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Antibiotic use for preterm birth

#Background

Aotearoa follows a risk-based approach to the prevention of early onset Group B streptococcus infection for newborn pēpi. Although the incidence of Group B streptococcus carrier status is unlikely to change significantly by gestational age at birth, preterm pēpi are more vulnerable to this potentially life-threatening infection and hence preterm labour is one of the five recognised risk factors. This risk-based approach to prevention has been associated with a reduction in the incidence of early onset Group B streptococcus infection, including in Aotearoa. The original New Zealand Consensus Guidelines were released in 2004,1 and were updated in 2014.2 Following their introduction, the New Zealand Paediatric Surveillance Unit showed a halving of incidence from 0.5 per 1000 livebirths (in 1998-9) to 0.26 per 1000 livebirths (in 2009-11).3

Preterm labour is commonly associated with clinical and subclinical infection which has led to consideration of more widespread antibiotic use in wāhine/people in preterm labour, beyond prophylaxis treatment for Group B streptococcus infection. The most recent (2013) Cochrane Review included 14 trials and 7837 wāhine/people, the largest trial by far was the United Kingdom ORACLE II trial (more than 6200 participants), for which longer-term childhood outcomes to seven years of age are available.4 Prophylactic antibiotic use was not associated with any difference in perinatal or infant mortality or in rates of preterm birth. Importantly it was associated with an increase in neonatal death (RR 1.57, 95% CI 1.03-2.40) and a possible increase in any functional impairment and cerebral palsy at the age of seven years, reaching significance for combined macrolide (e.g. erythromycin) and beta‐lactam (e.g. penicillin and cephalosporin) antibiotic use and cerebral palsy (RR 2.83, 95% CI 1.02-7.88).4

#Recommendations and Practice

Early onset Group B streptococcus infection prophylaxis

Guideline Recommendations
— Antibiotic use for early onset Group B streptococcus infection prophylaxis

  • All wāhine/people in established preterm labour with or without intact membranes should be offered intrapartum antibiotic prophylaxis.
  • All wāhine/people undergoing induction or augmentation of preterm labour should be offered intrapartum antibiotic prophylaxis.

Recommended intrapartum antibiotic prophylaxis regimes:

  • Intravenous benzylpenicillin loading dose 1.2 g, followed by repeat doses 0.6 g every 4 hours until birth.
  • For wāhine/people with penicillin allergy and low risk of anaphylaxis, intravenous cephazolin loading dose 2 g, followed by 1 g every 8 hours until birth.
  • For wāhine/people with penicillin allergy and high risk of anaphylaxis, intravenous vancomycin loading dose 1 g, followed by 1 g every 12 hours until birth.

Good Practice
— Antibiotic use for early onset Group B streptococcus infection prophylaxis

  • Intrapartum antibiotic prophylaxis should be commenced as soon as established preterm labour is diagnosed, even if birth is expected within the next hour.
  • Intrapartum antibiotic prophylaxis should continue until birth (or be stopped if labour does not continue).
  • Group B streptococcus antibiotic prophylaxis is not required for wāhine/people undergoing a preterm prelabour caesarean section.
  • Wāhine/people in preterm labour should be provided with verbal and written information on early onset Group B streptococcus infection and the benefits and risks of antibiotic prophylaxis.
  • Interpreter services and cultural support should be available and offered to all wāhine/people and whānau to support the provision of information.

Active preterm labour

Guideline Recommendations
— Antibiotic use in active preterm labour

  • Routine antibiotic use (in addition to Group B streptococcus prophylaxis) is not recommended for wāhine/people in preterm labour, with intact membranes and no clinical signs of chorioamnionitis.
  • Wāhine/people in preterm labour with clinical signs of chorioamnionitis should receive broad spectrum antibiotic treatment regardless of their planned mode of birth.

Good Practice
— Antibiotic use in active preterm labour

  • Each unit should have a recommended standardised antibiotic regime for suspected chorioamnionitis and this should be used consistently.

Examples of recommended antibiotic regimes for suspected chorioamnionitis include:

  • Intravenous amoxycillin 2 g every 6 hours AND intravenous gentamicin 5 mg/kg of estimated ideal body weight with daily dose according to blood levels AND intravenous metronidazole 500 mg every 12 hours.
  • Intravenous cefuroxime 750 mg every 6 hours AND intravenous gentamicin 5 mg/kg of estimated ideal body weight with daily dose according to blood levels.
  • Intravenous cefuroxime 1.5 g every 8 hours AND intravenous metronidazole 500 mg every 12 hours.
  • For wāhine/people with penicillin allergy, intravenous clindamycin 600 mg every 8 hours AND intravenous gentamicin 5 mg/kg of estimated ideal body weight with daily dose according to blood levels.
  • For wāhine/people with penicillin allergy, intravenous meropenem 1 g every 8 hours.

The Carosika Whānau Information on Care in Preterm Labour may be used to support conversations with wāhine/people and whānau about antibiotic use.

Published: October 2024 | PDF

Download - The Carosika Whānau Information on Care in Preterm Labour may be used to support conversations with wāhine/people and whānau about antibiotic use.

Preterm caesarean section

Guideline Recommendations
— Antibiotic use in preterm caesarean section

  • Routine prophylactic antibiotic use at caesarean section is recommended for all wāhine/people at all gestations to reduce the risk of surgical site infection, this should be administered as per local guidelines.
  • Wāhine/people with clinical signs of chorioamnionitis should receive broad spectrum antibiotic treatment regardless of their planned mode of birth (example regimes provided for preterm labour).

 

 

#Included guidelines

The search identified 10 guidelines relevant to Group B streptococcus infection in pregnancy5-13 and a further 11 guidelines on the general acute management of preterm labour, two were specific to extreme preterm birth,14-24 that met criteria for high-quality and/or were recommended for use by the Review Panel. Only one guideline relevant to Group B streptococcus infection in pregnancy was assessed to be high-quality in Overall Assessment (score >60%) (but not in Rigour of Development),2 all others were assessed by the Review Panel to be suitable for use with modifications;5-13 eight of these guidelines were specific to district health boards.5-10,12,13 Of the guidelines on the general acute management of preterm labour, one was assessed to be high-quality in Rigour of Development (score >60%) and in Overall Assessment (score >60%).22 This guideline only focused on antibiotic use for preterm labour and stated that antibiotic use for Group B streptococcus prophylaxis was beyond the scope of the guideline. One guideline was assessed to be high-quality in Overall Assessment (score >60%) only;20 this guideline was specific to birth at the limits of survival. The remaining nine guidelines were assessed by the Review Panel to be suitable for use with modifications and all were specific to district health boards;14-19,21,23,24 the majority only included recommendations on antibiotic use for Group B streptococcus prophylaxis and referred to their local Group B streptococcus infection in pregnancy guidelines.

Recommendations in this section on antibiotic use of Group B streptococcus prophylaxis are based on the 2014 New Zealand Consensus Guidelines on the prevention of early onset neonatal Group B streptococcus infection.2 This guideline was first developed in 2004 by a multidisciplinary group representing relevant national colleges and societies.1 The group reconvened in 2012 and published a consensus statement with reviewed recommendations. Recommendations in this section on general antibiotic use in preterm labour are based on the World Health Organization (WHO) recommendations on interventions to improve preterm birth outcomes.22

#Impact on equity

Review Panel assessments of the identified guidelines relevant to antibiotic use in preterm labour identified potential to reduce and increase differences by equity factors. However, no comments were specific to antibiotic use. Of note, a common theme was of the opportunity to create consistency in practice but with the need to ensure access to care and consistent practice is prioritised.

#Research in progress that may inform future practice recommendations

None identified.

#Statement on rationale for any differing recommendations from the high-quality guidelines

Recommendations are consistent with the identified high-quality guidelines. Recommendations on antibiotic regimes for suspected chorioamnionitis were not supplied in high-quality guidelines and are adapted from district health board guidelines where this information was provided, including review of guidelines on maternal sepsis and chorioamnionitis.

#Auditable Standards

To be added

Standards should be considered across your population and by ethnic group to allow objective assessment of equity in practice.

The Carosika Antibiotic Use in Preterm Labour Audit Tool document may be used to support hospitals and healthcare professionals to undertake local practice audit on corticosteroid use in preparation for preterm birth.

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Download - The Carosika Antibiotic Use in Preterm Labour Audit Tool document may be used to support hospitals and healthcare professionals to undertake local practice audit on corticosteroid use in preparation for preterm birth.

 

#References

1. Campbell N, Eddy A, Darlow B, Stone P, Grimwood K. The prevention of early-onset neonatal group B streptococcus infection: technical report from the New Zealand GBS Consensus Working Party. N Z Med J. 2004;117(1200):U1023. PMID: 15475993.

2. Darlow B, Campbell N, Austin N, Chin A, Grigg C, Skidmore C, et al. The prevention of early-onset neonatal group B streptococcus infection: New Zealand Consensus Guidelines 2014. N Z Med J. 2015;128(1425):69-76. PMID: 26905989.

3. Darlow BA, Voss L, Lennon DR, Grimwood K. Early-onset neonatal group B streptococcus sepsis following national risk-based prevention guidelines. Aust N Z J Obstet Gynaecol. 2016;56(1):69-74. DOI: 10.1111/ajo.12378.

4. Flenady V, Hawley G, Stock OM, Kenyon S, Badawi N. Prophylactic antibiotics for inhibiting preterm labour with intact membranes. Cochrane Database Syst Rev. 2013(12):CD000246. DOI: 10.1002/14651858.CD000246.pub2.

5. Auckland District Health Board. Group B Streptococcus (GBS) - Prevention of Early-Onset Neonatal Infection. Auckland: Auckland District Health Board; 2020.

6. Capital and Coast District Health Board. Prevention of Early-onset Neonatal Group B Streptococcal Disease. Wellington: Capital and Coast District Health Board; 2021.

7. Canterbury District Health Board. Group B streptococcus - Management and prophylactic antibiotics in labour. Christchurch: Canterbury District Health Board; 2021.

8. Counties Manukau District Health Board. Group B Streptococcus - Prevention of Early Onset Neonatal Infection. Auckland: Counties Manukau District Health Board; 2019.

9. Hutt Valley District Health Board. Group B Streptococcus (GBS) in pregnancy. Hutt Valley: Hutt Valley District Health Board; 2021.

10. MidCentral District Health Board. Management rupture of membranes and antepartum/intrapartum Group B streptococcus (GBS). Palmerston North: MidCentral District Health Board; 2020.

11. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Maternal Group B Streptococcus in Pregnancy: Screening and Management; 2019. Available from: https://ranzcog.edu.au/RANZCOG\_SITE/media/RANZCOG-MEDIA/Women's Health/Statement and guidelines/Clinical-Obstetrics/Maternal-Group-B-Streptococcus-in-pregnancy-screening-and-management-(C-Obs-19).pdf?ext=.pdf.

12. Tairāwhiti District Health Board. The prevention of neonatal Group B streptococal infection (GBS). Gisborne: Tairāwhiti District Health Board; 2019.

13. Waikato District Health Board. Prevention of Neonatal Group B Streptococcus Infection (GBS). Hamilton: Waikato District Health Board; 2017.

14. Auckland District Health Board. Preterm Labour - Management of Threatened and Active Preterm Labour. Auckland; Auckland District Health Board; 2021. Available from: https://nationalwomenshealth.adhb.govt.nz/assets/Womens-health/Documents/Policies-and-guidelines/Preterm-Labour-PTL-Management-of-Threatened-and-Active-PTL.pdf.

15. Counties Manukau District Health Board. Preterm Labour Antenatal management of women at high risk of Preterm Birth, management of threatened and acute Preterm Labour (including cervical cerclage insertion). Auckland: Counties Manukau District Health Board; 2020.

16. Counties Manukau District Health Board. Extreme Preterm Birth at 22 to 25+6 weeks. Auckland: Counties Manukau District Health Board; 2021.

17. Lakes District Health Board. Preterm labour: Management of threatened and active preterm labour guideline. Rotorua: Lakes District Health Board; 2021.

18. MidCentral District Health Board. Management of threatened and active preterm labour. Palmerston North: MidCentral District Health Board; 2021.

19. Nelson Marlborough District Health Board. Pre-term labour guideline. Nelson: Nelson Marlborough District Health Board; 2020.

20. Newborn Clinical Network. New Zealand Consensus Statement on the Care of Mother and Baby(ies) at Periviable Gestations: Newborn Clinical Network; 2019. Available from: https://www.starship.org.nz/guidelines/new-zealand-consensus-statement-on-the-care-of-mother-and-baby-ies-at/.

21. Northland District Health Board. Preterm labour treatment guideline. Whangarei: Northland District Health Board; 2019.

22. World Health Organisation. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes. Geneva: World Health Organisation; 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/183037/9789241508988\_eng.pdf.

23. Waikato District Health Board. Preterm Labour. Hamilton: Waikato District Health Board; 2021.

24. Tairāwhiti District Health Board. Preterm labour and birth. Gisborne: Tairāwhiti District Health Board; 2019.

 

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