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Cited by 86Neonatal and Maternal InfectionsAntibiotic Use and ResistanceAntibiotic Resistance in Bacteria

Antimicrobial-resistant infections among postpartum women at a Ugandan referral hospital

Open access
Bebell, Lisa M., Ngonzi, Joseph, Bazira, Joel, Fajardo, Yarine, Boatin, Adeline A., Siedner, Mark J., Bassett, Ingrid V., Nyehangane, Dan +7 more·2017·PLOS ONE
DOI 10.1371/journal.pone.0175456PMC PMC5391058
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Abstract

INTRODUCTION: Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. METHODS: We performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care, measured vital signs after delivery, performed structured physical exam, symptom questionnaire, and microbiologic evaluation of febrile and hypothermic women. Malaria rapid diagnostic testing, blood and urine cultures were performed aseptically and processed at Epicentre Mbarara Research Centre. Antimicrobial susceptibility and breakpoints were determined using disk diffusion per EUCAST standards. Hospital diagnoses, treatments and outcomes were abstracted from patient charts. RESULTS: Mean age was 25 years, 12% were HIV-infected, and 50% had cesarean deliveries. Approximately 5% (205/4176) with ≥1 temperature measurement recorded developed postpartum fever or hypothermia; blood and urine samples were collected from 174 (85%), and 17 others were evaluated clinically. Eighty-four (48%) had at least one confirmed source of infection: 39% (76/193) clinical postpartum endometritis, 14% (25/174) urinary tract infection (UTI), 3% (5/174) bloodstream infection. Another 3% (5/174) had malaria. Overall, 30/174 (17%) had positive blood or urine cultures, and Acinetobacter species were the most common bacteria isolated. Of 25 Gram-negatives isolated, 20 (80%) were multidrug-resistant and cefepime non-susceptible. CONCLUSIONS: For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. Increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities.

AI snapshot

Written from the paper’s full text.

TL;DR

In a prospective cohort of Ugandan women presenting for delivery or postpartum care, 5% (205/4,176 with temperature measurements) developed postpartum fever or hypothermia, and 48% (84/174) of fully evaluated febrile/hypothermic women had at least one confirmed infection. Infections were dominated by antimicrobial-resistant Gram-negative rods, including Acinetobacter species, with 80% (20/25) of Gram-negative isolates multidrug-resistant and cefepime non-susceptible.

Key findings

  • Among 4,176 women with ≥1 temperature measurement, 205 (5%) developed postpartum fever or hypothermia; 174 (85%) underwent full clinical and microbiological evaluation, and 84/174 (48%) had one or more confirmed postpartum infections.
  • Diagnoses included clinical endometritis in 76/193 (39%), UTI in 25/174 (14%), bloodstream infection in 5/174 (3%), and malaria in 5/174 (3%); 30/174 (17%) had positive blood or urine cultures, and Acinetobacter species were the most common bacteria isolated.
  • Of 25 Gram-negative isolates, 20 (80%) were multidrug-resistant and cefepime non-susceptible; 9/11 (82%) Enterobacteriaceae causing UTI were ESBL-positive, and only 4/29 (14%) participants were prescribed an antibiotic to which their bacterial isolate was susceptible.
  • In-hospital incidence of endometritis, UTI, or bloodstream infection was 2%; there were two in-hospital maternal deaths, neither due to infection.

Methods

  • Prospective cohort study at Mbarara Regional Referral Hospital, Uganda, March–October 2015; women presenting for delivery or within 42 days postpartum were enrolled, with vital signs including oral temperature measured approximately every 8 hours after delivery.
  • Febrile (>38.0°C) or hypothermic (<36.0°C) participants underwent malaria rapid diagnostic testing, clean-catch urine collection, and aseptic blood cultures; microbiology was processed at Epicentre Mbarara Research Centre, with antimicrobial susceptibility by Kirby-Bauer disk diffusion using EUCAST version 5.0 breakpoints and ESBL testing for Enterobacteriaceae.
  • Structured interviews and chart review captured demographics, diagnoses, treatments, and outcomes; a randomly selected normothermic comparison group was included, and analyses used Chi2 or t-tests with p<0.05 in Stata 12.0.

Limitations

  • Stated: no genital tract cultures were collected; there was no post-discharge fever evaluation or outcome follow-up; possible early-discharge bias may have led to fewer temperature measurements and shorter follow-up among vaginal-delivery patients; other causes of postpartum fever were not investigated, and cesarean surgical site infection was not clinically confirmed, leaving no source in 52% of febrile/hypothermic women.
  • Stated/evident: antibiotic administration was rarely recorded, so receipt of prescribed antibiotics is uncertain; culture-positive UTI (25) and bloodstream infection (5) numbers were small, limiting precision; possible contaminants or colonizers were acknowledged, though the authors argue isolates came from participants with clinical infection and urinalysis findings consistent with UTI.

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

Integrity signals

Registry

Crossref · 10.1371/journal.pone.0175456

Cites

30 of 30 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

15 of 38 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    In low-resource settings, differences in antibiotic prophylaxis and treatment, cesarean delivery practices, HIV prevalence, access to microbiology testing, antimicrobial stewardship and infection control practices may lead to differences in infection incidence, microbiology, and antimicrobial resistance.

    “In low-resource settings, differences in antibiotic prophylaxis and treatment, cesarean delivery practices, human immunodeficiency virus (HIV) prevalence, access to microbiology testing, antimicrobial stewardship and infection control practices may lead to differences in infection incidence, microbiology, and antimicrobial resistance.[4, 5, 9, 10]”
    Quote in the paperSubstantial claim1 of 4 sources checked
    • cites [4] AC Seale, 2009, Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa, Lancet Infect Dis source

      The Risk factors for maternal sepsis and Incidence sections link caesarean delivery, antibiotic prophylaxis, and clean delivery practices to sepsis risk or incidence; the Aetiology and Conclusions sections also describe how limited microbiology facilities affect what can be identified. The paper says the contribution of HIV prevalence to maternal sepsis is largely unknown, and the passages do not support the claim about antimicrobial stewardship or differences in antimicrobial resistance. Page numbers are unavailable in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [5] B Allegranzi, 2011, Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis, Lancet source
    • cites [9] CA Petti, 2006, Laboratory medicine in Africa: a barrier to effective health care, Clinical infectious diseases: an official publication of the Infectious Diseases Society of America source
    • cites [10] AE Miller, 2013, Causes of puerperal and neonatal sepsis in resource-constrained settings and advocacy for an integrated community-based postnatal approach, Int J Gynaecol Obstet source
  • Premisecitation

    Prospective studies on the incidence, microbiology and antimicrobial resistance of postpartum infections are lacking.

    “prospective studies on incidence, microbiology and antimicrobial resistance are lacking.”
    • Also stated in: § Introduction · plain
      “However, prospective studies of pregnancy-related infections are scant, and most data come from retrospective studies of maternal deaths without formal microbiological investigation or antimicrobial susceptibility testing.[2–6]”
    Quote in the paperSubstantial claim4 of 5 sources checked
    • cites [2] AC Seale, 2013, Neonatal severe bacterial infection impairment estimates in South Asia, sub-Saharan Africa, and Latin America for 2010, Pediatric research source

      The Discussion’s ‘Data Gaps and Improving the Data’ section identifies missing evidence on neurodevelopmental outcomes after neonatal infections, not prospective studies of postpartum infections. ‘Programmatic Implications’ raises antimicrobial resistance as a concern but does not say that studies of postpartum incidence, microbiology, or resistance are lacking. Searches for postpartum and maternal infection study gaps did not find a passage addressing the claim; page numbers were unavailable in our copy. (LLM, conf=0.77)

      Experimental — accuracy not yet measured
    • cites [3] J van Dillen, 2010, Maternal sepsis: epidemiology, etiology and outcome, Current Opinion in Infectious Diseases source

      The Epidemiology section says most maternal-sepsis estimates, especially in low-income countries, come from retrospective studies without clinical investigations, supporting a shortage of prospective incidence data. It does not say that prospective studies of postpartum-infection microbiology or antimicrobial resistance are lacking, and its wording is narrower than a blanket claim that prospective studies are lacking. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
    • cites [4] AC Seale, 2009, Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa, Lancet Infect Dis source

      The Incidence of maternal sepsis section says most sub-Saharan African estimates come from retrospective studies without microbiological investigation, while the Aetiology section says microbiological data are few. This supports a shortage of prospective incidence and microbiology studies in that setting, although the paper does describe one prospective study. The passages do not establish a corresponding shortage of studies on antimicrobial resistance. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [5] B Allegranzi, 2011, Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis, Lancet source
    • cites [6] J Ngonzi, 2016, Puerperal sepsis, the leading cause of maternal deaths at a Tertiary University Teaching Hospital in Uganda, BMC Pregnancy Childbirth source

      The Abstract Conclusions recommend more research on the microbiology and epidemiology of puerperal sepsis, and the Study limitations state that this study was retrospective. These passages support a research gap, but they do not establish that prospective studies of incidence are lacking or address antimicrobial resistance. No page numbers are available in our copy. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
  • Premisecitation

    Peri-cesarean antibiotic prophylaxis (a single dose of β-lactam antibiotic) prior to cesarean delivery reduces the incidence of postpartum endometritis threefold.

    “Peri-cesarean antibiotic prophylaxis (a single dose of β-lactam antibiotic) prior to cesarean delivery reduces the incidence of postpartum endometritis threefold.[26, 27]”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [26] FM Smaill, 2014, Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section, The Cochrane database of systematic reviews source

      The Background’s Main results report less endometritis with prophylactic antibiotics than with placebo or no treatment (RR 0.38), approximately a threefold difference in incidence. But the review pools different antibiotics, dosing schedules, and administration times; it does not establish that a single dose of a β-lactam given before cesarean delivery produces that specific effect. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [27] WHO. WHO recommendations for prevention and treatment of maternal peripartum infections Geneva: World Health Organization; 2015 [cited 2016 17 October]. Available from: <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/peripartum-infections-guidelines/en/" xlink:type="simple">http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/peripartum-infections-guidelines/en/</ext-link>.

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

  • Premisecitation

    UTI microbiology and antimicrobial resistance in sub-Saharan Africa is not well described.

    “Though UTI microbiology and antimicrobial resistance in sub-Saharan Africa is not well described,[4, 5, 25]”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [4] AC Seale, 2009, Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa, Lancet Infect Dis source

      The Risk factors for early onset neonatal sepsis section says mothers with a history of urinary tract infections are seldom identified in sub-Saharan Africa, probably because bacterial cultures were not done. This lends limited support to a gap in UTI microbiological data, but the paper does not establish the broader claim about UTI microbiology or address UTI antimicrobial resistance. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
    • cites [5] B Allegranzi, 2011, Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis, Lancet source
    • cites [25] R Laxminarayan, 2013, Antibiotic resistance-the need for global solutions, Lancet Infect Dis source
  • Findingown data

    Overall, 17% (30/174) of febrile or hypothermic participants had positive blood or urine cultures.

    “Overall, 30/174 (17%) had positive blood or urine cultures”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 25
  • May combine two claims. 26
  • The quote only partly states this claim. 1

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

    Premisecitation

    Cesarean delivery is the single most important risk factor for postpartum infection.

    “Cesarean delivery is considered the single most important risk factor for postpartum infection due to skin and uterine disruption, bladder catheterization, and healthcare system contact, though peri-procedural antibiotic prophylaxis reduces the risk significantly.[3, 8]”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [3] J van Dillen, 2010, Maternal sepsis: epidemiology, etiology and outcome, Current Opinion in Infectious Diseases source
    • cites [8] D Maharaj, 2007, Puerperal pyrexia: a review. Part I, Obstetrical & gynecological survey source

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

    Premisecitation

    The most common postpartum infections include endometritis (puerperal sepsis), urinary tract infections, bloodstream infections, and cesarean surgical site infections.

    “The most common postpartum infections include endometritis (puerperal sepsis), urinary tract infections (UTIs), bloodstream infections, and cesarean surgical site infections.[3, 5, 7]”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [3] J van Dillen, 2010, Maternal sepsis: epidemiology, etiology and outcome, Current Opinion in Infectious Diseases source

      The Etiology section identifies endometritis and urinary tract infections and reports bacteraemia among cases of postpartum invasive group A streptococcal infection. The Outcome section discusses wound infections after caesarean section. These passages support the infection types, but they do not establish that all four are among the most common postpartum infections; the bacteraemia finding concerns a specific, uncommon infection. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [5] B Allegranzi, 2011, Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis, Lancet source
    • cites [7] SE Lapinsky, 2013, Obstetric infections, Critical care clinics source

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

    Premisecitation

    Peri-procedural antibiotic prophylaxis reduces the risk of postpartum infection significantly.

    “Cesarean delivery is considered the single most important risk factor for postpartum infection due to skin and uterine disruption, bladder catheterization, and healthcare system contact, though peri-procedural antibiotic prophylaxis reduces the risk significantly.[3, 8]”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [3] J van Dillen, 2010, Maternal sepsis: epidemiology, etiology and outcome, Current Opinion in Infectious Diseases source
    • cites [8] D Maharaj, 2007, Puerperal pyrexia: a review. Part I, Obstetrical & gynecological survey source

  • May combine two claims.

    Premisecitation

    Nosocomial UTIs are understudied and likely underestimated in resource-limited settings.

    “which are understudied and likely underestimated in resource-limited settings.[5, 22]”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [5] B Allegranzi, 2011, Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis, Lancet source
    • cites [22] M Scherbaum, 2014, Incidence, pathogens and resistance patterns of nosocomial infections at a rural hospital in Gabon, BMC infectious diseases source

      The Background says that few studies have examined nosocomial infections in developing countries and that their overall magnitude remains largely underestimated. The Results identify urinary-tract infections among the infections studied, but the paper does not specifically say that nosocomial UTIs are understudied or underestimated. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Urethral catheterization is common for cesarean deliveries and incurs a 3-8% daily risk of bacteriuria, markedly enhancing risk of UTI.

    “Urethral catheterization is common for cesarean deliveries, and incurs a 3–8% daily risk of bacteriuria, markedly enhancing risk of UTI.[14, 24]”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [14] TM Hooton, 2010, Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America, Clinical infectious diseases: an official publication of the Infectious Diseases Society of America source

      The Epidemiology section gives a 3%–8% daily incidence of bacteriuria with indwelling catheterization, and the Introduction describes a strong link between urinary catheterization and subsequent UTI. The cited passages do not establish that catheterization is common for cesarean deliveries or give a cesarean-specific risk estimate. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [24] B Stray-Pdersen, 1990, Bacteriuria in the puerperium. Risk factors, screening procedures, and treatment programs, American journal of obstetrics and gynecology

      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).

    Premisecitation

    Mounting evidence demonstrates the emergence of Acinetobacter as a cause of hospital-associated and occasionally community-acquired infection in resource-limited settings.

    “mounting evidence demonstrates the emergence of this pathogen as a cause of hospital-associated and occasionally community-acquired infection in resource-limited settings.[5, 16–20]”
    Quote in the paperNot a substantial claim3 of 6 sources checked
    • cites [5] B Allegranzi, 2011, Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis, Lancet source
    • cites [16] LS Munoz-Price, 2008, Acinetobacter infection, N Engl J Med source
    • cites [17] A Onken, 2015, Prevalence and Antimicrobial Resistance of Microbes Causing Bloodstream Infections in Unguja, Zanzibar, PLoS One source

      The Results > Microbes table reports Acinetobacter bloodstream infections in both community- and hospital-acquired cases in Zanzibar. But nine of the ten Acinetobacter isolates were community-acquired, so this study does not support describing community acquisition as only occasional; it also does not establish an emergence trend. Our copy provides no page number for the table. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [18] M Lowings, 2015, High prevalence of oxacillinases in clinical multidrug-resistant Acinetobacter baumannii isolates from the Tshwane region, South Africa—an update, BMC infectious diseases source

      The Background describes A. baumannii as an emerging pathogen associated with outbreaks in healthcare facilities, and the paper studies isolates from hospitals in South Africa. Our copy does not describe community-acquired infections, so it does not support that part of the claim. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [19] SH Lob, 2016, Regional differences and trends in antimicrobial susceptibility of Acinetobacter baumannii, International journal of antimicrobial agents source
    • cites [20] AL Carlson, 2016, Controlling Nosocomial Transmission of Drug-Resistant Pathogens at Different Endemic Stages in a Resource-Limited Setting, Infection control and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America source

      The paper’s opening discussion (p. 2) identifies extensively drug-resistant Acinetobacter baumannii as a common nosocomial infection in Thailand, supporting the hospital-associated portion of the claim. It does not address community-acquired Acinetobacter infection. Its single-center data also show a decline in incidence, so they do not establish the claimed emergence. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    Mean catheter days among CAUTI participants was 1.9 (SD 0.6), which did not differ from non-CAUTI catheterized participants (2.4, SD 1.4, P = 0.14).

    “Mean catheter days among CAUTI participants was 1.9 (SD 0.6), which did not differ from non-CAUTI catheterized participants (2.4, SD 1.4, P = 0.14).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Six (24%) UTIs were caused by Gram-positive organisms, and the remaining 19/25 (76%) by Gram-negatives.

    “Six (24%) UTIs were caused by Gram-positive organisms, and the remaining 19/25 (76%) by Gram-negatives.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Of 76 women with clinical endometritis, 61 (82%) delivered by cesarean, representing 7% of 875 cesarean deliveries.

    “Of 76 women with clinical endometritis, 61 (82%) delivered by cesarean, 7% of 875 cesarean deliveries.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Acinetobacter spp. were the most common organisms associated with UTIs (11/25, 44%), followed by Escherichia coli (5/25, 20%).

    “Acinetobacter spp. were the most common organisms associated with UTIs (11/25, 44%), followed by Escherichia coli (5/25, 20%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Of six UTIs identified by organisms staining positive on Gram stain, 1/6 (17%) was caused by Candida spp., 3/6 (50%) by coagulase-negative Staphylococcus spp., and 1/6 each (17%) by Enterococcus faecalis and Enterococcus faecium.

    “Of six UTIs identified by organisms staining positive on Gram stain, 1/6 (17%) was caused by Candida spp., 3/6 (50%) by coagulase-negative Staphylococcus spp., and 1/6 each (17%) by Enterococcus faecalis and Enterococcus faecium (Tables 2 and 4).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Eighteen of 22 Gram-negative rods (82%) were cefepime non-susceptible, and 17/22 (77%) were ciprofloxacin non-susceptible.

    “Eighteen of 22 Gram-negative rods (82%) were cefepime non-susceptible, and 17/22 (77%) were ciprofloxacin non-susceptible (Table 3).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Of 25 UTIs, 19 (76%) were catheter-associated UTIs (CAUTIs), including 5/19 (26%) cases of pyelonephritis and 14/19 (74%) lower-tract UTIs.

    “Of 25 UTIs, one (4%) was uncomplicated, five (20%) were non-catheter-associated pyelonephritis, and 19 (76%) were catheter-associated UTIs (CAUTIs), including 5/19 (26%) cases of pyelonephritis and 14/19 (74%) lower-tract UTIs (Table 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A single pathogen was recovered from 23/25 (92%) UTIs, while two pathogens were recovered in 2/25 (8%).

    “A single pathogen was recovered from 23/25 (92%) UTIs, while two pathogens were recovered in 2/25 (8%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In this cohort, prophylactic antibiotic prescription was near-universal, including among those diagnosed with postpartum infection.

    “Prophylactic antibiotic prescription was near-universal in our cohort, including those diagnosed with postpartum infection”
    Quote in the paperSubstantial claim

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

    Findingown data

    Among the three UTI participants who reported antibiotic use within the last year, the third grew both multi-drug resistant Klebsiella pneumoniae and Acinetobacter spp.

    “the 3rd grew both multi-drug resistant Klebsiella pneumoniae and Acinetobacter spp.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Among the three UTI participants who reported antibiotic use within the last year, urine culture grew yeast cells in the second.

    “yeast cells in the second”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Of five participants with positive malaria rapid diagnostic tests, 2/5 (40%) met criteria for endometritis.

    “2/5 (40%) for endometritis.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    6/82 (7%) with confirmed infection reported antibiotic use in the last year.

    “including 6/82 (7%) with confirmed infection.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    No blood cultures were positive for mycobacteria.

    “No blood cultures were positive for mycobacteria.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Of five participants with positive malaria rapid diagnostic tests, 1/5 (20%) met criteria for bloodstream infection.

    “1/5 (20%) for bloodstream infection”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In this cohort, urine catheter placement was documented in 96% of cesarean deliveries, for an average of 2 (SD 1) days.

    “In our cohort, urine catheter placement was documented in 96% of cesarean deliveries, for an average of 2 (SD 1) days.”
    Quote in the paperSubstantial claim

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

    Findingown data

    Of five participants with positive malaria rapid diagnostic tests, 1/5 (20%) met criteria for UTI.

    “Of five participants with positive malaria rapid diagnostic tests, 1/5 (20%) met criteria for UTI”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There were two in-hospital maternal deaths, neither of which were due to infection.

    “There were two in-hospital maternal deaths, neither of which were due to infection.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Among the three UTI participants who reported antibiotic use within the last year, urine culture grew Enterococcus faecalis in one.

    “of these, urine culture grew Enterococcus faecalis in one”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Over 99% (4,235) of eligible women presenting to MRRH for care during the study period were enrolled, and four withdrew before data collection.

    “Of all eligible women presenting to MRRH for care during the study period, over 99% (4,235) were enrolled, and four withdrew before data collection was performed.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Cesarean surgical site infection was not confirmed by research staff and not included in the composite primary outcome.

    “Cesarean surgical site infection was not confirmed by research staff and not included in the composite primary outcome.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    We randomly selected 1,581 normothermic participants as a comparison group to achieve at least a 4:1 ratio of normothermic:febrile/hypothermic participants, maximizing power to detect differences between groups.

    “We randomly selected 1,581 normothermic participants as a comparison group to achieve at least a 4:1 ratio of normothermic:febrile/hypothermic participants, maximizing power to detect differences between groups.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    Of 205 (5%) febrile or hypothermic participants, 174 (85%) completed physical exam and symptom questionnaire, blood and urine cultures, and malaria RDT.

    “Of 205 (5%) febrile or hypothermic participants, 174 (85%) completed physical exam and symptom questionnaire, blood and urine cultures, and malaria RDT.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Antibiotic administration is rarely recorded in charts, though antibiotic prescription is well-documented.

    “Though antibiotic prescription is well-documented in charts, antibiotic administration is rarely recorded.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    For women in rural Uganda with postpartum fever, there is a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species.

    “For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Women presenting to Mbarara Regional Referral Hospital are representative of women in rural Uganda with postpartum fever.

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

    Study design and conductreasoning

    The microbiology laboratory (Epicentre Mbarara Research Centre) complies with Good Clinical Laboratory Practice standards and undergoes regular on-site quality control and training.

    “Epicentre complies with Good Clinical Laboratory Practice standards, is seeking accreditation with Strengthening Laboratory Management Toward Accreditation (SLMTA), and is overseen by Epicentre France, whose staff perform regular on-site quality control and training.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    At least one temperature measurement was recorded for 4,176 (99%) of participants, and two or more measurements were recorded for 2917 (69%).

    “At least one temperature measurement was recorded for 4,176 (99%) of participants, and two or more measurements were recorded for 2917 (69%).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Antibiotic breakpoints were defined using European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines, version 5.0.

    “Antibiotic breakpoints were defined using European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines, version 5.0.[11]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] EUCAST. Breakpoint tables for interpretation of MICs and zone diameters. Version 5.0.: The European Committee on Antimicrobial Susceptibility Testing; 2015.

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

  • May combine two claims.

    Study design and conductown data

    Overall, 1,567 (92%) had both chart review and interview data, and 1586 with either chart review or interview data were included in the analysis.

    “Overall, 1,567 (92%) had both chart review and interview data, and 1586 with either chart review or interview data were included in the analysis (Fig 1).”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Klebsiella pneumonia and Escherichia coli are more common causes of UTIs in pregnancy and the postpartum period.

    “Klebsiella pneumonia and Escherichia coli, more common causes of UTIs in pregnancy and the postpartum period,[21]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] D Maharaj, 2007, Puerperal Pyrexia: a review. Part II, Obstetrical & gynecological survey source

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

    Premisecitation

    The puerperium is especially high-risk for UTI due to physiologic and hormonal changes inhibiting lower urinary tract defenses against invading bacteria.

    “The puerperium is especially high-risk for UTI due to physiologic and hormonal changes inhibiting lower urinary tract defenses against invading bacteria.[23]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] MJ Lucas, 1993, Urinary infection in pregnancy, Clinical obstetrics and gynecology source

  • May combine two claims.

    Study design and conductnone given

    The study had near-complete microbiologic evaluation of febrile and hypothermic women using a reliable microbiology laboratory.

    “and near-complete microbiologic evaluation of febrile and hypothermic women using a reliable microbiology laboratory.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Antibiotic overuse for obstetric conditions and procedures is common in clinical practice worldwide.

    “Antibiotic overuse for obstetric conditions and procedures is common in clinical practice worldwide,[27]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] WHO. WHO recommendations for prevention and treatment of maternal peripartum infections Geneva: World Health Organization; 2015 [cited 2016 17 October]. Available from: <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/peripartum-infections-guidelines/en/" xlink:type="simple">http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/peripartum-infections-guidelines/en/</ext-link>.

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

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Guidelines recommend avoiding therapeutic multi-drug antibiotic regimens and limiting prophylaxis to the simplest and shortest regimens possible to minimize selection pressure for antibiotic-resistant organisms.

    “Peri-cesarean antibiotic prophylaxis guidelines recommend avoiding therapeutic multi-drug antibiotic regimens, limiting prophylaxis to the simplest and shortest regimens possible to minimize selection pressure for antibiotic-resistant organisms.[27]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] WHO. WHO recommendations for prevention and treatment of maternal peripartum infections Geneva: World Health Organization; 2015 [cited 2016 17 October]. Available from: <ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/peripartum-infections-guidelines/en/" xlink:type="simple">http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/peripartum-infections-guidelines/en/</ext-link>.

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

  • May combine two claims.

    Study design and conductown data

    The study did not clinically confirm cesarean surgical site wound infection or diagnose dehydration, thrombophlebitis, pneumonia, or viral infection due to resource constraints.

    “We did not clinically confirm cesarean surgical site wound infection; diagnose dehydration, thrombophlebitis, pneumonia, or viral infection due to resource constraints”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Guidelines encourage consideration of local bacterial resistance when prescribing antibiotics for postpartum infection treatment and prophylaxis.

    “Guidelines encourage consideration of local bacterial resistance when prescribing antibiotics for postpartum infection treatment and prophylaxis,[29, 30]”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [29] Z Alfirevic, 2010, Different classes of antibiotics given to women routinely for preventing infection at caesarean section, The Cochrane database of systematic reviews source
    • cites [30] K Gupta, 2011, International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases, Clinical infectious diseases: an official publication of the Infectious Diseases Society of America source

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

    Study design and conductnone given

    The study did not investigate other causes of postpartum fever in the population.

    “Lastly, we did not investigate other causes of postpartum fever in our population.”
    Quote in the paperNot a substantial claim
43 of 43

  • The paper relies on this without support.

    Most research on postpartum infection has occurred in high-resource settings.

    “To date, most research on postpartum infection has occurred in high-resource settings.”

  • The paper relies on this without support.

    Women presenting to Mbarara Regional Referral Hospital are representative of women in rural Uganda with postpartum fever.

    “For women in rural Uganda with postpartum fever, we found a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species.”
    “Participants were recruited from Mbarara Regional Referral Hospital (MRRH) in Mbarara, Uganda between March and October, 2015.”

  • The paper relies on this without support.

    Receipt of 3rd generation cephalosporins (including ceftriaxone) is a risk factor for Acinetobacter baumanii infection or colonization.

    “Receipt of 3rd generation cephalosporins (including ceftriaxone) is a known risk factor for Acinetobacter baumanii infection or colonization”

  • The paper relies on this without support.

    Acinetobacter are not common causes of urinary tract and bloodstream infection in young, healthy populations.

    “Though Acinetobacter are not common causes of urinary tract and bloodstream infection in young, healthy populations”

  • The paper relies on this without support.

    The local practice of administering three days’ intravenous antibiotics followed by five days’ oral antibiotics post-cesarean at MRRH has arisen from low maternity ward nurse-to-patient staffing ratios (between 1:25 and 1:50) leading to concerns of less timely identification of infections.

    “This local practice of administering three days’ intravenous antibiotics followed by five days’ oral antibiotics post-cesarean has arisen from low maternity ward nurse-to-patient staffing ratios (between 1:25 and 1:50) leading to concerns of less timely identification of infections.”

  • The paper relies on this without support.

    Lack of reliable microbiology testing makes infection recognition, diagnosis, and appropriate antimicrobial treatment impractical or impossible.

    “In addition, lack of reliable microbiology testing makes infection recognition, diagnosis, and appropriate antimicrobial treatment impractical or impossible.”

  • The paper relies on this without support.

    In resource-limited settings such as MRRH, clinicians may not always adhere to these guidelines, rationalizing treatment as prevention.

    “and in resource-limited settings such as MRRH, clinicians may not always adhere to these guidelines, rationalizing treatment as prevention.”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Bebell et al. (2017) identified single marital status (OR 2.6, 95% CI 1.1-6.1, p=0.026) as an independent predictor of ESBL-E infection.

    “Bebell et al. ( 2017)) identified single marital status (OR 2.6, 95% CI 1.1-6.1,p = 0.026), low CD4+ count of <200/ml (OR 2.9, 95% CI 1.1-7.7,p = 0.031), and current UTI symptoms (OR 2.5, 95% CI 1.1-6.0,p = 0.03) as independent predictors of ESBL-E infection.”

    From Maternal colonization or infection with extended-spectrum beta-lactamase-producing Enterobacteriaceae in Africa: A systematic review and meta-analysis (2017) · cites this paper as Bebell et al. (2017)

    The Results (Enrollment and demographics, Table 1; page unavailable) compare marital status between women with and without confirmed infection, not ESBL-E infection. The Methods (Data entry and statistical analysis; page unavailable) describe group comparisons, and the Results (Urinary tract infections, Table 3; page unavailable) report ESBL findings by bacterial species. Searches for single marital status, OR 2.6, and independent ESBL-E predictors found no passage reporting the claimed association. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Bebell et al. (2017) identified low CD4+ count of <200/ml (OR 2.9, 95% CI 1.1-7.7, p=0.031) as an independent predictor of ESBL-E infection.

    “Bebell et al. ( 2017)) identified single marital status (OR 2.6, 95% CI 1.1-6.1,p = 0.026), low CD4+ count of <200/ml (OR 2.9, 95% CI 1.1-7.7,p = 0.031), and current UTI symptoms (OR 2.5, 95% CI 1.1-6.0,p = 0.03) as independent predictors of ESBL-E infection.”

    From Maternal colonization or infection with extended-spectrum beta-lactamase-producing Enterobacteriaceae in Africa: A systematic review and meta-analysis (2017) · cites this paper as Bebell et al. (2017)

    The Results (Enrollment and demographics, Table 1; page unavailable) compare CD4 categories between women with and without confirmed infection, not ESBL-E infection. The Methods (Data entry and statistical analysis; page unavailable) describe group comparisons, and the Results (Urinary tract infections; page unavailable) report ESBL prevalence. Searches for the stated odds ratio, confidence interval, p-value, and independent-predictor analysis found no passage reporting the claimed association. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

  • Bebell et al. (2017) identified current UTI symptoms (OR 2.5, 95% CI 1.1-6.0, p=0.03) as an independent predictor of ESBL-E infection.

    “Bebell et al. ( 2017)) identified single marital status (OR 2.6, 95% CI 1.1-6.1,p = 0.026), low CD4+ count of <200/ml (OR 2.9, 95% CI 1.1-7.7,p = 0.031), and current UTI symptoms (OR 2.5, 95% CI 1.1-6.0,p = 0.03) as independent predictors of ESBL-E infection.”

    From Maternal colonization or infection with extended-spectrum beta-lactamase-producing Enterobacteriaceae in Africa: A systematic review and meta-analysis (2017) · cites this paper as Bebell et al. (2017)

    The Results (Urinary tract infections; page not available) report that 9 of 11 Enterobacteriaceae causing UTIs tested positive for ESBL production, but do not assess current UTI symptoms as an independent predictor of ESBL-E infection. Searches for the stated odds ratio and for a regression analysis found no supporting passage in our copy. (LLM, conf=0.78)

    Experimental — accuracy not yet measured

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.

  • Reported ESBL count conflicts with susceptibility table

    Major

    Table 3 lists six urinary E. coli and three urinary Klebsiella pneumoniae isolates, of which four and three, respectively, were ESBL-positive. That is seven of nine urinary Enterobacteriaceae, rather than the stated nine of eleven.

  • Bloodstream infection percentage is incorrect

    Minor

    Four of five bloodstream infections is 80%, not 60%.

    Reported 60 · recomputed 80

  • Cesarean percentage among endometritis cases is incorrect

    Minor

    The reported 61 cesarean deliveries among 76 endometritis cases is approximately 80%, not 82%.

    Reported 82 · recomputed 80.263158

  • Table 4 reports one of three as zero percent

    Minor

    The coagulase-negative Staphylococcus row gives 1 (0) for both gentamicin and norfloxacin, although one of three is approximately 33%.

    Reported 0 · recomputed 33.333333

  • Conflicting counts of selected normothermic participants

    Minor

    Methods say 1,581 normothermic participants were randomly selected, while Results say 1,786 normothermic women were selected. The latter is also the size labeled as the total cohort in Table 1.

  • Clinical-evaluation count exceeds the reported partial-evaluation group

    Minor

    The paper reports 174 complete evaluations and another 17 partial evaluations, but says 19 additional women were evaluated clinically without microbiologic evaluation. Those 19 cannot all fit within the 17 participants reported as having partial evaluations.

6 of 6

Cites

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Related

Authors
Bebell, L. M., Ngonzi, J., Bazira, J., Fajardo, Y., Boatin, A. A., Siedner, M. J., Bassett, I. V., Nyehangane, D., Nanjebe, D., Jacquemyn, Y., van Geertruyden, J.-P., Mwanga-Amumpaire, J., Bangsberg, D. R., Riley, L. E., & Boum, Y.
Affiliations
  • Massachusetts General Hospital (US)
  • Mbarara University of Science and Technology (UG)
  • Epicentre Uganda (UG)
  • University of Antwerp (BE)
Corresponding author
Bebell, Lisa M.
ORCID
Venue
PLOS ONE
Publisher
Public Library of Science (PLoS)
Published
2017-04-13
Volume
12
Issue
4
Pages
e0175456
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0175456
PMC
PMC5391058
OpenAlex
W2605519895
Semantic Scholar
92b8ae306e07cfc95b871961cae8fdec59b51fc6
Cited by
86
References
30
Citations by year
2026: 1 · 2025: 5 · 2024: 10 · 2023: 5 · 2022: 4 · 2021: 11 · 2020: 4 · 2019: 41 · 2018: 4 · 2017: 1
FWCI
11.77
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion, cc-by)
  • PDXScholar (Portland State University) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Medecins Sans Frontieres Field Research (Medecins Sans Frontieres) (submittedVersion, other-oa)
Funders
  • Fogarty International Center (R25 TW009337)
  • National Institute of Allergy and Infectious Diseases (5T32AI007433-22)
  • Harvard University Center for AIDS Research (P30 AI060354)
  • National Institute of Mental Health (K23 MH09916)
  • Sullivan Family Foundation
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Neonatal and Maternal Infections
  • Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Medicine › Antibiotic Resistance in Bacteria
Keywords
antimicrobial resistance, postpartum fever, puerperal fever, postpartum endometritis, urinary tract infection, bloodstream infection, Acinetobacter, multidrug resistance, cefepime resistance, Gram-negative bacteria, malaria, HIV, antimicrobial stewardship, infection control, Uganda
MeSH terms
Cefepime, Acinetobacter, Acinetobacter Infections, Adolescent, Adult, Cephalosporins, Female, Humans, Pregnancy, Pregnancy Complications, Infectious, Prospective Studies, Uganda, Drug Resistance, Multiple, Bacterial, Postpartum Period

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.

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