Initial antibiotic therapy for severe postprocedural pelvic infection

For patients with severe postprocedural pelvic infection who have 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. Antibiotics should be administered immediately after blood samples are taken for culture. Collect an endocervical swab sample as soon as possible; however, do not delay antibiotic administration to do so. 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 (group A streptococcus [GAS]) or Clostridium species; see Streptococcus pyogenes bloodstream infections, including toxic shock syndrome or Clostridial necrotising skin and soft tissue infection.

Empirical regimens may also need to be modified according to local epidemiology, if known, and consideration given to the potential relevance of an individual’s recent microbiology results. For patients with risk factors for infection with a multidrug-resistant gram-negative bacterium, seek advice from a clinical microbiologist or infectious diseases physician.

For empirical therapy in patients who are pregnant or who have features of severe postprocedural pelvic infection, as a 3-drug regimen, use:

A ceftriaxone-based regimen may be used for patients in whom intravenous therapy is likely to continue for 72 hours or longer¹, to avoid the need to switch the aminoglycoside-based regimens at 72 hours. A ceftriaxone-based regimen is also recommended if the patient has contraindications or precautions that preclude aminoglycoside use or has had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin. As a 2-drug regimen, use:

For patients who have had a severe immediate³ hypersensitivity reaction to a penicillin, ceftriaxone plus metronidazole (as 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 immediate³ hypersensitivity reaction to a penicillin in whom ceftriaxone is not used, or for patients who have had a severe delayed⁴ hypersensitivity reaction to a penicillin, seek expert advice. A suitable 2-drug regimen, while awaiting expert advice, may be: