Aetiology and use of antibiotics in pregnancy-related infections: results of the WHO Global Maternal Sepsis Study (GLOSS), 1-week inception cohort

Abstract

Background: Pregnancy-related infections are important contributors to maternal sepsis and mortality. We aimed to describe clinical, microbiological characteristics and use of antibiotics by source of infection and country income, among hospitalized women with suspected or confirmed pregnancy-related infections.

Methods: We used data from WHO Global Maternal Sepsis Study (GLOSS) on maternal infections in hospitalized women, in 52 low-middle- and high-income countries conducted between November 28th and December 4th, 2017, to describe the frequencies and medians of maternal demographic, obstetric, and clinical characteristics and outcomes, methods of infection diagnosis and causative pathogens, of single source pregnancy-related infection, other than breast, and initial use of therapeutic antibiotics. We included 1456 women.

Results: We found infections of the genital (n = 745/1456, 51.2%) and the urinary tracts (UTI) (n = 531/1456, 36.5%) to be the most frequent. UTI (n = 339/531, 63.8%) and post-caesarean skin and soft tissue infections (SSTI) (n = 99/180, 55.0%) were the sources with more culture samples taken and microbiological confirmations. Escherichia coli was the major uropathogen (n = 103/118, 87.3%) and Staphylococcus aureus (n = 21/44, 47.7%) was the commonest pathogen in SSTI. For 13.1% (n = 191) of women, antibiotics were not prescribed on the same day of infection suspicion. Cephalosporins (n = 283/531, 53.3%) were the commonest antibiotic class prescribed for UTI, while metronidazole (n = 303/925, 32.8%) was the most prescribed for all other sources. Ceftriaxone with metronidazole was the commonest combination for the genital tract (n = 98/745, 13.2%) and SSTI (n = 22/180, 12.2%). Metronidazole (n = 137/235, 58.3%) was the most prescribed antibiotic in low-income countries while cephalosporins and co-amoxiclav (n = 129/186, 69.4%) were more commonly prescribed in high-income countries.

Conclusions: Differences in antibiotics used across countries could be due to availability, local guidelines, prescribing culture, cost, and access to microbiology laboratory, despite having found similar sources and pathogens as previous studies. Better dissemination of recommendations in line with antimicrobial stewardship programmes might improve antibiotic prescription.

Keywords: Antibiotic; Infections; Maternal morbidity; Maternal sepsis.

Fig. 1

Study population flowchart. Percentages are shown as n of total sample. 1. GLOSS study population; 2. Women with other infections (respiratory, bloodstream, peritonitis or abdominal cavity, central nervous systems, unspecified); 3. Breast infections were excluded due to small numbers; 4. Clinically confirmed refers to infections confirmed only by clinical examination, imaging or laboratory; 5. Microbiologically confirmed refers to infections with identified pathogen with either by Gram staining or other type of microscopy finding, any matching positive cultures of any body fluid. A match to the source of infection was a case where the specimen for the source of the positive culture sample (taken at any time) was considered adequate for the diagnosis of that infection

Fig. 2

Most commonly antibiotic combinations prescribed among women with a single source of pregnancy-related infection, by source of infection. The first three most common combinations are shown. 1. UTI was excluded, for which prescription of combination of antibiotics is not recommended

Fig. 3

Most commonly prescribed antibiotics among women with one source of pregnancy-related infection, by source of infection and country income level. LIC low-income countries, L-MIC lower-middle-income countries, UMIC upper-middle income countries, HIC high-income countries (2018 World Bank classification) (N = 1456)