Severe postpartum endometritis

Empirical antibiotic therapy for severe postpartum endometritis

Postpartum endometritis is considered severe if the infection is associated with systemic features, 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.

Rarely, patients who are critically ill may have infection caused by Streptococcus pyogenes or Clostridium species; see Streptococcus pyogenes bloodstream infections, including toxic shock syndrome or Clostridial necrotising skin and soft tissue infection.

For treatment of severe postpartum endometritis, as a three-drug regimen, use:

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

For patients who have had a severe immediate¹ hypersensitivity reaction to a penicillin, the cefazolin containing regimen 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:

Modification and duration of therapy for severe postpartum endometritis

Modify therapy based on the results of culture and susceptibility testing (if possible), and clinical response. If results of susceptibility testing are not available by 72 hours and empirical intravenous therapy is still required, stop the gentamicin-containing regimen and seek expert advice.

For uncomplicated infections, continue intravenous antibiotic therapy for at least 24 to 48 hours after the resolution of leucocytosis and clinical signs and symptoms (ie fever, uterine tenderness, purulent vaginal discharge), and then stop antibiotic therapy. Oral antibiotic therapy is not required.

For complicated infection (eg abscess, bacteraemia), a longer course of intravenous therapy may be required followed by a switch to oral therapy once the patient is clinically stable (see Guidance for antimicrobial intravenous to oral switch). If the results of susceptibility testing are not available and oral continuation therapy is appropriate, use oral amoxicillin+clavulanate (as for nonsevere postpartum endometritis).