Empirical therapy for intra-amniotic infection

Patients with intra-amniotic infection can present with sepsis or septic shock (see Identifying sepsis or septic shock for definitions). For patients with sepsis or septic shock, start antibiotic therapy within 1 hour of presentation to medical care or, for ward-based patients, development of sepsis or septic shock, immediately after appropriate samples are taken for culture. For nonantibiotic management of sepsis or septic shock, see Resuscitation of patients with sepsis or septic shock.

Patients undergoing caesarean section require surgical prophylaxis (see Caesarean section for regimens). If the intra-amniotic infection treatment regimen has an appropriate spectrum of activity for prophylaxis, additional surgical prophylaxis is not required. However, adjust the timing of the dose to achieve adequate plasma and tissue concentrations at the time of surgical incision and for the duration of the procedure. See also Surgical antibiotic prophylaxis for patients receiving treatment for established infection.

For empirical therapy of suspected or confirmed intra-amniotic infection, as a two-drug regimen, use:

If the results of culture and susceptibility testing are not available by 72 hours and empirical therapy is still required, stop the gentamicin-containing regimen and seek expert advice.

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, as a three-drug regimen, use:

If the results of culture and susceptibility testing are not available by 72 hours and empirical therapy is still required, stop the gentamicin-containing regimen and seek expert advice.

For patients who have had a severe immediate¹ hypersensitivity reaction to a penicillin, the cefazolin containing regimen (at the dosage above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For patients who have had a severe immediate¹ hypersensitivity reaction to a penicillin in whom cefazolin is not used, or for patients who have had a severe delayed² hypersensitivity reaction to a penicillin, a non–beta-lactam regimen is required (a two-drug regimen of gentamicin plus clindamycin or a three-drug regimen of gentamicin, vancomycin and metronidazole). The regimen containing clindamycin is preferred to reduce the risk of antimicrobial resistance but group B streptococcus resistance to clindamycin is increasing. Only use the following regimen if the group B streptococcus isolate is susceptible to clindamycin:

For patients who require a non–beta-lactam regimen, if the group B streptococcus isolate is resistant to clindamycin, or the group B streptococcus status (or susceptibility) is unknown, in the above regimen replace clindamycin with the combination of:

If the results of culture and susceptibility testing are not available by 72 hours and empirical therapy is still required, stop the gentamicin-containing regimen and seek expert advice.