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.