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Cited by 12Antibiotic Use and ResistanceNeonatal and Maternal InfectionsUrinary Tract Infections Management

The aetiology and antimicrobial resistance of bacterial maternal infections in Sub-Saharan Africa—a systematic review and meta-analysis

Open access
Chapuma, Chikondi, Twabi, Hussein H., Monk, Edward J. M., Jafali, James, Weeks, Andrew, Beales, Emily, Kulapani, David, Selemani, Apatsa +9 more·2024·BMC Infectious Diseases
DOI 10.1186/s12879-024-09855-3PMC PMC11401422
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Abstract

BACKGROUND: Understanding the aetiological organisms causing maternal infections is crucial to inform antibiotic treatment guidelines, but such data are scarce from Sub-Saharan Africa (SSA). We performed this systematic review and meta-analysis to address this gap. METHODS: Microbiologically confirmed maternal infection data were collected from PubMed, Embase, and African Journals online databases. The search strategy combined terms related to bacterial infection, pregnancy, postnatal period, observational studies, SSA. Exclusion criteria included colonization, asymptomatic infection, and screening studies. Pooled proportions for bacterial isolates and antimicrobial resistance (AMR) were calculated. Quality and completeness of reporting were assessed using the Newcastle-Ottawa and STROBE checklists. FINDINGS: We included 14 papers comprising data from 2,575 women from four sources (blood, urine, surgical wound and endocervical). Mixed-growth was commonly reported at 17% (95% CI: 12%-23%), E. coli from 11%(CI:10%-12%), S. aureus from 5%(CI: 5%-6%), Klebsiella spp. at 5%(CI: 4%- 5%) and Streptococcus spp. at 2%(CI: 1%-2%). We observed intra-sample and inter-sample heterogeneity between 88-92% in all meta-analyses. AMR rates were between 19% -77%, the highest with first-line beta-lactam antibiotics. Convenience sampling, and limited reporting of laboratory techniques were areas of concern. INTERPRETATION: We provide a comprehensive summary of microbial aetiology of maternal infections in SSA and demonstrate the paucity of data available for this region. We flag the need to review the current local and international empirical treatment guidelines for maternal bacterial infections in SSA because there is high prevalence of AMR among common causative bacteria. FUNDING: This research was supported by the NIHR-Professorship/NIHR300808 and the Wellcome-Strategic-award /206545/Z/17/Z. TRIAL REGISTRATION: Prospero ID CRD42021238515.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review and meta-analysis of 14 studies from Sub-Saharan Africa found that *E. coli*, *S. aureus*, and *Klebsiella* spp. were the most common bacterial causes of maternal infection, with high resistance to commonly used first-line antibiotics. The authors conclude that current empirical treatment guidelines for maternal bacterial infections in SSA need review because of substantial antimicrobial resistance.

Key findings

  • Among 2,575 women from 14 papers, pooled proportions of bacterial isolates were mixed growth 17% (95% CI 12–23%), *E. coli* 11% (10–12%), *S. aureus* 5% (5–6%), *Klebsiella* spp. 5% (4–5%), and *Streptococcus* spp. 2% (1–2%).
  • Among positive cultures, the predominant causative agents were *E. coli* 36% (33–38%), mixed growth 20% (14–27%), *Veillonella* spp. 20% (1–72%), *S. aureus* 18% (16–20%), and *Klebsiella* spp. 15% (13–17%).
  • Pooled resistance was high: *E. coli* resistance to penicillin was 65%, gentamicin 22%, ciprofloxacin 24%, and ceftriaxone 36%; *Klebsiella* spp. resistance was 77%, 33%, 19%, and 40%, respectively; *S. aureus* resistance was 68%, 30%, 24%, and 32%, respectively.
  • Heterogeneity was high, reported as 88–92% in all meta-analyses in the abstract and 79–96% or 80–96% in subgroup analyses.

Methods

  • Systematic review and meta-analysis registered with PROSPERO (CRD42021238515), searching PubMed, Embase, and African Journals Online up to 29 March 2023 for observational studies of symptomatic, laboratory-confirmed maternal bacterial infection in SSA, excluding colonization, asymptomatic infection, and screening studies.
  • Included 14 papers comprising 2,575 women, with data from blood, urine, surgical wound, and endocervical samples; 10 papers reported antimicrobial resistance data.
  • Pooled proportions for bacterial isolates and AMR were estimated using random-effects models with the DerSimonian–Laird method in R; subgroup analyses were performed by sample type, and reporting quality was assessed with STROBE and Newcastle–Ottawa checklists.

Limitations

  • The paper states that data were insufficient to pool resistance estimates for carbapenems and co-trimoxazole, that included studies were mostly from government and tertiary hospitals and may skew toward hospital-acquired resistant infection, and that prior antibiotic exposure was not always reported or accounted for.
  • The paper also states that most studies used convenience sampling rather than random sampling, anaerobic culture was limited, contaminant handling was inconsistently reported, and HIV-status data were missing for most studies, limiting stratified analysis.
  • Evident from the text: only 14 studies were included, only 10 reported AMR, and heterogeneity was high (reported as 88–92% in all meta-analyses), which limits precision and generalizability of the pooled estimates.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12879-024-09855-3

Cites

27 of 27 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

13 of 19 cited sources checked · 8 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Limited availability of validated diagnostics (culture and sensitivity) poses difficulties in prompt identification and management of maternal infection in Sub-Saharan Africa.

    “In addition, limited availability of validated diagnostics (culture and sensitivity) poses difficulties in prompt identification and management of maternal infection in SSA [8].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [8] Iskandar K, Molinier L, Hallit S, Sartelli M, Hardcastle TC, Haque M, et al. Surveillance of antimicrobial resistance in low- and middle-income countries: a scattered picture. Antimicrob Resist Infect Cont. 2021;10(1):1–19. https://doi.org/10.1186/s13756-021-00931-w. Available from: https://aricjournal.biomedcentral.com/articles/. Cited 2023 Feb 13. source

      The sections on limited diagnostics and communication issues (page not provided) describe shortages, unreliable laboratory results, reporting delays, and physicians relying on clinical judgment. They support a general difficulty with testing and clinical decisions in low- and middle-income countries, but do not establish the claim specifically for culture and sensitivity testing, maternal infection, or Sub-Saharan Africa. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
  • Premisecitation

    Majangara et al. [27] did not find a specific microbial agent that significantly associated with HIV status.

    “Majangara et al. [27] was the only study reviewed here that stratified data according to HIV status and reported increased length of hospitalization stay for HIV positive women with puerperal sepsis but they did not find a specific microbial agent that significantly associated with HIV status.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [27] Majangara R, Chirenje ZM, Gidiri MF. The association of puerperal sepsis with HIV infection at two tertiary hospitals in Zimbabwe HHS Public Access. Int J Gynaecol Obstet. 2019;144(1):67–72. source
  • Premisecitation

    Majangara et al. [27] reported increased length of hospitalization stay for HIV positive women with puerperal sepsis.

    “Majangara et al. [27] was the only study reviewed here that stratified data according to HIV status and reported increased length of hospitalization stay for HIV positive women with puerperal sepsis but they did not find a specific microbial agent that significantly associated with HIV status.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [27] Majangara R, Chirenje ZM, Gidiri MF. The association of puerperal sepsis with HIV infection at two tertiary hospitals in Zimbabwe HHS Public Access. Int J Gynaecol Obstet. 2019;144(1):67–72. source

      The Abstract Results report a longer hospital stay for women with HIV who had severe immunosuppression (19.0 versus 10.2 days for other women with HIV). The Results report no statistically significant differences by HIV status overall, so the claim omits the qualification that the increase was associated with severe immunosuppression, not HIV-positive status alone. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premiseown data

    Majangara et al. [27] was the only study reviewed here that stratified data according to HIV status.

    “Majangara et al. [27] was the only study reviewed here that stratified data according to HIV status and reported increased length of hospitalization stay for HIV positive women with puerperal sepsis but they did not find a specific microbial agent that significantly associated with HIV status.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [27] Majangara R, Chirenje ZM, Gidiri MF. The association of puerperal sepsis with HIV infection at two tertiary hospitals in Zimbabwe HHS Public Access. Int J Gynaecol Obstet. 2019;144(1):67–72. source
  • Findingown data

    The proportion of study participants with suspected maternal infection who had laboratory-confirmed diagnosis ranged from 20.4% to 100%.

    “The proportion of study participants with suspected maternal infection who had laboratory confirmed diagnosis ranged from 20.4% to 100%.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 16
  • May combine two claims. 17
  • The quote only partly states this claim. 2

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two authors independently assessed included studies for reporting completeness and quality using STROBE and Newcastle-Ottawa checklists.

    “To assess reporting completeness and quality of included studies, two authors (CVD with either EJMM or EB) independently assessed included studies according to Strengthening the Reporting of Observational Studies in Epidemiology [14–16] and the Newcastle–Ottawa Scale [17, 18], respectively.”
    Quote in the paperNot a substantial claim4 of 5 sources checked
    • cites [14] Vandenbroucke JP, Von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration. PLoS Med. 2007;4(10):1628–54. source
    • cites [15] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495–9. source
    • cites [16] Cuschieri S. The STROBE guidelines. Saudi J Anaesth. 2019;13(Suppl 1):S31–4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/30930717. Cited 2023 May 15. source
    • cites [17] Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments - PMC. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021422/. Cited 2023 May 15.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [18] Lo CKL, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments. BMC Med Res Methodol. 2014;14(1):45 Available from: /pmc/articles/PMC4021422/ . Cited 2023 May 15. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Up to 10% of maternal deaths in Sub-Saharan Africa are due to infection, which is twice the proportion observed in high-income countries.

    “Of these deaths, up to 10% are due to infection which is twice the proportion observed in high income countries [7].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [7] Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: A WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–33. Available from: http://www.thelancet.com/article/S2214109X1470227X/fulltext. Cited 2024 Sep 9. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The global burden of maternal deaths is highest in Sub-Saharan Africa.

    “The global burden of maternal deaths is highest in Sub-Saharan Africa (SSA) [4, 5].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [4] Bonet M, Brizuela V, Abalos E, Cuesta C, Baguiya A, Chamillard M, et al. Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study. Lancet Glob Health. 2020;8(5):661–71 Available from: www.thelancet.com/lancetgh. Cited 2021 Jan 4. source

      The Introduction (page unavailable) discusses maternal deaths due to infection and compares low- and middle-income countries with high-income countries. The Results (page unavailable) also group outcomes by country income, but neither passage compares maternal deaths across world regions. Searches for sub-Saharan Africa and regional maternal mortality found no passage establishing that its burden is the highest. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [5] Chou D, Daelmans B, Jolivet RR, Kinney M, Say L. Ending preventable maternal and newborn mortality and stillbirths. BMJ (Online). 2015;351:19–22 Available from: www.who.int/reproductivehealth. Cited 2021 Aug 26. source

      The ‘Limited progress’ section gives a global maternal-death total for 2013 but does not compare regions. Searches for sub-Saharan Africa and regional shares of maternal deaths found no passage establishing where the burden is highest. (LLM, conf=0.70)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    There are challenges in estimating maternal sepsis burden due to differences in its definitions.

    “However, there are challenges in estimating maternal sepsis burden due to differences in its definitions [9, 10].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [9] Singer M, Deutschman CS, Seymour C, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315:801–10 Available from: https://jamanetwork.com/journals/jama/fullarticle/2492881. Cited 2021 Aug 26. source

      The Variable Definitions section describes inconsistent sepsis terminology and coding, and the Implications section says standardized definitions are crucial to accurately appreciating the scale of sepsis. These passages support the general difficulty of estimating sepsis burden, but the paper does not address maternal sepsis specifically. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [10] Bonet M, Nogueira Pileggi V, Rijken MJ, Coomarasamy A, Lissauer D, Souza JP, et al. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation Reproductive Health. BioMed Cent. 2017;14:1–13. https://doi.org/10.1186/s12978-017-0321-6. Available from: https://reproductive-health-journal.biomedcentral.com/articles. Cited 2021 Aug 26. source

  • May combine two claims.

    Findingown data

    All 14 included articles reported data on aetiology, and 10 reported on antimicrobial resistance.

    “All 14 articles reported data on aetiology, and ten reported on AMR.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Antimicrobial resistance rates ranged from 19% to 77%, with the highest resistance to first-line beta-lactam antibiotics.

    “AMR rates were between 19% -77%, the highest with first-line beta-lactam antibiotics.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    Convenience sampling and limited reporting of laboratory techniques were areas of concern in the included studies.

    “Convenience sampling, and limited reporting of laboratory techniques were areas of concern.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The systematic review included 14 papers comprising data from 2,575 women from four sources: blood, urine, surgical wound and endocervical.

    “We included 14 papers comprising data from 2,575 women from four sources (blood, urine, surgical wound and endocervical).”
    • Also stated in: § Results · plain
      “Therefore, 14 articles were eligible for data extraction.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingreasoning

    Of 58 papers eligible for full-text review, 14 articles were eligible for data extraction.

    “Fifty-eight papers were eligible for full-text review; 12 articles were excluded because of no correspondence from authors in studies that reported little detail on results; three papers were on premature rupture of membranes (PROM) screening, six papers had no microbiological data, two were microbiome papers, 20 articles targeted the wrong population, and one article had incoherent results.”
    • Also stated in: § Results · plain
      “Therefore, 14 articles were eligible for data extraction.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Of the included studies, eight were from East Africa (five from Ethiopia), two from Southern Africa, and three from West Africa.

    “Eight studies were from East Africa (five from Ethiopia), two from Southern Africa and three from West Africa (Fig. 2).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The database search identified 3108 papers for abstract screening after removing duplicates.

    “This systematic review and meta-analysis database search identified 3108 papers for abstract screening after removing duplicates (Fig. 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The main study results of interest for this review were clear and detailed for all included studies.

    “The main study results of interest for this review, however, were clear and detailed for all included studies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The studies included in the meta-analyses were performed in government and mostly tertiary hospitals and not private or primary healthcare facilities.

    “Another challenge was that the studies included in our meta-analyses were performed in government and mostly tertiary hospitals and not private or primary healthcare facilities.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    E. coli resistance rates to first-line antibiotics (penicillins) and second-line drugs (ciprofloxacin) were both >20%.

    “In addition, resistance rates of E. coli to first-line antibiotics (penicillins) and second-line drugs (ciprofloxacin) were both > 20% and of great concern.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The limitations of the studies and funding sources were not reported comprehensively.

    “Other criteria that should have been reported more comprehensively were the limitations of the studies and funding sources.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most studies report convenience sampling of patients with suspected maternal sepsis and no randomized sampling was reported.

    “Most studies report convenience sampling of patients with suspected maternal sepsis and no randomized sampling was reported, which may limit the generalizability of the findings to the wider maternal population.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    E. coli, S. aureus, and Klebsiella spp. are the most common pathogens associated with maternal infections.

    “Our study shows that E. coli, S. aureus, and Klebsiella spp. are the most common pathogens associated with maternal infections.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    All studies dropped at least three points on the Newcastle-Ottawa score, spread across 2-3 assessment categories.

    “Notably, all studies dropped at least three points, spread across 2–3 assessment categories, with 8/14 (57.1%) dropping two points in a single category and at particular risk of introducing bias.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Some studies reported resistance to penicillin by Gram-negative causative agents.

    “Also, some studies reported resistance to penicillin by Gram-negative causative agents (known to be inherently resistant to penicillin).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: E. coli and Klebsiella spp. are commonly and intrinsically resistant to penicillin.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Two independent authors screened titles and abstracts, with disagreements resolved by discussion or a third author.

    “Two independent authors (CC and CVD) screened titles and abstracts with aid from a librarian (AS) in Rayyan.”
    • Also stated in: § Search strategy and selection criteria · plain
      “CC and CVD resolved disagreements through discussion; if they could not reach an agreement, a third author (DL) resolved the disagreement.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The systematic review was registered with PROSPERO (CRD42021238515).

    “This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO) on March 2021 (Registration number: CRD42021238515).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    This challenge limits the data interpretation in the context of maternal infections.

    “This challenge limits the data interpretation in the context of maternal infections.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Over two-thirds of global maternal deaths occur in Sub-Saharan Africa, with at least 200,000 deaths per year.

    “Over two-thirds of global maternal deaths occur in SSA, with at least 200,000 deaths per year [6, 1].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [6] UNICEF. Maternal mortality rates and statistics - UNICEF DATA. UNICEF Data: Monitoring the situation of children and women. 2019. p. 1–8. Available from: https://data.unicef.org/topic/maternal-health/maternal-mortality/. Cited 2022 Feb 20.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [1] WHO, UNICEF, UNFPA WBG and the UNPD. WHO | Trends in maternal mortality: 1990 to 2015. WHO. 2016. p. 18–25. Available from: https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/. Cited 2021 Aug 26.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning

    The limited data on carbapenems and co-trimoxazole likely reflects local prescribing behaviour as third-generation drugs such as carbapenems are rarely available.

    “This likely reflects the local prescribing behaviour as third-generation drugs such as carbapenems are rarely available.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A notable limitation of GLASS data is the lack of stratified data on age and gender, and it did not specifically look at the pregnant/post-partum population.

    “A notable limitation of GLASS data is the lack of stratified data on age and gender, and it did not specifically look at the pregnant/post-partum population to inform the global picture of bacterial infection and AMR.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] Global antimicrobial resistance and use surveillance system (GLASS) report: 2022. Available from: https://www.who.int/publications/i/item/9789240062702. Cited 2023 Feb 13.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The WHO reported third-generation cephalosporin resistance for E. coli at 42%, K. pneumoniae between 59%-65%, and MRSA at 35% causing bloodstream infections.

    “In their report, the WHO reported third-generation cephalosporin- resistance for E. coli at 42%, K. pneumoniae between (59% – 65%) and methicillin-resistant S. aureus (MRSA) at 35% causing bloodstream infections [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] Global antimicrobial resistance and use surveillance system (GLASS) report: 2022. Available from: https://www.who.int/publications/i/item/9789240062702. Cited 2023 Feb 13.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Interpretationown data

    The heterogeneity can be explained by the summary table and subgroup analysis by sample type.

    “This heterogeneity can be explained by our summary table and subgroup analysis by sample type.”
    Quote in the paperSubstantial claim
27 of 27

  • The paper relies on this without support.

    There is no global data on the microbial aetiology of maternal infections needed to guide management of maternal infections in low- and middle-income countries.

    “There is still no global data on the microbial aetiology of maternal infections, which is needed to guide management of maternal infections in LMIC, where the burden of disease is the highest”

  • The paper relies on this without support.

    No systematic review has summarized the microbiological agents causing maternal bacterial infection in Sub-Saharan Africa or their resistance patterns.

    “Despite significantly higher maternal infection-related mortality in SSA, to date there has been no systematic review that summarizes the underlying microbiological agents causing maternal bacterial infection in SSA, nor their resistance patterns.”

  • The paper relies on this without support.

    The origins of the maternal infection problem in Sub-Saharan Africa lie in low-quality care areas, including inconsistent infection prevention, poor infection treatment, delayed sepsis diagnosis, and inadequate sepsis management.

    “The problem's origins lie in the low quality of care areas, including inconsistent infection prevention, poor infection treatment, delayed sepsis diagnosis, and inadequate sepsis management.”

  • The paper relies on this without support.

    Data on the microbiologic causes of bacterial maternal infections can inform policies and identify antimicrobial resistance threats in Sub-Saharan Africa.

    “Data on the microbiologic causes of bacterial maternal infections can inform policies (programme strategies and treatment guidelines) and identify antimicrobial resistance (AMR) threats in SSA.”

  • The paper relies on this without support.

    E. coli and Klebsiella spp. are commonly and intrinsically resistant to penicillin.

    “Notably, E. coli and Klebsiella spp. are commonly and intrinsically resistant to penicillin, respectively.”

  • The paper relies on this without support.

    Some antibiotics used in the general population cannot be used in pregnancy due to adverse effects on the unborn infant.

    “In addition, some antibiotics used in the general population cannot be used in pregnancy due to adverse effects on the unborn infant.”

  • The paper relies on this without support.

    Resistance genes in Enterobacterales to co-trimoxazole and carbapenems are frequently associated with mobile genetic elements that increase the likelihood of pan-drug-resistant and extreme-drug-resistant isolates.

    “For example, the reporting AST of K. pneumoniae to co-trimoxazole and carbapenems is of public health relevance because resistance genes in Enterobacterales to these antibiotics are frequently associated with mobile genetic elements that increase the likelihood of pan-drug-resistant and extreme-drug-resistant isolates.”

  • The paper relies on this without support.

    Most patients in SSA with severe maternal infection will attend government hospitals.

    “Nonetheless, most patients in SSA with severe maternal infection will attend government hospitals.”

  • The paper relies on this without support.

    HIV increases the risk of maternal morbidity and mortality.

    “considering that HIV increases the risk of maternal morbidity and mortality”

  • The paper relies on this without support.

    High rates of treatment failure for invasive and non-invasive bacterial infections, particularly in resource-constrained populations.

    “Furthermore, the documented high rates of treatment failure (for invasive and non-invasive bacterial infections), particularly alarming in resource-constrained populations, emphasize the critical need for immediate attention.”

  • The paper relies on this without support.

    Ampicillin (a penicillin) is first-line antibiotic for treating maternal peripartum infection in combination with gentamicin.

    “These include ampicillin (a penicillin) as first-line antibiotics for treating maternal peripartum infection in combination with gentamicin.”

  • The paper relies on this without support.

    The ability to deliver high-quality treatment is directly influenced by the accuracy and reliability of laboratory results.

    “The ability to deliver high-quality treatment is directly influenced by the accuracy and reliability of laboratory results, emphasizing the importance of addressing and rectifying potential limitations in detection methods.”

  • The paper relies on this without support.

    Ceftriaxone is the highest priority agent among the critically important antimicrobials for human medicine.

    “AMR has also been observed in amoxicillin and ceftriaxone, the highest priority agent among the critically important antimicrobials for human medicine.”
13 of 13

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Pooled wound-culture positivity conflicts with study rates

    Major

    The text reports approximately 8% positive wound cultures, but all three wound-only studies in Table 1 report rates of at least 64.3%.

  • Reference 32 does not identify the study cited in Table 1

    Minor

    Table 1 cites reference 32 for Orji 2022, but reference 32 is a Kifilie 2018 paper.

  • Heterogeneity range contradicts the Results

    Minor

    The Discussion says heterogeneity was 88-92% in all meta-analyses, but the Results report a 79-96% range.

  • Reported confirmation-rate range excludes studies in Table 1

    Minor

    The stated minimum is 20.4%, but Table 1 reports 7.8% for Bebell 2017 and 16.8% for Orji 2022.

4 of 4

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments - PMC. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021422/. Cited 2023 May 15.
  2. Kifilie AB, Dagnew M, Tegenie B, Yeshitela B, Howe R, Abate E. Bacterial Profile, Antibacterial Resistance Pattern, and Associated Factors from Women Attending Postnatal Health Service at University of Gondar Teaching Hospital, Northwest Ethiopia. Int J Microbiol. 2018;2018. Available from: https://pubmed.ncbi.nlm.nih.gov/29681942/. Cited 2024 Jan 8. · DOI

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Authors
Chapuma, C., Twabi, H. H., Monk, E. J. M., Jafali, J., Weeks, A., Beales, E., Kulapani, D., Selemani, A., Nliwasa, M., Gadama, L., Nyirenda, T., Msefula, C., Dunlop, C., Lissauer, S., Feasey, N., Van der Veer, C., & Lissauer, D.
Affiliations
  • University of Liverpool (GB)
  • Kamuzu University of Health Sciences (MW)
  • University of Birmingham (GB)
Corresponding author
Chapuma, Chikondi
ORCID
Venue
BMC Infectious Diseases
Publisher
Springer Science and Business Media LLC
Published
2024-09-14
Volume
24
Issue
1
Pages
978-978
ISSN
1471-2334 (ISSN-L)
DOI
10.1186/s12879-024-09855-3
PMC
PMC11401422
OpenAlex
W4402539299
Cited by
12
References
27
Citations by year
2026: 5 · 2025: 6 · 2024: 1
FWCI
1.05
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Infectious Diseases (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (publishedVersion, cc-by)
  • LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion, cc-by)
  • LSTM Online Archive (Liverpool School of Tropical Medicine) (submittedVersion, cc-by-nc-nd)
  • PubMed Central (submittedVersion, cc-by-nc-nd)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Funders
  • National Institute for Health and Care Research (NIHR300808)
  • Medical Research Council (MR/S004793/1)
Topics
  • Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Neonatal and Maternal Infections
  • Health Sciences › Medicine › Epidemiology › Urinary Tract Infections Management
Keywords
maternal infection, antimicrobial resistance, etiology, Escherichia coli, Staphylococcus aureus, Klebsiella, Streptococcus, beta-lactam resistance, empirical antibiotic therapy, sub-Saharan Africa, postnatal infection
MeSH terms
Anti-Bacterial Agents, Bacteria, Bacterial Infections, Female, Humans, Pregnancy, Pregnancy Complications, Infectious, Africa South of the Sahara, Drug Resistance, Bacterial

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-18.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-18.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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