New study reveals cefoxitin as effective first-line treatment for intraamniotic infections

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A recent Clinical Infectious Diseases study evaluated the effectiveness of Cefoxitin in the treatment of Endometritis and Intraamniotic Infections (IAI).

This follows the update of local order sets and guidelines in June 2023 recommending first-line cefoxitin monotherapy to treat IAI and endometritis.

Study: Cefoxitin for Intraamniotic Infections and Endometritis: A Retrospective Comparison to Traditional Antimicrobial Therapy Regimens within a Health System. Image Credit: Ground Picture/Shutterstock.comStudy: Cefoxitin for Intraamniotic Infections and Endometritis: A Retrospective Comparison to Traditional Antimicrobial Therapy Regimens within a Health System. Image Credit: Ground Picture/Shutterstock.com

Background

IAIs are polymicrobial infections of the placenta, amniotic fluid, fetal membranes, fetus, or decidua. They can seriously endanger the life of the fetus or the pregnant person if not detected and treated urgently using intrapartum antibiotics and delivery.

IAIs have also been seen to be associated with a 2.3 higher odds of a cesarean delivery. Post-partum endometritis reflects the infection of the endometrium, decidua, or myometrium after the delivery of the fetus.

The American College of Obstetrics and Gynecologists (ACOG) has recommended gentamicin and ampicillin as a first-line antibiotic treatment for IAI.

It has also urged considering penicillin allergies in clindamycin, cefazolin, and vancomycin depending on allergy severity.

The shortage of intravenous clindamycin in the United States led to a local review of prescribing patterns in June 2023.

This review recommended cefoxitin monotherapy as the first-line antimicrobial therapy to treat endometritis and IAI, replacing gentamicin and ampicillin with or without clindamycin.

About the study

This study was retrospective and observational and was conducted in South Carolina. Adult hospitalized patients who were diagnosed with endometritis or chorioamnionitis were enrolled.

Data on patient outcomes and treatment were extracted from the electronic medical record (EMR) system. Individuals were excluded if the EMR lacked relevant data. 

The patients were divided into two groups. The first (n=122) included those treated between June 23, 2023, and August 31, 2023, i.e., during the period in which the guidelines were in place.

The second group (n=350) comprised those treated between April 1, 2016, and June 22, 2023, when traditional antimicrobial therapy regimens were in place. 

The primary composite study outcome was serious clinical events at 30 days post-delivery. Serious clinical events could be hospital readmission, ICU admission, death, or deep surgical site infection.

Individual components of the composite outcome constituted the secondary outcomes. The secondary outcome also included the length of hospital stay.

Key findings

The guidelines recommending cefoxitin monotherapy were non-inferior compared to traditional guidelines involving ampicillin and gentamicin with regard to serious clinical events post-delivery.

A reduction in the odds of readmission for endometritis and IAI was the main driver of the results documented here.

In the post-cefoxitin group, a 63% reduced odds of experiencing a serious clinical event and 69% lower odds of hospital readmission were noted. A comparable length of hospital stay across the two groups was observed. 

Additional considerations with cefoxitin are improved patient experience, ease of nursing workload, lower healthcare costs, and minimization of risk of medication errors. Cefoxitin is time-effective relative to the ampicillin/gentamicin/clindamycin “triple therapy.”

The multiple administration regimen makes the likelihood of error and general adverse reactions higher. Other disadvantages of gentamicin include weight-based dosing that delays prescription and the requirement of drug monitoring to ensure safety.

Strengths and limitations

This study's strengths include including a large healthcare system spanning multiple campuses and analysis of a modern patient cohort, antimicrobial resistance, and current pathogens.

A key limitation of the study centered around its observational and retrospective design, which meant that patients received varied antimicrobials across the groups.

A smaller number of events in the post-cefoxitin period could have led to fewer events and fewer instances of secondary infections. 

The dearth of microbiology data for treated infections was an added limitation of this study. This leads to an incomplete understanding of the potential pathogenic organisms involved in these infections. 

Furthermore, the clinical diagnosis of endometritis and chorioamnionitis is an added limitation. These conditions are generally identified and managed by those caring for laboring patients.

Recent research has shown that the clinical signs of chorioamnionitis diagnosis do not accurately detect patients with proven intra-amniotic infection. In 61% of patients with clinical IAI, microorganisms in the amniotic fluid were identified.

Of these individuals, about a quarter showed intra-amniotic inflammation without identifiable microorganisms. Here, an attempt was made to standardize the cohort based on ICD-10 codes. However, it must be noted that the diagnosis and ICD-10 codes depend on the treating clinician.

Conclusions

In sum, this study showed that the local shift to first-line antimicrobial therapy using cefoxitin monotherapy was effective and is expected to continue being the current practice.

Cefoxitin entails a much less complicated administration regimen for treating endometritis and IAI compared to the traditional regimen.

The preliminary findings suggest that cefoxitin could be a promising avenue to modernize the treatment of endometritis and IAI.

Journal reference:
Dr. Priyom Bose

Written by

Dr. Priyom Bose

Priyom holds a Ph.D. in Plant Biology and Biotechnology from the University of Madras, India. She is an active researcher and an experienced science writer. Priyom has also co-authored several original research articles that have been published in reputed peer-reviewed journals. She is also an avid reader and an amateur photographer.

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