Chorioamnionitis treatment for women with isolated intrapartum fever: A cost-effectiveness analysis

Intrapartum fever (≥38°C) occurs in many laboring patients annually in the United States, but whether an isolated fever should be treated as chorioamnionitis remains controversial. Antibiotic treatment may help reduce the impact of infection as compared to expectant management but may lead to other complications and increase costs. This study evaluated the cost-effectiveness of treating isolated intrapartum fever as chorioamnionitis.

We constructed a decision-analytic model in TreeAge Pro to compare outcomes between expectant management and antibiotic treatment with ampicillin/gentamicin for isolated intrapartum fever. Our theoretical cohort was 222,000 patients, representing laboring patients with an intrapartum temperature ≥38°C in the United States annually. Outcomes were postpartum endometritis, neonatal early-onset sepsis (nEOS), neonatal death, neonatal neurodevelopmental delay (NDD), acute kidney injury (AKI) from gentamicin toxicity, costs, and quality-adjusted life years (QALYs). We calculated the incremental cost per QALY ratio with a willingness-to-pay threshold of $100,000/QALY. We discounted QALYs at a rate of 3%. Model inputs were derived from literature and assessed using univariate sensitivity analyses.

In our theoretical cohort of 222,000 individuals with a fever in labor, antibiotic treatment reduced 7481 cases of postpartum endometritis (8649 vs. 16,131), 6047 cases of nEOS (961 vs. 7009), 71 fewer neonatal deaths (1254 vs. 1325), and 415 fewer cases of NDD (15,498 vs. 15,913) compared to expectant management. However, gentamicin use for chorioamnionitis resulted in 6036 more cases of AKI (8802 vs. 2766). Treating intrapartum fever as chorioamnionitis decreased costs and increased QALYs at baseline; thus, it was a dominant strategy. In the Monte Carlo multivariable probabilistic simulation, treating intrapartum fever with antibiotics proved cost-effective in 99.94% of trials, indicating that the cost-effectiveness of this strategy was robust to variation in the underlying variables.

Treating intrapartum fever with antibiotics is a cost-effective strategy to reduce the adverse outcomes of untreated intrapartum fever. Adopting a protocol to treat all intrapartum fevers ≥38°C as chorioamnionitis with appropriate antibiotics may lead to improved outcomes and reduced costs.