Antibiotic Tx beneficial in PPROM, choice of agent is controversial: reduces chorioamnionitis by 40%

OB/GYN News,  Oct 15, 2003  by Sherry Boschert

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SAN FRANCISCO -- Ample evidence supports the routine use of antibiotics in cases of preterm premature rupture of membranes, but the choice of antibiotics remains controversial, Dr. Melinda Scully Noah said.

Use of any antibiotic to treat preterm premature rupture of membranes (PPROM) reduced the rate of chorioamnionitis by 40% and the rate of neonatal infection, including pneumonia, by about 33%, according to a 2003 Cochrane review of 19 trials involving more than 6,000 women, she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Antibiotic treatment also decreased the rate of births within 48 hours of diagnosis, allowing time to administer betamethasone, and reduced births within 7 days of diagnosis, she said at the meeting.

There were trends toward reduced use of surfactant and neonatal oxygen therapy and fewer abnormal results on neonatal head ultrasounds after antibiotic treatment (Cochrane Database Syst. Rev.[2]:CD001058, 2003).

The review authors recommended avoiding [beta]-lactam antibiotics in women at risk for preterm delivery because one trial found a higher rate of necrotizing enterocolitis with Augmentin (amoxicillin /clavulanate). A macrolide antibiotic, such as erythromycin, would be a better choice, based on the available evidence.

"We don't really know enough. There's only this one trial [with Augmentin]. It certainly is concerning. I think what most people would say is that one should choose the narrowest antibiotic that will benefit patients and also minimize resistance. Penicillin seems to do that," and erythromycin would be another option, said Dr. Noah of the university.

Knowing the patterns of drug-resistant organisms at your institution would be helpful in deciding on treatment, she added.

The bulk of the Cochrane data came from the 4,826-patient Oracle I trial, the study that included Augmentin. The Oracle authors recommended treating PPROM with erythromycin, which was not associated with adverse events, and avoiding Augmentin. It is believed that Augmentin and other broad-spectrum antibiotics dynamically kill bacteria, causing the bacteria to release exotoxins and other harmful agents that initiate an inflammatory response and increase the risk for necrotizing enterocolitis, she said.

PPROM occurs in approximately 1%-3% of pregnancies and is a factor in 30%-40% of preterm births. The leading cause of PPROM is infection; 30%-40% of women with PPROM have positive amniotic fluid cultures.

ARTICLES BY SHERRY BOSCHERT San Francisco Bureau

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