Should all pregnant individuals with preterm premature rupture of membranes (PPROM) receive a urine culture and latency antibiotics, considering beta-lactam resistance?

From the Guidelines

All pregnant individuals with preterm premature rupture of membranes (PPROM) should receive a urine culture and latency antibiotics, as recommended by the American College of Obstetricians and Gynecologists (ACOG) and supported by the Society for Maternal-Fetal Medicine 1. The standard regimen includes intravenous ampicillin and erythromycin for 48 hours, followed by oral amoxicillin and erythromycin for an additional 5 days, as outlined in the society for maternal-fetal medicine consult series #71: management of previable and periviable preterm prelabor rupture of membranes 1. Key points to consider in the management of PPROM include:

• Urine cultures are essential to identify asymptomatic bacteriuria or urinary tract infections that may have contributed to membrane rupture.
• Latency antibiotics are crucial as they significantly prolong pregnancy, reduce chorioamnionitis rates, decrease neonatal infections, and improve neonatal outcomes.
• While beta-lactam resistance is a valid concern, the benefits of this antibiotic regimen outweigh the risks, and culture results can guide therapy adjustments if resistance is detected 1.
• Providers should also monitor for signs of infection (maternal fever, uterine tenderness, fetal tachycardia) and consider alternative antibiotics based on local resistance patterns when necessary.
• The decision to administer antibiotics after previable and periviable PPROM should be made on a case-by-case basis, taking into account the individual patient's risks and benefits, and the lack of evidence of clear benefit of antibiotics following previable PPROM at <20 weeks 1.
• Modifications to the antibiotic regimen may be necessary if inpatient hospitalization for intravenous therapy is deferred, and caution is advised against prolonged or repeated antibiotic courses beyond what would be used for PPROM at later gestational ages to optimize antibiotic stewardship 1.

From the Research

Urine Culture and Latency Antibiotics in PPROM

• The American College of Obstetricians and Gynecologists (ACOG) recommends that women with preterm premature rupture of membranes (PPROM) receive antibiotics to prolong pregnancy and reduce maternal and neonatal morbidity 2.
• A study published in the Journal of the American Medical Association (JAMA) found that antibiotic treatment during expectant management of PPROM reduced infant morbidity, including respiratory distress and necrotizing enterocolitis 3.
• The choice of antibiotic is important, as some studies have shown that certain antibiotics, such as amoxicillin/clavulanic acid, may increase the risk of necrotizing enterocolitis in neonates 2.
• A study published in the Journal of the Formosan Medical Association found that a combination of azithromycin and a third-generation cephalosporin was effective in eradicating pathogens in women with PPROM in Taiwan 4.
• However, another study published in BMC Pregnancy and Childbirth found that gram-negative bacteria, such as Klebsiella pneumoniae and Escherichia coli, were prevalent in urinary tract infections (UTIs) among pregnant women in Uganda, and that these bacteria were often resistant to commonly used antibiotics 5.
• The study also found that all isolates were resistant to ampicillin, amoxicillin, and amoxicillin/clavulanic acid, highlighting the importance of choosing the right antibiotic regimen 5.
• ACOG recommends that women with PPROM be screened for UTIs and group B streptococcus carriage, and treated with appropriate antibiotics if positive 2.
• A study published in Obstetrics and Gynecology Clinics of North America recommends that all pregnant women be screened for bacteriuria at their first prenatal visit, and that women with UTIs be followed up closely after treatment to prevent recurrence 6.

Beta-Lactam Resistance

• Beta-lactam resistance is a concern in the treatment of UTIs in pregnant women, as some studies have shown that certain bacteria, such as Klebsiella pneumoniae and Escherichia coli, are resistant to beta-lactam antibiotics 5.
• A study published in BMC Pregnancy and Childbirth found that 29.0% of Enterobacteriaceae isolates produced extended-spectrum beta-lactamases, highlighting the importance of choosing the right antibiotic regimen 5.
• ACOG recommends that women with PPROM receive antibiotics that are effective against beta-lactam resistant bacteria, such as penicillins or macrolide antibiotics 2.