Endometritis Antibiotic Management

Aka: Endometritis Antibiotic Management, Chorioamnionitis Antibiotic Management

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II. Indications

  1. Endometritis
  2. Chorioamnionitis
  3. Septic Abortion

III. Causes: Organisms

  1. Bacteroides species
  2. Streptococcus (including Group B Streptococcus)
  3. Enterobacteriaceae
  4. Chlamydia trachomatis

IV. Management: Intrapartum Intra-Amniotic Infection (pregnancy)

  1. Primary Protocol: No Penicillin Allergy
    1. Ampicillin 2 g IV every 6 hours AND
    2. Gentamycin 2 mg/kg IV load, then 1.5 mg/kg (Maximum 80-100 mg) every 8 hours
      1. Adjust dosing per kinetics if >1-2 days use
      2. Alternative: 5 mg/kg IV every 24 hours
  2. Alternative Protocol: Non-Anaphylactic Penicillin Reaction
    1. Cefazolin 2 g IV every 8 hours AND
    2. Gentamicin (see dosing above)
  3. Alternative Protocol: Anaphylaxis to Penicillins
    1. Clindamycin 900 mg IV every 8 hours OR Vancomycin 1 g IV every 12 hours AND
    2. Gentamicin (see dosing above)
  4. Alternative agents
    1. Ampicillin-Sulbactam (Unasyn) 3 grams IV every 4-6 hours (high Gram Negative resistance)
    2. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 8 hours
    3. Ertapenem 1 g IV every 24 hours
    4. Cefotetan 2 g IV every 12 hours
    5. Cefoxitin 2 g IV every 8 hours
  5. References
    1. (2019) Intrapartum Management of Intraamniotic Infection, ACOG Committee Opinion
      1. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Intrapartum-Management-of-Intraamniotic-Infection

V. Management: Postpartum Endometritis, Septic Abortion

  1. First-Line Agents
    1. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 8 hours
    2. Meropenem 1-2 grams IV then 0.5 to 1 g IV every 8 hours
  2. Alternative Agents
    1. Imipenem 0.5 g IV every 6 hours
    2. Ertapenem 1 g IV every 24 hours
    3. Ampicillin-Sulbactam (Unasyn) 3 grams IV every 4-6 hours (high Gram Negative resistance)
  3. Alternative Protocol: Clindamycin and Ceftriaxone
    1. Clindamycin 900 mg IV every 8 hours (high GBS resistance) AND
    2. Ceftriaxone 2 grams IV every 24 hours

VI. Management: Antibiotics added anaerobic coverage

  1. Indications
    1. Cesarean Section
    2. Foul amniotic discharge
  2. Agents
    1. Clindamycin 900 mg IV every 6 hours OR
    2. Metronidazole 15 mg/kg IV load then 7.5 mg/kg IV q6 hours

VII. Management: Antibiotics added Chlamydia coverage

  1. Indications
    1. Late onset Endometritis (>48 hours postpartum)
    2. Chlamydia PCR positive
  2. IV options (in addition to primary Antibiotic regimen above)
    1. Doxycycline 100 mg IV every 12 hours
      1. Do not use intrapartum or in Lactation
    2. Clindamycin 900 mg IV every 6 hours
  3. Outpatient agents after discharge
    1. Zithromax 1 gram PO x1 dose
    2. Erythromycin 500 mg PO qid for 7 days
    3. Erythromycin EthylSuccinate (EES)
      1. Dose: 800 mg PO qid for 7 days
    4. Doxycycline 100 mg PO bid
      1. Do not use intrapartum or in Lactation
    5. Clindamycin
      1. No efficacy data on oral Clindamycin against Chlamydia (IV is effective)

VIII. Management: Antibiotics if postpartum Hematoma present

  1. Indications
    1. Must be after delivery
    2. Endometritis and postpartum Hematoma
  2. Agents (choose 2)
    1. Doxycycline (not during pregnancy) AND
    2. Gentamicin (preferred) or Cefoxitin or Ampicillin/sulbactam (or as otherwise directed by local sensitivities)
  3. References
    1. Swadron, Schmitz, Bridwell, Carius in Herbert (2019) EM:Rap 19(3): 12-4

IX. References

  1. Sanford Guide (2019) Accessed IOS App 9/18/2019

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