Predicting peripartum infection in laboring patients at high risk in Cameroon, Africa

Gabriella D Cozzi; Yuanfan Ye; Rahel Mbah; Doreen M Mbunwe; Seraphine Pekwarake; Edwan Yui Bunwi; Anthony Fondzeyuf; Mary G Ngong; Jodie A Dionne; Lorie M Harper; Victoria C Jauk; Waldemar A Carlo; Gregory Halle-Ekane; Pius M Tih; Jeff M Szychowski; Alan T Tita; Akila Subramaniam

doi:10.1016/j.ejogrb.2023.12.003

Predicting peripartum infection in laboring patients at high risk in Cameroon, Africa

Eur J Obstet Gynecol Reprod Biol. 2024 Feb:293:9-14. doi: 10.1016/j.ejogrb.2023.12.003. Epub 2023 Dec 6.

Authors

Gabriella D Cozzi¹, Yuanfan Ye², Rahel Mbah³, Doreen M Mbunwe³, Seraphine Pekwarake³, Edwan Yui Bunwi³, Anthony Fondzeyuf³, Mary G Ngong³, Jodie A Dionne⁴, Lorie M Harper⁵, Victoria C Jauk⁶, Waldemar A Carlo⁷, Gregory Halle-Ekane⁸, Pius M Tih³, Jeff M Szychowski⁹, Alan T Tita⁶, Akila Subramaniam⁶

Affiliations

¹ Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA. Electronic address: gabriellacozzi@uabmc.edu.
² Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
³ Cameroon Baptist Convention Health Services, Cameroon, Africa.
⁴ Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA.
⁵ Department of Women's Health, Division of Maternal Fetal Medicine, University of Texas at Austin, Dell School of Medicine, Austin, TX, USA.
⁶ Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA.
⁷ Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA.
⁸ Cameroon Baptist Convention Health Services, Cameroon, Africa; University of Buea, Cameroon, Africa.
⁹ Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA.

PMID: 38096705
DOI: 10.1016/j.ejogrb.2023.12.003

Abstract

Objective: To develop a predictive model for peripartum infection among high risk laboring patients in Cameroon, Africa.

Study design: We conducted a secondary analysis of the Cameroon Antibiotic Prophylaxis Trial (NCT03248297), a multicenter 3-arm double-blind randomized controlled trial of oral azithromycin ± amoxicillin among term pregnancies with prolonged labor or rupture of membranes in Cameroon 1/2018-5/2020. Patients with chorioamnionitis prior to randomization, study drug contraindications, or planned cesarean were excluded. The outcome of interest was a composite of maternal peripartum infection (chorioamnionitis, endometritis, sepsis by World Health Organization criteria, wound infection/abscess) diagnosed up to 6 weeks postpartum. Potential predictors were compared between patients with and without the composite outcome, and evaluated at a 0.05 alpha level. Statistically significant exposures were analyzed using multivariable regression (to generate adjusted odds ratios and 95 % confidence intervals) with backwards selection to generate a parsimonious model. Receiver operating characteristic curves with associated area under the curve assessed the model's predictive ability. A nomogram based on the final best fit multivariable model was constructed.

Results: Of 756 patients in the parent trial, 652 were analyzed: 45 (7 %) had peripartum infection. Those with infection were more likely to be nulliparous, lower education level, higher gestational age, receive antibiotics per hospital protocols, and undergo cesarean. In our best-fit multivariable model, none/primary education (vs university), cesarean birth, and antibiotic receipt per physician discretion (vs for cesarean prophylaxis) were significantly associated with increased infection risk. This model was moderately predictive (AUC = 0.75, 95 % CI 0.67-0.82). When using this 3 factor model, for a patient with a cesarean birth, receipt of antibiotics per physician discretion, and university education, the probability of peripartum infection was 35 % (95 % CI 0.11-0.73).

Conclusions: While several variables such as parity are associated with infectious morbidity within 6 weeks among high risk laboring patients in Cameroon, only education level, antibiotic indication, and cesarean birth were independently associated, and a model including these 3 factors was moderately predictive. Validation of our findings in a larger population is warranted.

Keywords: Cesarean section; Chorioamnionitis; Education level; Maternal morbidity; Sepsis; Wound infection.

Publication types

Randomized Controlled Trial
Multicenter Study

MeSH terms

Anti-Bacterial Agents / therapeutic use
Cameroon / epidemiology
Chorioamnionitis* / epidemiology
Female
Humans
Labor, Obstetric*
Peripartum Period
Pregnancy

Substances

Anti-Bacterial Agents