Microbiology of puerperal sepsis and its clinical implications among HIV-infected and HIV-uninfected women in a hospital sample in Zimbabwe

Abstract

Title: Microbiology of puerperal sepsis and its clinical implications in a Hospital sample in Zimbabwe Introduction: Puerperal sepsis is infection of the female genital tract occurring at any time between the rupture of membranes or labour, and the 42nd day postpartum. Puerperal sepsis has become the leading cause of maternal death in Harare public health institutions accounting for 19% and 30% of maternal deaths for the years 2010 and 2014 respectively, from being the fourth nationwide cause at 12.3% in the year 2007. The objectives of this study were to determine the identity and antibacterial susceptibility profiles of bacteria colonizing the genital tract and blood stream, and to assess clinical outcomes and association with HIV infection in women with puerperal sepsis. Methodology: A prospective cohort study was conducted at Parirenyatwa and Harare Hospitals between 02 September 2014 and 01 July 2015. Endocervical swabs and blood were collected for culture and susceptibility testing from 151 consecutive women who met the World Health Organisation criteria for puerperal sepsis. HIV sero-status, immunological status and antiretroviral therapy (ART) use were determined. Medical records were reviewed for assessment of clinical outcomes. Proportions, categorical values and means were compared using Z-test, .² test and t- test along with 95% confidence interval (CI) and p-value of <0.05. Results: The mean age was 25.1 ±5.8years and most women were multiparous(53.6%). The majority of women had delivered at a hospital (78.1%) and by caesarean section (57.6%). The commonest bacterial isolates were Escherichia coli (30.6%) and Klebsiella pneumoniae (15.3%). Multidrug resistant organisms (MDRO) accounted for 10.9% of the isolates. MDRO were associated with prolonged mean hospital stay 23.0days (d) compared to 10.5d in women without MDRO (p=0.009). The frequency of genital colonization with Enterobacter species was significantly higher in HIV infected (9.1%) than uninfected women (1.7%) (p=0.04). Among HIV infected women (21.9%), severe immunosuppression (CD4 <200/mm³) was associated with a greater need for laparotomy 42.9% vs 4.5% (p=0.01) and prolonged mean hospital stay 19.0d vs 10.2d (p=0.03) compared to mild-advanced (CD4 count 200-500/ mm³) and insignificant immunosuppression (CD4 >500/mm³). There was a non-significant trend towards,earlier onset of sepsis; and higher rates of pelvic abscess, septic shock, wound dehiscence, peritonitis, death and need for admission into the intensive care unit (ICU) in women with severe immunosuppression. Antiretroviral therapy use did not independently influence outcomes. Puerperal sepsis case fatality rate was 7.3%. Conclusion: Gram negative bacilli, particularly E. coli, are the commonest bacterial isolates in puerperal sepsis. There is emergence of MDRO gram negative bacilli resistant to carbapenems, especially K. pneumoniae. MDRO and HIV associated severe immunosuppression are risk factors for prolonged hospital stay and need for surgery. Robust infection control strategies, emphasis on rational drug use and clinical culture surveillance to identify MDRO and monitor epidemiologic trends is recommended.