In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
What Should Prompt Recognition of Sepsis in the Puerperium?
D - All health professionals should be aware of the symptoms and signs of maternal sepsis and critical illness and of the rapid, potentially lethal course of severe sepsis and septic shock. Suspicion of significant sepsis should trigger urgent referral to secondary care.
Clinical signs suggestive of sepsis include one or more of the following: pyrexia, hypothermia, tachycardia, tachypnoea, hypoxia, hypotension, oliguria, impaired consciousness and failure to respond to treatment. These signs, including pyrexia, may not always be present and are not necessarily related to the severity of sepsis.
The common symptoms of sepsis in the puerperium include fever, diarrhoea, vomiting, abdominal pain, generalised maculopapular rash (staphylococcal or streptococcal sepsis), offensive vaginal discharge and signs of infection in caesarean wounds. Agonising pain out of proportion to the clinical signs suggests a deep infection, and necrotising fasciitis/myositis must be considered. [Evidence level 3]
Table 2 in the original guideline document details common symptoms of sepsis in the puerperium. See Appendix 1 in the original guideline document for a definition and classification of toxic shock syndrome.
What Investigations Should Be Performed?
D - Blood cultures are the key investigation and should be obtained prior to antibiotic administration; however, antibiotic treatment should be started without waiting for microbiology results.
D - Serum lactate should be measured within 6 hours of the suspicion of severe sepsis to guide management. Serum lactate ≥4 mmol/l is indicative of tissue hypoperfusion.
D - Any relevant imaging studies should be performed promptly in an attempt to confirm the source of infection. This could include a chest X-ray, pelvic ultrasound scan or computed tomography scan if pelvic abscess is suspected.
Blood cultures and other samples taken should be guided by clinical suspicion of focus of infection, such as throat swabs, mid-stream urine, high vaginal swab, placental swabs, sputum, cerebrospinal fluid, epidural site swab, caesarean section or episiotomy site wound swabs and expressed breast milk, and should ideally be obtained prior to starting antibiotic therapy as the results may become uninformative within a few hours of commencing antibiotics. Antibiotics should be given as soon as possible. Results of laboratory tests should be checked and recorded regularly and the medical microbiologist consulted to ensure specimens are processed appropriately and results communicated directly to the clinician at the earliest opportunity. Gram stain, culture results and sensitivities should be used to tailor antimicrobial therapy.
If diarrhoea is particularly offensive following antimicrobial therapy, a stool sample should be submitted for Clostridium difficile toxin testing. A history of diarrhoea warrants routine culture (e.g., Salmonella, Campylobacter). The laboratory should be informed if there is a clinical indication for investigations for unusual pathogens such as Listeria monocytogenes (consumption of soft cheese or cured meats) or if there is a history of foreign travel (parasites, typhoid or cholera).
Bacterial numbers may be scanty or not seen on initial Gram staining of swabs, fluids, or debrided tissue. However, organisms seen on Gram staining will guide empirical prescribing. A paucity of leucocytes and the presence of Gram-positive cocci in chains indicate streptococcal infection. 'Mixed organisms" (i.e., mixed Gram- negative and -positive organisms) would suggest the possibility of gut organisms, including anaerobes, as part of a synergistic infection.
Diagnostic criteria for sepsis are available in Appendix 2 of the original guideline document (in the absence of specific criteria for women in the puerperium).
Table 3 in the original guideline indicates tasks which should be performed within the first 6 hours of the identification of severe sepsis.
How Should Sepsis in the Puerperium Be Managed?
Which Antibiotics Should Be Used?
D - Administration of intravenous broad-spectrum antibiotics within 1 hour of suspicion of severe sepsis, with or without septic shock, is recommended as part of the Surviving Sepsis resuscitation care bundle.
D - If genital tract sepsis is suspected, prompt early treatment with a combination of high-dose broad spectrum intravenous antibiotics may be life saving.
Antibiotic therapy should be guided by the Gram stain of any aspirate or biopsy; however, in practice the patient is usually so sick there is no time to wait, hence initial empirical prescribing of broad-spectrum antibiotics is essential. Intravenous broad-spectrum antibiotics should be given within 1 hour of suspicion of severe sepsis. [Evidence level 4]
Information on antimicrobials which may aid in guiding choice is given in Table 4 in the original guideline, but hospital guidelines differ and local guidance should be followed since the incidence of resistant organisms varies throughout the UK. The decision as to which antimicrobials to include in the hospital formulary and maternity unit guidelines for severe sepsis in the puerperium should be agreed by clinicians and the hospital microbiologist.
National guidelines for the management of community-acquired pneumonia, Panton–Valentine leukocidin (PVL)-producing Staphylococcus aureus and methicillin-resistant S. aureus (MRSA)-associated infections should be consulted where necessary. [Evidence level 4]
What Is the Role of Intravenous Immunoglobulin (IVIG)?
D - IVIG is recommended for severe invasive streptococcal or staphylococcal infection if other therapies have failed.
IVIG is available from the blood transfusion department. All commercial brands of IVIG available in the UK contain antibodies to streptococcal and staphylococcal exotoxins. Actual administration of IVIG should be through a blood warming device and hospital guidelines/protocols for replacement therapy in haematology patients may be used. However, when faster replacement is necessary in severely ill patients, the Mount Sinai hospital protocol may be helpful. [Evidence level 4]
What Are the Neonatal Issues If Sepsis Develops in the Puerperium?
D - The baby is especially at risk of streptococcal and staphylococcal infection during birth and during breastfeeding. The umbilical area should be examined and a paediatrician consulted in the event of sepsis in the puerperium.
The infant of a mother colonised with Group B Streptococci should be managed as per RCOG Green-top Guideline No.36: Prevention of early onset neonatal group B streptococcal disease. [Evidence level 4]
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g. case reports, case series
4 Expert opinion
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ and
directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group