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JOGC

No. 233-Antibiotic Therapy in Preterm Premature Rupture of the Membranes

  • Mark H. Yudin
    Affiliations
    Toronto, ON
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  • Julie van Schalkwyk
    Affiliations
    Vancouver, BC
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  • Nancy Van Eyk
    Affiliations
    Halifax, NS
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  • Author Footnotes
    ∗ Infectious Diseases Committee: Mark H. Yudin (Chair), MD, Toronto, ON; Marc Boucher, MD, Montréal, QC; Eliana Castillo, MD, Vancouver, BC; Beatrice Cormier, MD, Montréal, QC; Andrée Gruslin, MD, Ottawa, ON; Deborah M. Money, MD, Vancouver, BC; Kellie Murphy, MD, Toronto, ON; Gina Ogilvie, MD, Vancouver, BC; Caroline Paquet, RM, Trois-Rivières, QC; Audrey Steenbeek, RN, Halifax, NS; Nancy Van Eyk, MD, Halifax, NS; Julie van Schalkwyk, MD, Vancouver, BC; Thomas Wong, MD, Ottawa, ON. Maternal Fetal Medicine Committee: Robert Gagnon (Chair), MD, Montréal, QC; Lynda Hudon (Co-Chair), MD, Montréal, QC; Melanie Basso, RN, Vancouver, BC; Hayley Bos, MD, London, ON; Marie-France Delisle, MD, Vancouver, BC; Dan Farine, MD, Toronto, ON; Kirsten Grabowska, MD, Vancouver, BC; Savas Menticoglou, MD, Winnipeg, MB; William Robert Mundle, MD, Windsor, ON; Lynn Carole Murphy-Kaulbeck, MD, Allison, NB; Annie Ouellet, MD, Sherbrooke, QC; Tracy Pressey, MD, Vancouver, BC; Anne Roggensack, MD, Calgary, AB. Disclosure statements have been received from all members of the committees.

      Abstract

      Objective

      To review the evidence and provide recommendations on the use of antibiotics in preterm premature rupture of the membranes (PPROM).

      Outcomes

      Outcomes evaluated include the effect of antibiotic treatment on maternal infection, chorioamnionitis, and neonatal morbidity and mortality.

      Evidence

      Published literature was retrieved through searches of Medline, EMBASE, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary and key words (PPROM, infection, and antibiotics). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and new material incorporated in the guideline to July 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

      Values

      The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

      Benefits, Harms, and Costs

      Guideline implementation should assist the practitioner in developing an approach to the use of antibiotics in women with PPROM. Patients will benefit from appropriate management of this condition.

      Validation

      This guideline has been reviewed and approved by the Infectious Diseases Committee and the Maternal Fetal Medicine Committee of the SOGC, and approved by the Executive and Council of the SOGC.

      Sponsor

      The Society of Obstetricians and Gynaecologists of Canada.

      Recommendations

      • 1.
        Following PPROM at 32 weeks' gestation, antibiotics should be administered to women who are not in labour in order to prolong pregnancy and to decrease maternal and neonatal morbidity (I-A).
      • 2.
        The use of antibiotics should be gestational-age dependent. The evidence for benefit is greater at earlier gestational ages (<32 weeks) (I-A).
      • 3.
        For women with PPROM at >32 weeks' gestation, administration of antibiotics to prolong pregnancy is recommended if fetal lung maturity cannot be proven and/or delivery is not planned (I-A).
      • 4.
        Antibiotic regimens may consist of an initial parenteral phase followed by an oral phase, or may consist of only an oral phase (I-A).
      • 5.
        Antibiotics of choice are penicillins or macrolide antibiotics (erythromycin) in parenteral and/or oral forms. (I-A) In patients allergic to penicillin, macrolide antibiotics should be used alone (III-B).
      • 6.
        The following two regimens may be used (the two regimens were used in the largest PPROM randomized controlled trials that showed a decrease in both maternal and neonatal morbidity): (1) ampicillin2g IV every 6 hours and erythromycin 250 mg IV every 6 hours for 48 hours followed by amoxicillin 250 mg orally every 8 hours and erythromycin 333 mg orally every 8 hours for 5 days (I-A); (2) erythromycin 250 mg orally every 6 hours for 10 days (I-A).
      • 7.
        Amoxicillin/clavulanic acid should not be used because of an increased risk of necrotizing enterocolitis in neonates exposed to this antibiotic. Amoxicillin without clavulanic acid is safe (I-A).
      • 8.
        Women presenting with PPROM should be screened for urinary tract infections, sexually transmitted infections, and group B streptococcus carriage, and treated with appropriate antibiotics if positive (II-2B).

      Key Words

      Abbreviations:

      IUI (intrauterine infection), NEC (necrotizing enterocolitis), PPROM (preterm premature rupture of the membranes), RDS (respiratory distress syndrome)
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