Key Clinical Message:
ESBL-producing Enterobacteriaceae pose challenging infection control issues and are a serious global threat that requires prompt and sustained action. Screening strategies designed to monitor them could be useful in women from endemic areas to prevent perinatal transmission and the introduction of multi-resistant strains to the maternity ward.
Introduction: Chorioamnionitis is a common infection of pregnancy, typically occurring in the setting of prolonged membrane rupture or labor. It complicates 1-4% of all births in the US1. However, its frequency varies significantly with gestational age, specific risk factors and diagnostic criteria. It may be diagnosed clinically based on signs such as maternal fever, microbiologically based on amniotic fluid culture obtained by amniocentesis, or by histopathologic examination of the placenta and umbilical cord2-3. Associated risk factors include obesity, anaemia, diabetes, prolonged duration of membrane rupture, prolonged labour, nulliparity, African American ethnicity, multiple vaginal examinations, meconium-stained liquor, smoking and drug abuse, epidural anaesthesia, compromised immunity and colonization with group B streptococcus, bacterial vaginosis, sexually transmissible genital infection and vaginal colonization with ureaplasma2.
The main preventative strategy is administration of antibiotics to women with preterm prelabour rupture of membranes which reduces the incidence of clinical chorioamnionitis, prolongs the time to delivery and improves neonatal outcomes. Optimal management of clinical chorioamnionitis includes antibiotic therapy and delivery of the infected products of conception5.
We present a case of clinical chorioamnionitis with associated fetal compromise, neonatal sepsis and severe maternal wound infection caused by multi-drug resistant extended spectrum beta-lactamase (ESBL)-producing Escherichia Coli (E. Coli) and the challenges associated with its management.
Case Report: A 33-year-old Indian lady, G3P1 reported to the emergency department at 33 weeks with history of passing clear fluid vaginally for one hour. She denied having any history of fever, urinary symptoms, or vaginal discharge. Her previous delivery was by Caesarean Section (CS) in 2014. She was on metformin for gestational diabetes diagnosed at 28 weeks.
On examination she was clinically stable (Pulse-76/min, regular, BP-100/60 mm Hg, oral temperature-36.4 C). Systemic examination was unremarkable. Abdominal examination revealed fundal height of 32 cm, with normal uterine tone and regular fetal heart rate. Speculum examination revealed clear leaking. Routine labs (complete blood count, C-reactive protein (CRP) and blood for type and screen) were sent. Antenatal steroids were offered, blood sugar monitoring with diet control was advised and sliding dose of insulin Injection was initiated. Oral Erythromycin was started for GBS prophylaxis. Both the patient and her family were counselled in detail regarding the conservative management and risks of chorioamnionitis and prematurity.
Her admission laboratory test results were normal (Hemoglobin-11.6 g/dL, blood group O positive, WBC-9.5x103/Ul, ANC-7x103/Ul and CRP-7 mg/L). Ultrasound scan for growth revealed small for date fetus (growth corresponding to <7th centile with oligohydramnios with normal uterine artery dopplers). She was clinically stable in the first 48 hours. Within 72 hours of admission, she developed tachycardia (PR-122/min) and increased WBC (12.9x103/microliter) and ANC (10.9x103/Ul) but was afebrile. CTG in the evening on the same day revealed unprovoked recurrent decelerations followed by prolonged deceleration for more than 3 minutes. In view of pathological cardiotocography findings she had emergency CS. Routine prophylactic antibiotics Cephazoline and Azithromycin were administered prior to surgery. She delivered small for date baby boy, weight 1570g, Apgar scores 91,105. The liquor was meconium-stained and foul smelling. The arterial and the venous pH were 7.30 and 7.36 respectively. Placental tissue was sent for culture and sensitivity and broad-spectrum antibiotics (ceftriaxone and metronidazole) were started after the surgery with the diagnosis of chorioamnionitis.
However, she had persistent tachycardia with increasing CRP levels (420 mg/L). The culture result of placental tissue and high vaginal swab (HVS) confirmed profuse growth of ESBL producing E. coli. Infectious disease team was involved and IV (intravenous) Ertapenem was commenced based on sensitivity profile of results of culture. She remained clinically stable for 72 hours and WBC counts and CRP were showing a decreasing trend. She was discharged home on IV Ertapenem to be taken on outpatient basis. However, on post-operative day 6, she was readmitted because of wound infection and was febrile (oral temperature-38.2 C). Wound swab culture grew ESBL producing E. Coli as well and antibiotic was changed to IV Meropenem. Wound care team was involved.
After instituting Meropenem, she recovered well, and the blood counts and CRP were reduced to near normal. Meropenem was continued for 7 days. She was discharged home in clinically stable condition.
The baby was born vigorous, was initially on continuous positive airway pressure. Within few hours of birth developed signs of sepsis (pulse rate-186/m, blood pressure-44/30 mm Hg, temperature 37.9C and SPO2 dropped to 93%) with respiratory distress syndrome and was intubated and required inotropes (dopamine infusion). Broad spectrum antibiotics (Amikacin and Ampicillin) were given. Blood culture revealed gram negative bacteria within 9 hours of birth, so Meropenem was added and Ampicillin was discontinued. Fetal Echocardiography showed PDA 2.2 mm with bidirectional shunting and lower limit of contractility, dilated IVC with evidence of pulmonary hypertension.
Baby developed high fever (39.5 C) on second day of birth, requiring paracetamol. Total parenteral nutrition (TPN) was initiated. Laboratory results were suggestive of leucopenia (WBC 4.5x103/uL), low platelet count(96x103/uL), high CRP(56mg/L), high serum Urea(9.7 mmol/L), high serum creatinine(76 umol/L) and high total bilirubin levels(142.3 umol/L). Blood culture result confirmed growth of ESBL- producing E. Coli. Due to persistent hypotension, higher doses of Dopamine infusion were given. On day 4, hemoglobin level dropped from 19 g/dl to 15 g/dl so X-ray skull and ultrasound Brain was performed and intracranial bleeding was excluded. In addition to sepsis, neonatal jaundice was noted, and ABO incompatibility was diagnosed. Lumber puncture was performed which revealed leukocytosis (216/uL and raised RBCs (11 /uL). Its culture showed no growth, though was treated as meningitis.
Gradually in 10 days, the baby improved clinically. TPN was continued for 12 days and then oral feeding was commenced. Neonatal Jaundiced settled without the need of phototherapy. Antibiotic (Meropenem) was given for four weeks. Baby was discharged on 28th day of admission.