A
bout 5% of mother’s are diagnosed with chorioamnionitis clinically during labor, and while this fact obviously puts these mothers’ infants at risk for infection, we have long been searching for the best way to handle that risk. Strategies have ranged from empiric antibiotics for all exposures to increasingly elaborate risk prediction tools.
Credit goes to the Italians for recently evaluating a strategy of clinical examination alone as an assessment of chorioamnionitis exposed infants who are born well-appearing. Joshi and colleagues (10.1542/peds.2017-2056), quickly recognized a good idea when they saw it, and adopted the strategy in the level II NICU setting in a quality improvement study published last year in Pediatrics. This effort reduced infant antibiotic exposure by 88%, although still separated mothers and babies for the first 24 hours after birth. In a follow-up quality improvement study released this month in Hospital Pediatrics, Joshi and colleagues (10.1542/hpeds.2018-0201) rolled out the same strategy in the setting of couplet care in the postpartum unit, with the goal of keeping mothers and their chorioamnionitis exposed babies together.
Their clinical monitoring strategy included physician examination at birth and nurse examinations every 30 minutes for 2 hours and then every 4 hours until 24 hours of life. Using this strategy, Joshi and colleagues were able to safely keep 92.5% of mothers and babies together. Because early onset sepsis is a very rare event, assessing the comparative effectiveness of the available strategies will take time to confirm equivalent outcomes, but the experiences of the Italian investigators and Joshi and colleagues at Stanford suggest that good old-fashioned clinical assessments are an effective way to balance the risk of sepsis with the harms of unnecessary antibiotic exposure and mother/infant separation.
