Practice Guidelines

ACOG Releases Guidelines for Prophylactic Antibiotic Use in Labor and Delivery

Carrie A. Morantz

The American College of Obstetricians and Gynecologists (ACOG) has released a practice bulletin about the use of prophylactic antibiotics during labor and delivery. The bulletin presents a review of clinical situations in which prophylactic antibiotics frequently are prescribed and weighs the evidence supporting the use of antibiotics in these situations. The full report appeared in the October 2003 issue of Obstetrics and Gynecology.

Development of Resistant Organisms

Antimicrobial prophylaxis has been shown to increase resistant skin flora postoperatively; studies have reported colonization rates of 66 to 91 percent. Awareness of the potential risks of resistant bacterial infections has been increasing. A comparison of very-low-birth-weight neonates (i.e., less than 1,500 g [3 lb, 5 oz]) born between 1998 and 2000 with those born between 1991 and 1993 showed a reduction in early-onset neonatal sepsis from group B streptococci and an increase in sepsis caused by Escherichia coli. Sepsis in very-low-birth-weight neonates with ampicillin-resistant E. coli is more likely to be fatal than infection with susceptible strains. According to ACOG, the increases in E. coli sepsis and the increasing resistance to ampicillin appear to be confined to preterm and low-birth-weight neonates. In addition to resistant E. coli, group B streptococci isolates resistant to erythromycin and clindamycin have been reported.

Clinical Considerations and Recommendations

Evidence is insufficient to recommend antibiotic prophylaxis for emergency or prophylactic cervical cerclage. Few studies have evaluated the use of antibiotics during prophylactic cervical cerclage. Because the rate of complications is low (i.e., 1 to 5 percent), a study with a sample size large enough to determine the benefits of prophylactic antibiotic therapy would be difficult to implement.

Antibiotic prophylaxis may be considered for patients with premature rupture of membranes, particularly in cases of extreme prematurity, to prolong the latency period between membrane rupture and delivery. Certain broad-spectrum antibiotics lead to improved latency and may be particularly useful in cases of extreme prematurity. However, prolonged latency does not necessarily result in improved neonatal outcomes. Therefore, emerging data about resistant bacteria make it necessary to assess the risks and benefits for each patient.

According to ACOG, all high-risk patients undergoing cesarean delivery should receive prophylaxis with narrow-spectrum antibiotics such as cephalosporin. Several well-designed studies have documented the efficacy of prophylactic antibiotics in reducing the rates of postpartum endometritis and wound infection in patients who have undergone a cesarean delivery and are at high risk for infection. High-risk patients include those who have had cesarean deliveries after membrane rupture or labor and patients who undergo emergency procedures for which preoperative cleansing may have been inadequate. Other patients who may be at increased risk for postoperative infection include patients whose surgeries last for more than one hour and those who experience high blood loss. Risks of febrile morbidity, urinary tract infection, and wound infection also are reduced by antibiotic prophylaxis.

Whether patients at lower risk for infection benefit from antibiotic therapy is less clear. No differences in rates of wound infection, endometritis, urinary tract infection, pneumonia, or febrile morbidity were noted in a randomized controlled study of 480 women undergoing cesarean delivery. In a prospective study of 82 women, the incidence of febrile morbidity and endometritis was reduced by antibiotic prophylaxis. Although the evidence is inconclusive, prophylactic antibiotics are recommended in low-risk patients undergoing cesarean delivery.

In patients undergoing uncomplicated obstetric delivery who have certain cardiac conditions (i.e., prosthetic cardiac valves, previous bacterial endocarditis, complex cya-notic congenital cardiac malformations, surgically constructed systemic pulmonary shunts or conduits), prophylaxis for bacterial endocarditis is optional. However, antibiotics are recommended if the delivery is complicated by intra-amniotic infection. Prophylaxis ideally should be given shortly before delivery (within 30 minutes) and should not be given for more than six to eight hours.

AAP Releases Policy Statement on Poison Treatment in the Home

Genevieve W. Ressel

A subcommittee for the American Academy of Pediatrics (AAP) has released a statement about poisoning in the home. The full-length report was published in the November 2003 issue of Pediatrics. According to the American Association of Poison Control Centers, approximately 1.2 million children younger than six years ingest a poisonous substance each year.

Death caused by unintentional poisoning is uncommon, and the rate has decreased dramatically during the past 50 years. The two most important factors have been child-resistant containers and safer medications. Other reasons for the decrease include:

• Safer consumer products
• Anticipatory guidance
• Public education
• Legislation
• Establishment of poison control centers
• Development of product formulation and poison treatment databases
• Development of sophisticated medical care resources
• Availability of new antidotes
• Replacement of more toxic pharmaceuticals with less hazardous drugs.

One of the initiatives previously supported by the AAP was to keep a 1-oz bottle of syrup of ipecac in the home to be used for inducing emesis on the advice of a physician or a poison control center. There was controversy within the AAP about this recommendation because of the concern that the efficacy of ipecac had never been proved. Other organizations have stated that routine administration of ipecac in the emergency department should be abandoned, but they did not make a definitive statement about using ipecac in the home. The reassessment of ipecac administration has stimulated interest about using activated charcoal as a potential intervention for treating poisonings in the home.

Ipecac

Ipecac is safe and the only recommended method of inducing emesis. The amount of a substance removed from the stomach is inversely related to the time between ingestion and emesis. Research has shown that even when ipecac is administered immediately after ingesting a poison, it does not completely remove it from the stomach.

Emesis is an unpleasant experience, and adverse effects include persistent vomiting, lethargy, and diarrhea. Lethargy is problematic because it may be a confounding variable during the observation of a patient who has ingested a substance with the potential to cause sedation. Another concern is the administration of ipecac when it is not indicated because caregivers did not consult with a health care professional first or because the health care professional recommended it when it was not necessary. The AAP now reports that syrup of ipecac selectively administered in the home will not improve outcomes or reduce the use of emergency services in a large portion of the population served by poison control centers.

A child who experiences continued vomiting may not be able to tolerate other treatments such as activated charcoal, N-acetylcysteine, or whole bowel irrigation. In most situations, treating a nondisease with this noxious intervention is safe but has annoying side effects. There is a portion of the population that receives this therapy despite the lack of a valid indication, and no other country promotes use of ipecac in the home. Considering all the factors, American poison control centers rarely recommend this intervention anymore.

Charcoal

Activated charcoal is the most effective intervention for reducing the bioavailability of ingested substances. Mitigating factors against its use in the home include the following:

• It is poorly accepted by young children, making the administration of the recommended dose problematic.
• In emergency departments, it is commonly administered by nasogastric tube.
• During storage, it tends to form sediment in clumps that are difficult to re-suspend.
• It is often vomited and messy, making caregiver acceptance an issue.

According to the AAP, it is reasonable to assume that home-activated charcoal administration will, like ipecac, be overused and inappropriately used, so there should be clear evidence for patient benefit before its implementation as a public health intervention.

Treatment in the Home

The primary goal should always be to prevent a poisoning event, and the following reminders should be part of guidance during prenatal and well-infant visits:

• Keep potential poisons out of sight and out of reach.
• Always reengage child-resistant closures immediately after using a pharmaceutical or consumer product.
• Never transfer a substance from its original container to an alternate one.
• Safely dispose of all unused medication and medication that is no longer needed.
• Do not refer to medicines as candy.
• Post the poison control center number near the telephone. The universal telephone number in the United States is 800-222-1222. Calls are routed to the local poison control center.

Early and effective treatment after a poisoning event is a priority. In young children, the routes of exposure include ingestion, skin contact, eye contact, and inhalation. First aid treatment in the home includes copious irrigation of the skin or eye with tap water for 15 to 20 minutes or safe removal from the potentially dangerous environment in the case of inhalation exposure. The next step is to call for help. If the patient is conscious and alert, call the local poison control center. If the patient has collapsed or stopped breathing, call 9-1-1 for emergency assistance.

Dilution by having the child drink 100 to 200 mL of water or another drink is a routine recommendation for the ingestion of a nonpharmaceutical. This is not recommended after ingestion of a medication because there is concern that this procedure would hasten the drug's absorption caused by earlier exit from the stomach. The next decision is whether further in-home assessment or intervention at a hospital is required. The poison control center will advise the caregiver if these steps are necessary.

Recommendations

The AAP provides the following recommendations:

• Poison prevention should continue as an integral part of anticipatory guidance activities for physicians taking care of infants and children.
• Syrup of ipecac should not be used routinely as a poison treatment intervention in the home.
• Physicians who care for children should remind parents to dispose of any ipecac currently in the home.
• Current research does not support the routine administration of activated charcoal in the home because efficacy and safety have not been demonstrated.
• The first action for a caregiver of a child who may have ingested a toxic substance should be to consult with the local poison control center.