Antibiotics for preterm rupture of membranes.
BACKGROUND
Premature birth carries substantial neonatal morbidity and mortality. Subclinical infection is associated with preterm rupture of membranes (PROM). Prophylactic maternal antibiotic therapy might lessen infectious morbidity and delay labour, but could suppress labour without treating underlying infection.


OBJECTIVE
To evaluate the immediate and long-term effects of administering antibiotics to women with PROM before 37 weeks, on maternal infectious morbidity, neonatal morbidity and mortality, and longer-term childhood development.


METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (29 April 2010).


METHODS
Randomised controlled trials comparing antibiotic administration with placebo that reported clinically relevant outcomes were included as were trials of different antibiotics. Trials in which no placebo was used were included for the outcome of perinatal death alone.


METHODS
We extracted data from each report without blinding of either the results or the treatments that women received. We sought unpublished data from a number of authors.


RESULTS
We included 22 trials, involving 6800 women and babies.The use of antibiotics following PROM is associated with statistically significant reductions in chorioamnionitis (average risk ratio (RR) 0.66, 95% confidence interval (CI) 0.46 to 0.96, and a reduction in the numbers of babies born within 48 hours (average RR 0.71, 95% CI 0.58 to 0.87) and seven days of randomisation (average RR 0.79, 95% CI 0.71 to 0.89). The following markers of neonatal morbidity were reduced: neonatal infection (RR 0.67, 95% CI 0.52 to 0.85), use of surfactant (RR 0.83, 95% CI 0.72 to 0.96), oxygen therapy (RR 0.88, 95% CI 0.81 to 0.96), and abnormal cerebral ultrasound scan prior to discharge from hospital (RR 0.81, 95% CI 0.68 to 0.98). Co-amoxiclav was associated with an increased risk of neonatal necrotising enterocolitis (RR 4.72, 95% CI 1.57 to 14.23).One study evaluated the children's health at seven years of age (ORACLE Children Study) and found antibiotics seemed to have little effect on the health of children.


CONCLUSIONS
The decision to prescribe antibiotics for women with PROM is not clearcut. Benefits in some short-term outcomes (prolongation of pregnancy, infection, less abnormal cerebral ultrasound before discharge from hospital) should be balanced against a lack of evidence of benefit for others, including perinatal mortality, and longer term outcomes. If antibiotics are prescribed it is unclear which would be the antibiotic of choice.Co-amoxiclav should be avoided in women at risk of preterm delivery due to increased risk of neonatal necrotising enterocolitis.
Kenyon
Sara
S
School of Health and Population Sciences, University of Birmingham, Public Health Building, Edgbaston, UK, B15 2TT.
Boulvain
Michel
M
Neilson
James P
JP
D019980:Amoxicillin-Potassium Clavulanate Combination / Q000009:adverse effects; D000900:Anti-Bacterial Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002648:Child; D002821:Chorioamnionitis / Q000517:prevention & control; D002658:Developmental Disabilities / Q000517:prevention & control; D005260:Female; D005322:Premature Rupture of Fetal Membranes / Q000188:drug therapy*; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D007902:Length of Stay; D018942:Macrolides / Q000627:therapeutic use; D054238:Perinatal Mortality; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000401:mortality / Q000517:prevention & control*; D047928:Premature Birth / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic
D000900:Anti-Bacterial Agents; D018942:Macrolides; D019980:Amoxicillin-Potassium Clavulanate Combination