin/tazobactam

Dose 2 g ampicillin every 6 hours and 2 mg/kg loading dose then 1.5 mg/kg every 8 hours of gentamicin OR single dose of 4 to 7 mg/kg gentamicin once daily 3.375 g of piperacillin every 6 hours and 1.5 g of Tazobactam every 6 hours

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Ampicillin-sulbactam 3 g every 6 hours Ticarcillin-clavulanic acid 3.1 g every 6 hours Cefoxitin 2 g every 8 to 12 hours Cefuroxime 1.5 g every 8 hours IF PENICILLIN ALLERGIC Vancomycin 500 mg every 6 hours Erythromycin 1 g every 6 hours Clindamycin 900 mg every 8 hours ADD ONE OF THESE AGENTS IF CESAREAN BIRTH PERFORMED Clindamycin 900 mg every 8 hours OR single dose 900 mg at cord clamping Metronidazole 500 mg every 6 hours Sources: Gibbs et al., Gilstrap et al., Hopkins and Smaill, and Edwards and Duff * This regimen is considered as the most cost-effective

2. Delivery • The cut-off age of gestation wherein neonatal survival is assured depends on the capability of the nursery of each individual institution • IAI is an indication for delivery but it is not an indication for cesarean birth • The critical interval from diagnosis to delivery after which neonatal or maternal complications increase has not been identified • There is little evidence to suggest that cesarean section (CS) offers advantages to the fetus over vaginal birth and maternal morbidity may be increased by CS • Route of delivery: standard obstetric indications • When CS is indicated, the standard transperitoneal low transverse incision is appropriate. • Guidelines favoring the prompt termination of pregnancy ! Nonresponsive nonstress test (NST) and a positive contraction stress test (CST) ! Fetal bradycardia ! Fresh appearance of meconium with any concomitant evidence of fetal compromise ! Evidence of maternal decompensation or worsening of maternal disease ! Increasing maternal pyrexia despite antibiotic therapy of 120 minutes duration IAI-related indications for histopathologic examination of the placenta • Suspicion or confirmed infection • Premature delivery (especially before 34 weeks) • Maternal fever • Thick or particulate meconium • Prolonged rupture of membranes (> 24 hours) • Neonatal admission to the NICU • Stillbirth • Death in the perinatal period • Umbilical cord blood pH < 7.0 • APGAR score < 6 at 5 minutes • Neonatal ventilator assistance more than 10 minutes • Neonatal intubation

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References 1 2 3 4 5

Faro S, Soper D. Infectious diseases in women. 2001, WV Saunders and Co. Friedman E., Acker D, Sachs B. Obstetrical decision making, 2nd ed. 1987, B.C. Decker Inc. Monif G. Infectious diseases in obstetrics and gynecology. 2008, Taylor and Francis. Antibiotic regimens for the management of IAI: Cochrane 2002 Fahey, Jennifer O. Clinical management of intra-amniotic infection and chorioamnionitis: A review of the literature. J Midwifery Women Health 2008;53(3):227-235.

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PUERPERAL INFECTION Jennifer T. Co, MD

Puerperal infection is any infection occurring within 6 weeks after delivery. The algorithm below and its discussion is intended for the management of puerperal infection resulting from postpartum endometritis. Fever is the cardinal manifestation of puerperal infection. Puerperal morbidity is defined by the Joint Committee on Maternal Welfare as a temperature of 38oC occurring in any two of the first 10 days postpartum, exclusive of the first 24 hours. Exclusion of the first 24 hours is based upon the observation that following spontaneous vaginal delivery, only 6-8% of women will have an isolated febrile spike in the first 24 hours and that only 25% of them will develop overt infection requiring antibiotics.1 CRITERIA FOR SIGNIFICANT FEVER NECESSITATING WORK UP (1) A. Two consecutive temperatures > 38 C taken at least 34 hours apart B. One temperature > 38.5 C C. Three temperatures > 38 C in any 24 hour period

INFECTIOUS VS. NON-INFECTIOUS CAUSE OF FEVER A complete history and physical examination are essential to differentiate the cause of fever. Baseline adjunct laboratory examinations include a complete blood count, urinalysis or chest radiograph. Non-infectious causes of fever may include breast engorgement, dehydration or anesthesia complications. The febrile pattern in these cases tends to be low grade and lasts only briefly. Infectious causes are accompanied by concomitant signs of inflammation on the affected site, cellulitis, chills, presence of foul smelling or purulent discharge and elevated WBC count.

DETERMINING FOCUS OF INFECTION Sources of infection in the puerperal period may not be confined to the genital tract. However these extragenital infections are less common and may include infections involving the urinary, respiratory and gastrointestinal tracts, the breast, as well as wound infections. Most of them can be ruled out by history and physical examination alone. Patients should be asked at a minimum about coughing, chest pain, pain at the insertion of intravenous catheters, breast tenderness and leg pain. Examination of these areas may also aid in determining the site of infection. Chest X rays are rarely of benefit unless signs and symptoms point to a pulmonary cause of infection.3

Postpartum Endometritis (Uterine Focus) Several predisposing factors may increase the suspicion of postpartum endometritis: • Manner of delivery. This is the most significant risk factor with cesarean section identified as a factor for puerperal ...