Prophylactic antibiotic administration in pregnancy to prevent infectious morbidity and mortality
This commentary is now outdated and has been replaced by a new commentary. It is included in RHL for archival purposes only. It may be cited as: Schulz KF. Population-based interventions for reducing sexually transmitted infections, including HIV infection: RHL commentary (last revised: 3 August 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.
RHL Commentary by Bamigboye AA
1. EVIDENCE SUMMARY
This review includes six well-conducted randomized double-blind trials. It shows that in unselected women who received systemic prophylactic antibiotics in the second and third trimesters of pregnancy there was a reduction in the risk of pre-labour rupture of membranes (Peto odds ratio 0.32, 95% confidence interval 0.14–0.73). Prophylactic antibiotics also reduced the risk of low birth weight (Peto odds ratio 0.48, 95% confidence interval 0.27–0.84) and postpartum infectious morbidity in selected high-risk mothers. High-risk was defined in three of the six studies as women with a history of preterm deliveries, women with pre-pregnancy weight of less than 50 kg or women with a history of low birth weight babies of less than 2500 grams.
Vaginal administration of clindamycin in high-risk women who had a history of preterm birth did not offer any benefit; rather, it increased the risk of neonatal sepsis.
The search strategy was rigorous and all reports of studies that were identified as potentially eligible were assessed. Data extraction, analysis and presentation were clear and concise.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Preterm birth is the most common cause of perinatal mortality and morbidity in both developed (1) and developing regions of the world. Antepartum infection is an important cause of preterm prelabour rupture of the membranes and preterm labour. In a tertiary institution in the Western Cape Province of South Africa, 38.1% of very-low-birth weight babies were due to preterm pre-labour rupture of membranes and preterm labour (2).
Financial and logistic requirements in managing premature babies far exceed the resources available to health care systems in the developing world. Antenatal screening for infectious conditions is often limited to occasional urine dipstick tests during the few antenatal care attendances. Hence, any intervention that can limit the occurrence of infectious morbidity that will translate into reduction in the incidence of preterm delivery should be explored.
2.2. Applicability of the results
Three of the six studies were conducted in developing countries, and there appears to be no difference in outcome compared with the remaining three studies that were conducted in developed countries. Thus, the results of the systematic review seem to be applicable to under-resourced settings, keeping in mind the role played by poorer socioeconomic conditions in increasing the risk of infectious morbidity.
2.3. Implementation of the intervention
It should be feasible to prescribe antibiotics routinely in under-resourced settings. Health-care workers and planners can consider the trade-off between the cost of prescribing antibiotics routinely to all women and the savings resulting from reduction in the occurrence of pre-labour rupture of the membranes. Data supporting the use of prophylactic antibiotics in women with specific risk factors are compelling since the review found a reduction in substantive outcomes.
3. RESEARCH
Many important short- and long-term outcomes such as adverse drug reactions, maternal morbidity from infections, neonatal sepsis, admission to intensive care unit, etc. were not adequately addressed in the trials included in the review. Equally, the sample size for detecting necessary outcomes in unselected women may not have been adequate. In the light of these shortcomings, a multicenter study involving both developing and developed countries would be justified.
References
- Danielian PJ, Hall MH. The epidemiology of prematurity. Current obstetrics gynecology 1996;6:137–142.
- Odendaal ES, Steyn DW, Odendaal HJ. Obstetrics causes for delivery of very low birth weight babies. South African journal of obstetrics and gynecology 2003;9 (1):16–20.
This document should be cited as: Bamigboye AA. Prophylactic antibiotic administration in pregnancy to prevent infectious morbidity and mortality : RHL commentary (last revised: 3 August 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.