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Antibiotic regimens for endometritis after delivery
Abstract
Postpartum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labor and birth. Antibiotic treatment is warranted.
The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed.
We searched the Cochrane Pregnancy and Childbirth Group's trials register (30 January 2004).
Randomized trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected.
We abstracted data independently and made comparisons between different types of antibiotic regimen based on type of antibiotic and duration and route of administration. Summary relative risks were calculated.
Thirty-eight trials with 3983 participants were included. Fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with the other regimen (relative risk (RR) 1.44; 95% confidence interval (CI) 1.15 to 1.80). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.94; 95% CI 1.38 to 2.72). In three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, no differences were found in recurrent endometritis or other outcomes. In four studies comparing once daily with thrice daily dosing of gentamicin there were fewer failures with once daily dosing. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea.
The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin- resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.
... Endometritis is the most common febrile complication after delivery [2]. It occurs in 1-3% of vaginal births and is significantly more common after cesarean deliver [3]. Endometritis leads to prolonged postpartum hospital stays and stands as one of the most common reasons for postpartum readmissions, thus posing a substantial burden on the healthcare system [4][5][6]. ...
... The diagnosis of postpartum endometritis is based on the presence of fever in the absence of any other obvious cause. Tachycardia, uterine tenderness, foul-smelling lochia or purulent vaginal discharge and elevated white blood cells are common clinical findings used to support the diagnosis of endometritis [3,7]. ...
... The pathogenesis of endometritis is related to contamination of the uterine cavity with vaginal microorganisms during labor [3], and it is usually a polymicrobial infection associated with mixed aerobic and anaerobic flora [8]. According to previous publications, related micro-organisms include facultative anaerobes such as Escherichia coli, Group B streptococcus (GBS), and Enterococcus spp., and typical obligate anaerobes such as Peptostreptococcus, Bacteroides, and Clostridium spp. ...
Purpose
To evaluate the utility of cervical cultures in the diagnosis and management of postpartum endometritis.
Methods
A retrospective study was conducted on 1069 cervical cultures collected from postpartum women with suspected endometritis between 2011 and 2021. Patient demographics, obstetric history, clinical parameters, and culture results were analyzed. Microorganisms were categorized into five groups based on species and virulence. Statistical analysis was performed to identify associations between risk factors, pathogens, and disease severity.
Results
The positivity rate for distinct microorganisms in cervical cultures was 33.1%. Escherichia coli (10.8%) and Group B Streptococcus (7.5%) were the most common isolates. Prolonged labor duration and prolonged rupture of membranes were associated with Enterobacterales infections. Elevated white blood cell count was linked to Enterobacterales and beta-hemolytic Streptococci, while the former were also associated with higher rate of postpartum clinic visit. No significant differences in disease severity were found between other microorganism groups.
Conclusion
The study suggests that while cervical cultures can identify potential pathogens in postpartum endometritis, their clinical utility is questionable due to the polymicrobial nature of the disease and the isolation of commensal microorganisms. The lack of significant differences in disease severity across various microorganism groups raises questions regarding the contribution of distinct bacterial identification in endometritis management.
... Endometritis is the most common febrile complication after delivery (2). It occurs in 1-3% of vaginal births, and is signi cantly more common after caesarean delivery (3). Endometritis leads to prolonged postpartum hospital stays and stands as one of the most common reasons for postpartum readmissions, thus posing a substantial burden on the healthcare system (4-6). ...
... The diagnosis of postpartum endometritis is based on the presence of fever in the absence of any other obvious cause. Tachycardia, uterine tenderness, foul-smelling lochia or purulent vaginal discharge and elevated white blood cells are common clinical ndings used to support the diagnosis of endometritis (3,7). ...
... The pathogenesis of endometritis is related to contamination of the uterine cavity with vaginal microorganisms during labor (3), and it is usually a polymicrobial infection associated with mixed aerobic and anaerobic ora (8). According to previous publications related micro-organisms include facultative anaerobes such as Escherichia coli, Group B streptococcus (GBS), and Enterococcus spp., and typical obligate anaerobes such as Peptostreptococcus, Bacteriodes, and Clostridium spp. ...
Purpose
To evaluate the utility of cervical cultures in the diagnosis and management of postpartum endometritis.
Methods
A retrospective study was conducted on 1069 cervical cultures collected from postpartum women with suspected endometritis between 2011 and 2021. Patient demographics, obstetric history, clinical parameters, and culture results were analyzed. Microorganisms were categorized into five groups based on species and virulence. Statistical analysis was performed to identify associations between risk factors, pathogens, and disease severity.
Results
The positivity rate for distinct microorganisms in cervical cultures was 33.1%. Escherichia coli (10.8%) and Group B Streptococcus (7.5%) were the most common isolates. Prolonged labor duration and prolonged rupture of membranes were associated with Enterobacterales infections. Elevated white blood cell count was linked to Enterobacterales and Beta-hemolytic Streptococci, whilst the former were also associated with higher rate of postpartum clinic visit. No significant differences in disease severity were found between other microorganism groups.
Conclusion
The study suggests that while cervical cultures can identify potential pathogens in postpartum endometritis, their clinical utility is questionable due to the polymicrobial nature of the disease and the isolation of commensal microorganisms. The lack of significant differences in disease severity across various microorganism groups raises questions regarding the contribution of distinct bacterial identification in endometritis management.
... With additional antibiotics in those who fail initial therapy, less than 2% develop major infectious complications such as abscess or septic pelvic thrombophlebitis (6). The most recent systematic review (46) did not specifically address endometritis following vaginal delivery due to insufficient data. Recommendations for treatment of endometritis following cesarean delivery are clear: regimens with poor activity against penicillin-resistant Table 1 First-Line Therapy for Endometritis After cesarean delivery Clindamycin 900mg intravenously every 8 h plus Gentamicin 4mg/kg intravenously once daily a , (plus ampicillin 2g intravenously every 6 h) b Clindamycin (as above) plus aztreonam 2g ...
... The combination of clindamycin and an aminoglycoside remains the gold standard. Although small studies comparing clindamycin/gentamicin with single broad-spectrum agents (such as second-or third-generation cephalosporins, ureidopenicillins, or penicillins combined with a beta-lactamase inhibitor) show them to be equally effective, meta-analysis shows that only 20 women would need to be treated with clindamycin and gentamicin to prevent one failure with other regimens (46). Metronidazole-penicillin-aminoglycoside and clindamycin-aztreonam may be appropriate choices for postcesarean infection as well (8). ...
... Fewer failures occur with once-daily gentamicin dosing (46). Advantages of once-daily dosing include a superior bactericidal effect with higher peak serum concentrations, time for recovery of bacterial sensitivity between doses (post-antibiotic effect), lower trough levels resulting in less accumulation of the drug in the cochlear system, and cost savings (47,48). ...
... Incidence of endometritis, fever and wound infection is about 6-27%, 5-24%, 2-9% respectively [2]. When compared to vaginal delivery, endometritis is 10 times more common following cesarean section and can be easily complicated by generalized or localized peritonitis and septicemia [3]. ...
... Ascending infection by vaginal anaerobic bacteria is the main cause of endometritis [7]. Preoperative administration of antibiotic before cesarean delivery could reduce the incidence of infective morbidities by about 60-70% when compared with placebo or no treatment [3,8]. ...
Background: Post-cesarean section (CS) infections, namely, endometritis, fever and wound infection are considered a major health problem which necessitates effective interventions. Antibiotic prophylaxis before CS cannot completely eliminate the risk of postpartum infections. Preoperative antiseptic vaginal cleansing is one of the commonest methodsto reduce infectious morbidities after CS. Aim of the work: The aim of this work is to evaluate the effect of prophylactic administration of clindamycin vaginal suppository before elective CS on postpartum infectious morbidity. Methods: 196 patients were included in this intervention. They were divided equally into two groups (each 98 patients); intervention group (which received clindamycin 100 mg vaginal suppository at bedtime for 3 nights before CS) and control group (which received nothing). Both groups were followed till the end of puerperium for the development of postpartum infections namely, endometritis, fever, and wound infection. Results: There was statistically significant decrease in the frequency of endometritis, fever, and wound infection in the intervention group when compared to control group. Also, there was highly statistically significant decrease in the frequency of overall post-CS infectious morbidity in the intervention group when compared to control group. There was statistically significant difference between both groups as regard white blood cells count and C-reactive protein level 24 hours after cesarean section. Conclusion: Prophylactic administration of clindamycin vaginal suppository before elective CS reduces the risk of postpartum infections namely endometritis, fever, wound infection and overall post-CS infectious morbidity. Preoperative clindamycin vaginal suppository could be protective against post-CS infectious morbidities.
... Incidence of postpartum endometritis is mainly dependent on modes of delivery. The risk with vaginal deliveries is reported to be 1%-3%; however, for scheduled cesarean deliveries it is believed to be 5%-15% and 15%-20% for unscheduled cesarean deliveries [5]. Puerperal infections are usually polymicrobial. ...
... The etiologic agents include Chlamydia trachomatis, Neisseria gonorrhoeae, and less frequently Mycoplasma hominis and Mycoplasma genitalium. Other bacteria include Enterobacteriaceae and gram-positive cocci such as Streptococcus species and Enterococcus faecalis, among others [5]. ...
Group A streptococcus (GAS) is a rare yet potentially lethal cause of postpartum endometritis. Atypical early presentation and the routine use of post-delivery analgesics which might mask the symptoms preclude timely diagnosis and appropriate management. The invasive disease usually follows a rapidly progressive course that has considerable morbidity and mortality. Streptococcal toxic shock syndrome (TSS) can complicate this condition leading to refractory septic shock and possible death. We hereby present a case of a 42-year-old female patient who developed GAS postpartum endometritis complicated by streptococcal TSS resulting in death despite enormous resuscitative efforts. We aim to increase awareness of this lethal condition highlighting the importance of early recognition and prompt management.
... Generally, infections are 5 to 20% more common after CS compared to vaginal delivery (4), while endometritis was reported in 6-27% of CS (5). Endometritis is about 10 times more common after CS compared with vaginal delivery and can lead to bacteraemia, peritonitis, intra-abdominal abscess collection and sepsis (6). A report described the occurrence of other complications including post-caesarean pyrexia in 5 to 24% and wound complications (including seroma, haematoma, infection and breakdown of surgical incision) in 2-9% (7). ...
Objective: To evaluate the effect of preoperative vaginal antiseptic cleansing with Povidone-iodine on the occurrence of post-caesarean section infectious morbidity. Methodology: A single-blind randomized controlled study of 180 women who had preoperative vaginal preparation with povidone-iodine before emergency CS at the University of Ilorin teaching hospital during the study period, The primary outcome measures were fever, endometritis and wound infection. Analysis was done using Chi-square tests, t-tests and logistic regression. Results: The study result shows that the prevalence of post-caesarean section infection morbidity was 26.5%. There was a statistically significant difference in educational level attained and social class (p<0.001) between both groups. The incidence of post-caesarean infection was significantly lower among the subjects compared to the controls (16.3% vs.36.6%,p-0.003). Using univariate and multivariate binary logistic regression, PVP-I use and chorioamnionitis remain significant independent predictors of infectious morbidity. PVP-I is associated with lesser odds (OR; 0.307) while those with chorioamnionitis are eight times more likely to have a postoperative infection (p-0.006). Conclusion: The incidence of post-caesarean fever and endometritis was significantly reduced in those scrubbed with both abdominal and vaginal Povidone-iodine compared to those who had standard abdominal scrub alone for emergency caesarean section. Vaginal cleaning with Povidone-iodine is safe.
... However, due to the increased failure rate of ampicillin treatment, cephalosporins or clindamycin are recommended as alternatives [107]. A Cochrane review concluded that intravenous therapy with a combination regimen of clindamycin and gentamicin was clinically valuable for treating postpartum endometritis [108]. However, even with an adequate antibiotic regimen, symptoms such as abdominal pain, fever (>38°C), and tachycardia (>90 beats/min) indicate the need for administration of broad-spectrum antibiotics such as piperacillin/tazobactam or carbapenems [106]. ...
Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.
... This agreed with Haas et al. (14) found povidone-iodine irrigation to be significantly more effective at preventing surgical site infection than the comparison interventions of saline, water or no irrigation. Our findings were in conflict with the studies investigated by French and Smaill (15) as they did not find povidone-iodine irrigation to be significantly more effective at preventing surgical site infection than the comparison interventions of saline, water or no irrigation. Also, with Akl et al. (9) demonstrated that, there was no benefit of subcutaneous tissue swabbing with povidone iodine in decreasing wound infection following cesarean section. ...
Background: Cesarean section is the most performed major abdominal surgery. While cesarean delivery is usually an
uncomplicated procedure, up to 20% of patients can experience a complication following cesarean delivery with
infectious complications being the most common. Nosocomial infections represent one of the major sources of
morbidity and mortality in hospitalized patients around the world.
Objective: The aim of the current work was to evaluate if the different scrubbing methods of surgical team before
cesarean section by different materials change the rates of post-operative surgical site infection or not.
Patient and methods: This randomized controlled trial (RCT) study included a total of 278 pregnant women,
attending at Departments of Obstetrics and Gynecology, Menouf General Hospital and Menoufia University Hospitals,
during the period of September 2019 till August 2020.
Result: there was no statistically significant difference between the studied groups regarding their demographic and
clinical data. There was no statistically significant difference between group A and group B regarding offensive odor
at day 10 and 15 post-operatively. No offensive odor reported after day 25 or 30 postoperative (p>0.05). Also,
there was no statistically significant difference between group A and group B regarding approximation at day 10, 20,
25 and 30 post-operatively (p> 0.05. There was no statistically significant difference between group A and group B
regarding hotness, redness, tenderness,swelling, discharge and offensive odor at day 10, 20, 25 and 30 post-operatively
(p> 0.05).
Conclusion: It could be concluded that for the increasing rates of CS being performed without a clear medical
indication; new practice protocols should be implemented to reduce the rate of cesarean deliveries as CS surgery has
a 5–20 times higher risk of post-partum infection as compared to vaginal deliveries.
... Surgical site infections are infections of the incision, organ or space after a procedure and are responsible for infections in patients undergoing surgery. This complication is about 10 times more common when compared with [4,5] vaginal delivery and can lead to sepsis. ...
Objective: To evaluate the efficacy of pre-cesarean vaginal wash using 5% Povidone Iodine solution on rate of post-cesarean section (CS) surgical site infection and compared with No swabbing. Method: A Prospective Randomized controlled Trial was conducted in department of Obstetrics and Gynecology in Government medical college, Aurangabad. In interventional group, vaginal swabbing with a gauze pieces impregnated with 5% Povidone Iodine solution was done for 30 seconds. The swabbing of vagina was not performed in cases assigned to control group, however the standard surgical preparation of abdomen was done in a usual manner for both group. All subject received prophylactic antibiotic cover. Collected data was complied in pre-designed proforma and analysis was done using SPSS 15. Result: The risk of post operative fever and wound infection was significantly reduced in interventional group. No measure difference was noted in seroma and composite wound infection. Also less duration of hospital stay in interventional group was noted. No adverse effect of use of Povidone iodine was reported in the interventional group. Conclusion: Vaginal swabbing with 5% Povidone-iodine pre- LSCS is inexpensive and simple intervention even for low resource setting to decrease surgical site infection.
... 77 IV gentamicin and clindamycin are efficacious, although this regimen does not cover enterococcus. 100 Doxycycline plus cefoxitin or ampicillin/sulbactam is an additional regimen. In those who do not respond within the first 48-72 hours, ampicillin is added to cover for these pathogens. ...
The normal physiologic changes of pregnancy complicate evaluation for sepsis and subsequent management. Previous sepsis studies have specifically excluded pregnant patients. This narrative review evaluates the presentation, scoring systems for risk stratification, diagnosis, and management of sepsis in pregnancy. Sepsis is potentially fatal, but literature for the evaluation and treatment of this condition in pregnancy is scarce. While the definition and considerations of sepsis have changed with large, randomized controlled trials, pregnancy has consistently been among the exclusion criteria. The two pregnancy-specific sepsis scoring systems, the modified obstetric early warning scoring system (MOEWS) and Sepsis in Obstetrics Score (SOS), present a number of limitations for application in the emergency department (ED) setting. Methods of generation and subsequently limited validation leave significant gaps in identification of septic pregnant patients. Management requires consideration of a variety of sources in the septic pregnant patient. The underlying physiologic nature of pregnancy also highlights the need to individualize resuscitation and critical care efforts in this unique patient population. Pregnant septic patients require specific considerations and treatment goals to provide optimal care for this particular population. Guidelines and scoring systems currently exist, but further studies are required.
... It can be progressed to cause pelvic abscess, peritonitis, or even septicemia; which is of a great concern. [2] Broad spectrum prophylactic antibiotics prior CS deliveries, has been used as a standard practice. Despite that postoperative infectious morbidity still a serious complication after cesarean deliveries. ...
Objective: This study aims to assess effect of preoperative vaginal cleansing using chlorhexidine antiseptic on post cesarean section infectious morbidity.Methods: A randomized controlled trial was conducted on a random sample of 178 singleton term pregnant woman assigned for elective cesarean section. A simple random sample was recruited from the operating room of Obstetrics and Gynecology department, Zagazig University Hospitals-Egypt. Participants were randomly assigned either to conventional care group or study group. The conventional care group was exposed to the usual abdominal scrub with Povidone-iodine solution; while the study group subjected to vaginal cleansing using chlorhexidine antiseptic solution in addition to conventional preoperative care. Data were collected using an assessment sheet for demographic and clinical data and checklist for study outcomes.Results: Post intervention, assessment of the incisional wound revealed lower overall post cesarean section infectious morbidity rate among study group compared to those received conventional care (9.0% vs. 20.2% respectively; χ2 = 4.50, p = .034). Endometritis rate was significantly lower among the study group subjects equated to those of the conventional care group (2.2% vs. 10.1% respectively; χ2 = 4.75, p = .029), meanwhile febrile morbidity and surgical site infection rates showed non-significant reduction in favor to the study group subjects (p = .469 and 0.700 respectively).Conclusions: Preoperative vaginal cleansing using chlorhexidine was an effective practice for reducing post cesarean infection; where overall post cesarean infectious morbidity rate was lower among postpartum mothers subjected to vaginal cleansing compared to those exposed to conventional care alone; supporting the study hypothesis.
... Other regimens, such as those using extended-spectrum penicillin (e.g., ampicillin plus a beta-lactamase-inhibitor, such as sulbactam), may be equally as effective, but have not been compared with standard agents (Creasy et al., 2014). The optimal length of antibiotic treatment postpartum is unknown and varies from one dose of antibiotics after delivery to treatment for 24 to 48 postpartum hours (Chapman et al., 2014;French & Smaill, 2004;Hopkins & Smaill, 2002). If a cesarean delivery is performed, clindamycin 900 mg every 8 hours (or metronidazole) may be added for additional anaerobic coverage (Tita & Andrews, 2010). ...
... The combination of a second-or third-generation cephalosporin with metronidazole is another popular choice. (9) The study was designed to assess the value of using Chromohystroscopy modality in infertility workup after failed ICSI procedures in evaluating uterine receptivity and detect any signs of chronic endometritis by a less invasive method. ...
Background: Intra cytoplasmic sperm injection (ICSI), is a procedure adopted
worldwide as the ultimate micro-assisted fertilization approach due to its clinical
success.
Objectives: The objective of this study was to assess the value of using Chromohystroscopy modality in
infertility workup after failed ICSI procedures in evaluating uterine receptivity and detect any signs of chronic
endometritis by a less invasive method.
Methods: prospective cohort study. A total of 50infertile patients recruited from the infertility clinic in El-Shatby
University Hospital, Faculty of Medicine, Alexandria University. Cases were allocated into two groups. The first
group includes cases that had a failed trial of intracytoplasmic sperm injection. The second group includes control
cases from patients seeking for fertility treatment with no previous history of intracytoplasmic sperm injection
and with no history of anatomic uterine abnormalities. The selected sample size was found to be 50 women, and
were randomly selected and allocated in two groups each group was 25 women after fulfilling the inclusion
criteria.
Results: There was a statically significant increase in the incidence of endometritis among the study group 68%
in comparison to 16% in the control group.
Conclusions: In this study.Endometrial dyeing with methylene blue at hysteroscopy improves the detection of
chronic endometritis.
... Endometritis, febrile morbidity and wound infection are considered of the most frequent complications of post cesarean infections [1]. Endometritis is the commonest complication as it accounts up to 27%, followed by clinically significant fever, which was reported as 5-24%, while the incidence of wound infection is about 2-9% [2] Of great concern, postpartum endometritis which is more frequent in caesarian deliveries when compared to vaginal ones, and can be complicated by peritonitis, pelvic abscess even up to septicemia [3,4]. Although maternal mortality from these complications is rare, with an incidence of 6 deaths per 10,000 caesarean deliveries, but it may increase the personal and economic burden with prolonged hospital stay and hospital readmissions [5,6]. ...
Purpose: To evaluate the efficacy of preoperative vaginal cleansing using povidone-iodine solution 10% on rates of post cesarean section (CS) infectious morbidities (endometritis, febrile morbidity and wound infection).
Methods: This prospective randomized trial was conducted among 226 pregnant women scheduled for term elective CS. Patients were equally divided into two groups by simple randomization method. The study group had preoperative vaginal cleansing using povidone-iodine solution 10% for about 1 min, while the control group did not. All cases received the prophylactic antibiotics and the usual abdominal scrub. Adverse post CS infectious morbidities such as endometritis, febrile morbidity and wound infection were observed at the time of hospital discharge and weekly for 6 weeks postpartum.
Results: Both groups were matched regarding the baseline patients’ characteristics. Overall, post-CS infectious morbidity was significantly reduced from 20.7% in the control group to 7.5% in the intervention group. Marked significant reduction was seen in the incidence of endometritis (11.8% in the control group versus 2.8% in the intervention group). However, maternal fever and wound infection showed no significant difference between both groups.
Conclusion: Vaginal cleansing with povidone-iodine solution 10% prior to elective CS appears to be effective in reducing rates of post-CS infectious morbidity mainly endometritis.
... Endometritis occurs in the early post-partum period, usually within 48 h of delivery. 26,27 In the USA, the median time from discharge to readmission of patients with infections was 5 days, and the most common indication for readmission was infection (15.5%). 18 The recommended hospital stay for a healthy newborn in the USA is ,48 h following a vaginal delivery (extending beyond 24 h after an uncomplicated vaginal delivery). ...
Objectives:
To evaluate data on outpatient antibiotic use in women post-labour as a potential method of monitoring infections in this group of patients.
Methods:
Demographic and antibiotic prescription data originated from the registries of the National Health Fund (pol. Narodowy Fundusz Zdrowia). The measure of antibiotic use in this study was the percentage of women who purchased the drugs from prescriptions and DDDs.
Results:
Among 67 917 females who gave birth in the years 2013-14, 5050 (7.4%) purchased antibiotics prescribed by the obstetrician only. The average number of antibiotics bought per person was equivalent to ∼14 DDDs; in most cases (95.7%) these were β-lactams. Antibiotic use occurred significantly more frequently among younger patients (11.5% patients <18 years of age), those living in rural areas (8.2%) and those who underwent Caesarean section (8.1%). No significant differences were found between the reported day of labour and the post-partum use of antibiotics.
Conclusions:
Antibiotic prescribing data can be used to verify/complement the information originating from hospital infection registries to monitor rates of infection in obstetric patients.
... Respecto al tratamiento, una revisión de 15 ensayos que comparó clindamicina y un aminoglucósido con otros regímenes, mostró mayores fallas al tratamiento en los otros regímenes (riesgo relativo (RR) 1,44; IC95% 1,15 a 1,80). En tres estudios que compararon continuar el tratamiento oral luego de la terapia endovenosa contra el no continuar vía oral, no encontró diferencias en recurrencia de endometritis (15) . ...
Objetivos: Conocer las características demográficas y clínicas de las pacientes con diagnóstico de endometritis puerperal en un hospital general. Diseño: Estudio de tipo descriptivo, serie de casos, retrospectivo. Institución: Servicio de Ginecología y Obstetricia, Hospital Nacional Cayetano Heredia (HNCH), Lima, Perú. Participantes: Puérperas. Material: Se seleccionó casos con diagnóstico de endometritis puerperal en el periodo de julio de 2011 a julio de 2012, de la base de datos de la Unidad de Epidemiología del HNCH. Se recolectó los datos en una ficha, en la que se incluyó las características demográficas, clínicas, antecedentes, factores de riesgo, diagnóstico, tratamiento, evolución y complicaciones. Principales medidas de resultados: Características de los casos de endometritis puerperal. Resultados: Se encontró 32 casos de endometritis puerperal, con prevalencia de 0,6%. La edad media fue 23 +/- 6,2; el 76% tenía educación secundaria y 72% era primípara. La vía de parto fue cesárea en 53% de los casos. El síntoma más frecuente fue sensación de alza térmica y el signo más frecuente loquios con mal olor. Entre los factores de riesgo, a un tercio de pacientes se les realizó más de 5 tactos vaginales, con un máximo de 8; 6 pacientes tuvieron rotura prematura de membranas y en 7 en pacientes se describió líquido meconial. La evolución de la totalidad de las pacientes fue favorable. Conclusiones: Conocer el impacto de la endometritis puerperal en un hospital general permitirá tomar las medidas preventivas para reducir la incidencia de casos de endometritis, por ejemplo, mejorando la profilaxis y tratamiento de la anemia, limitando los tactos vaginales así como promoviendo las normas de bioseguridad.
... Panel 2 and the appendix show fi ndings from this stage of the analyses. When the eff ective service supported normal processes of reproduction and early life, the intervention is shown in italics in panel 2 (44 [61%] of 72 eff ective practices) 29,[59][60][61][62][63][64][65][66][68][69][70][71][72][73][74][75][76][77][78][80][81][82][83][84][86][87][88][89]95,[99][100][101][109][110][111][112][113][114]116,117,120,121,122 within the scope of midwifery. Ten (14%) 29 ...
In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women’s views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women’s capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.
... Endometritis is the commonest complication as it accounts for about 6-27%, followed by clinically significant fever, which was reported as 5-24%, while the incidence of wound infection is about 2-9% [2]. Of great concern, postpartum endometritis, which is 10 times more frequent post cesarean deliveries compared to vaginal ones, can be complicated by peritonitis, pelvic abscess even up to septicemia [3,4]. ...
Objective:
To evaluate the efficacy of preoperative vaginal cleansing using chlorhexidine 0.25% antiseptic wipes on rates of postcesarean section (CS) infectious morbidities (endometritis, febrile morbidity and wound infection).
Methods:
This prospective randomized trial was conducted among 218 pregnant women scheduled for term elective CS. Patients were equally divided into two groups by simple randomization. After spinal anesthesia and catheterization under aseptic technique, the study group had preoperative vaginal cleansing using chlorhexidine 0.25% antiseptic wipes for about 1 min, while the control group did not. All cases received the prophylactic antibiotics and the usual abdominal scrub. All participants received the routine postoperative care without other interventions. Adverse postcesarean infectious morbidities such as endometritis, febrile morbidity and wound infection were observed at the time of hospital discharge and weekly for 6 weeks postpartum.
Results:
Both groups were matched regarding the baseline patients' characteristics (age, gestational age, BMI, operative time and postoperative hospital stay). Overall, post-CS infectious morbidity were significantly reduced from 24.4% in the control group to 8.8% in the intervention group; p value <0.05. Marked reduction was seen in the incidence of endometritis (13.2% in the control group versus 2.9% in the intervention group; p value <0.05). However, fever and wound infection showed no significant difference between both groups.
Conclusion:
Cleansing the birth canal with chlorhexidine 0.25% wipes prior to elective CS appears to be effective in reducing rates of post-CS infectious morbidity mainly endometritis.
... Although evidence from Cochrane reviews is limited, intrapartum treatment with potent antibiotics is clinically reasonable (Hopkins and Smaill 2002). A Cochrane review of 39 RCTs involving 4,221 women evaluates the comparative efficacy and side effects of different antibiotic regimens for postpartum endometritis (French and Smaill 2004). Wound infection was significantly reduced and treatment was less likely to fail with a combination of an aminoglycoside (mostly gentamicin) and clindamycin compared with other regimens. ...
... The combination of the second or third-generation cephalosporin with metronidazole is another popular choice. 9 Marconi et al. and Kucuk and Safali reported that the endometrium is not an absorptive epithelium in normal circumstances and that structural damage of the cells allows passage of methylene blue dye into the cells. Dark blue staining represents structural damaged areas due to endometritis. ...
... The WHO defines endometritis as: "The infection of the genital tract occurring at any time between the onset of the rupture of membranes or labour and the 42nd day postpartum in which fever and one or more of the following are present: pelvic pain, abnormal vaginal discharge or odor, and delay in the rate of reduction of size of the uterus" [14]. The standard treatment for PP endometritis is a combination of broad-spectrum intravenous antibiotics [15][16][17]. However, there are currently no global standard guidelines for oral therapies in resource-poor regions-a lack that impacts women who have limited access to adequate healthcare facilities. ...
Background
Postpartum sepsis accounts for most maternal deaths between three and seven days postpartum, when most mothers, even those who deliver in facilities, are at home. Case fatality rates for untreated women are very high. Newborns of ill women have substantially higher infection risk.
Methods/Design
The objectives of this study are to: (1) create, field-test and validate a tool for community health workers to improve diagnostic accuracy of suspected puerperal sepsis; (2) measure incidence and identify associated risk factors and; (3) describe etiologic agents responsible and antibacterial susceptibility patterns. This prospective cohort study builds on the Aetiology of Neonatal Infection in South Asia study in three sites: Sylhet, Bangladesh and Karachi and Matiari, Pakistan. Formative research determined local knowledge of symptoms and signs of postpartum sepsis, and a systematic literature review was conducted to design a diagnostic tool for community health workers to use during ten postpartum home visits. Suspected postpartum sepsis cases were referred to study physicians for independent assessment, which permitted validation of the tool. Clinical specimens, including urine, blood, and endometrial material, were collected for etiologic assessment and antibiotic sensitivity. All women with puerperal sepsis were given appropriate antibiotics.
Discussion
This is the first large population-based study to expand community-based surveillance for diagnoses, referral and treatment of newborn sepsis to include maternal postpartum sepsis. Study activities will lead to development and validation of a diagnostic tool for use by community health workers in resource-poor countries. Understanding the epidemiology and microbiology of postpartum sepsis will inform prevention and treatment strategies and improve understanding of linkages between maternal and neonatal infections.
The microbial ecosystem of women undergoes enormous changes during pregnancy and the perinatal period. Little is known about the extent of changes in the maternal microbiome beyond the vaginal cavity and its recovery after birth. In this study, we followed pregnant women [maternal prepartum (mpre), n = 30] into the postpartum period [1 month postpartum, maternal postpartum (mpost), n = 30]. We profiled their oral, urinary, and vaginal microbiome; archaeome; mycobiome; and urinary metabolome and compared them with those of nonpregnant (np) women (n = 29). Overall, pregnancy status (np, mpre, and mpost) had a smaller effect on the microbiomes than body site, but massive transitions were observed for the oral and urogenital (vaginal and urinary) microbiomes. While the oral microbiome fluctuates during pregnancy but stabilizes rapidly within the first month postpartum, the urogenital microbiome is characterized by a major remodeling caused by a massive loss of Lactobacillus and thus a shift from Vaginal Community State Type (CST) I (40% of women) to CST IV (85% of women). The urinary metabolome rapidly reached an np-like composition after delivery, apart from lactose and oxaloacetic acid, which were elevated during active lactation. Fungal and archaeal profiles were indicative of pregnancy status. Methanobacterium signatures were found mainly in np women, and Methanobrevibacter showed an opposite behavior in the oral cavity (increased) and vagina (decreased) during pregnancy. Our findings suggest that the massive remodeling of the maternal microbiome and metabolome needs more attention and that potential interventions could be envisioned to optimize recovery and avoid long-term effects on maternal health and subsequent pregnancies.
IMPORTANCE
The perinatal microbiome is of specific interest for the health of the mother and infant. We therefore investigate the dynamics of the female microbiome from nonpregnant over prepartum to the postpartum period in urine and the oral and vaginal cavities. A specific focus of this study is put not only on the bacterial part of the microbiome but also on the underinvestigated contribution of fungi and archaea. To our knowledge, we present the first study highlighting those aspects. Our findings suggest that the massive remodeling of the maternal microbiome and metabolome needs more attention and that potential interventions could be envisioned to optimize recovery and avoid long-term effects on maternal health and subsequent pregnancies.
Introduction
Endometritis is the inflammatory condition of the uterus. Citral, a component of lemongrass oil, is known to exhibit anti-inflammatory activity.
Aim
The effects of citral on LPS-induced endometritis were tested and the mechanisms were investigated.
Methods
LPS-induced endometritis mice model was established and the effects of citral were detected using this model. Inflammatory cytokines were tested by ELISA. Ferroptosis was assessed by detecting GSH, ATP, MDA, and Fe²⁺ levels. Signaling pathway was tested by western blot analysis.
Results
Citral prevented LPS-induced endometritis through attenuating uterine pathological changes and inflammatory cytokine release. Meanwhile, citral prevents LPS-induced ferroptosis through attenuating MDA and Fe²⁺ levels, as well as increasing ATP and GSH levels. Furthermore, citral up-regulated Nrf2 and HO-1 expression and attenuated NF-κB activation. In addition, in Nrf2 knockdown mice, the inhibitory roles of citral on ferroptosis and endometritis were largely reversed.
Conclusion
Taken together, citral inhibited LPS-induced endometritis through preventing ferroptosis, which were regulated by Nrf2 signaling pathway.
A gestação é um período de grandes adaptações no organismo. Além das alterações em diversos sistemas, a própria gestação pode, também, gerar um estado de imunodepressão, favorecendo o surgimento de infecções. Dado o elevado risco materno, cujas estatísticas brasileiras são desfavoráveis, o presente artigo consiste em uma revisão narrativa sobre determinadas infecções relacionadas ao período gestacional. Para isso, foi feito um levantamento de publicações no banco de dados das bibliotecas eletrônicas Google Scholar, PubMed e Scielo. De modo geral, aborto infectado, corioamnionite, endometrite e pielonefrite aguda configuram doenças características de países em desenvolvimento/subdesenvolvidos, como o Brasil. Esse cenário reflete não apenas as condições em saúde, mas, inclusive, socioeconômicas da população brasileira. Portanto, compreender os fatores de risco e o quadro clínico dessas doenças auxilia em um diagnóstico mais rápido e eficaz. O tratamento deve ser assertivo e a prevenção estimulada, a fim de reduzir a elevada incidência de morbimortalidade materna.
There have been widely documented beneficial role of vaginal Lactobacillus species as an important biomarker for vaginal health and healthy pregnancy progression. When translating this to clinical settings, pregnant women with low proportions of Lactobacillus and commensurately high proportion of rich and highly diverse abnormal microbiota are most likely to encounter negative pregnancy outcome such as preterm birth and postpartum complications. However, multiple literatures have also addressed this notion that the absence of a Lactobacillus-dominated microbiota does not appear to directly imply to a diseased condition and may not be a major determinant of negative obstetric outcome. Caesarian delivery is notably a risk factor for preterm birth and postpartum endometritis, yet recent data shows a trend in the overuse of CS across several populations. Growing evidence suggest the potential role of vaginal/uterine cleaning practice during CS procedures in influencing postpartum infections, however there is a controversy that this practice is associated with increased rates of postpartum endometritis. The preponderance of bacterial vaginosis associated bacteria vagitype at postpartum which persist for a long period of time even after lochia regression in some women may suggest why short interpregnancy interval may pose a potential risk for preterm birth, especially multigravidas. While specifically linking a community of microbes in the female reproductive tract or an exact causative infectious agent to preterm birth and postpartum pathologies remains elusive, clinical attention should also be drawn to the potential contribution of other factors such as short interpregnancy interval, birth mode, birth practices and the postpartum vaginal microbiome in preterm birth which is explicitly described in this narrative review.
Infection is a preventable cause of maternal morbidity and pregnancy-related sepsis, accounting for 11% of maternal deaths. Epidemiology of postpartum infections is not nicely understood. Genital tract infections are the most common cause of persistent fever after delivery with endometritis and surgical site infections, being the frequent site for infections. Other causes include urinary tract infections, mastitis, septic thrombophlebitis, and other infections. Postpartum endometritis is the main cause of maternal morbidity and is more common after cesarean section. The infection is generally caused by microorganisms in the cervicovaginal tract which get inoculated into uterus during labor/delivery. Endometritis is of two types-acute and chronic; acute endometritis is characterised by formation of microabscess and neutrophil infiltration of the endometrium while chronic endometritis classically has plasmacyte infiltration in the endometrial stroma. Treatment of endometritis includes broad-spectrum antibiotic coverage with single agent or with combined antimicrobials.KeywordsPostpartum endometritisEndometritisChronic endometritisPuerperalInfectionsInfertility
A eficácia produtiva em um sistema de exploração de suínos está relacionada à eficiência reprodutiva, medida pelo número de leitões produzidos por fêmea ao ano. Os órgãos que compõem o sistema reprodutivo são sujeitos a lesões infecciosas, traumáticas e neoplásicas, que resultam em alterações histológicas e funcionais. Objetivou-se neste trabalho identificar as patologias mais comuns no aparelho genital de fêmeas suínas abatidas, a fim de estudar a natureza, localização, e a frequência das alterações histológicas e macroscópicas destas doenças. Foram examinados tratos reprodutivos de 169 cadáveres de fêmeas não prenhes (grupo um) e prenhes (grupo dois), fixadas em formol 10%, seguido pela análise das amostras de forma macroscópica e histológica. Observou-se que 73% das fêmeas do grupo um possuíam alterações patológicas, e a patologia mais frequente deste grupo foi a presença de cistos paraováricos. No entanto, o grupo dois apresentou grande frequência de fetos macerados, seguido de fetos mumificados. Concluiu-se, portanto, que as patologias mais frequentes foram de origem cística, inflamatória, de
Background: The objective of the current study was to evaluate the efficacy of preoperative betadine vaginal toileting in reducing post caesarean infections (endometritis, febrile illness, wound sepsis).Methods: This prospective longitudinal study was conducted at Maulana Azad Medical College, New Delhi over 3 months among 200 women who underwent caesarean delivery. Inclusion criteria were defined as women undergoing caesarean section. Exclusion criteria included placenta previa, active genital herpes, cord prolapse, chorioamnionitis, allergy to iodine. After taking informed consent, subjects were divided into two groups by simple randomization method using computer generated random numbers- Group 1 (case) - subjects who underwent 5% povidone iodine sponge stick cleansing in all the fornices and walls of vagina for 30 seconds after foley’s catheter insertion and before abdominal scrubbing. Group 2 (control) - subjects who didn't receive betadine vaginal toileting before caesarean section Subjects were followed for 10 days postpartum (or till suture removal/ discharge from hospital, whichever was late). Demographic data, operative details and postoperative parameters were compared between the two groups.Results: Both groups were matched for baseline patients’ characteristics (age, BMI, gestational age, operative time). Women who received preoperative betadine vaginal toileting had markedly less incidence of endometritis (case-3%, control-10%, p<0.05), overall postoperative morbidity (case-13%, control-33%, p<0.001). Incidence of postoperative febrile illness (case-6%, control-12%, p>0.05) and wound sepsis (case-5%, control-12%, p>0.05) were found to be less but not significant between both groups.Conclusions: Preoperative vaginal cleansing helps in reducing postoperative morbidity by decreasing incidence of postoperative infection.
This is a unique question‐and‐answer chapter for surgical residents and trainees, concentrating on the obstetric critical care. Critical care for the pregnant patient requires a broad understanding of the fetal risk of common Intensive Care Unit medications. Among benzodiazepines, lorazepam has been shown to be teratogenic in animal studies, for this reason, midazolam is theoretically a superior agent. Digoxin is safe in pregnancy and can be used in the management of peripartum cardiomyopathy. Ephedrine has been shown to increase both maternal blood pressure and fetal blood flow compared to epinephrine, which does not increase fetal blood flow due to vasoconstriction. In the normal pregnancy von Willebrand's factor (VWF) increases in the third trimester and ADAMTS13 activity is reduced. With acquired thrombocytopenic purpura (TTP), antibodies are produced against ADAMTS13, and the activity of ADAMTS13 is severely decreased. Hemolytic uremic syndrome (HUS) is caused by complement activation and referred to as complement‐mediated HUS.
This is the protocol for a review and there is no abstract. The objectives are as follows: The aim of this review is to assess the benefits and harms of different routes of prophylactic antibiotics given for preventing infectious morbidity in women undergoing caesarean section.
Childbirth and the postpartum period constitute an exciting yet challenging time for the mother, newborn, and family members. This includes physiological, physical, and psychosocial changes which many new mothers transition through uneventfully. However, this period can also pose overwhelming challenges with associated health issues. Hence, the importance of effective prenatal, intrapartum, and postpartum anticipatory guidance cannot be overemphasized.
Im Wochenbett finden Uterusrückbildung mit Wundheilung und Laktationsbeginn statt. Die Subinvolutio uteri kann über eine Endometritis/Endomyometritis zur Puerperalsepsis oder gar zum Toxic-shock-Syndrom (TTS) durch Streptococcus pyogenes oder Staphylococcus aureus führen.
Jedes Fieber, eine plötzlich auftretende Verschlechterung des Allgemeinzustands oder gar ein „systemic inflammatory response syndrome“ (SIRS) müssen abgeklärt und behandelt werden, um nicht zur schweren Sepsis oder septischen Schock zu führen. Auch an eine septische Ovarialvenenthrombose ist zu denken. Bei Sepsismanifestationen sollten großzügig die operative Entfernung des Infektionsherdes, eine hochdosierte antibiotische Kombinationstherapie und ggf. intensivmedizinische Maßnahmen erfolgen.
Auch Harnverhalt, Harnwegsinfektionen, Urininkontinenz oder Hämorrhoidalbeschwerden kommen im Wochenbett vor.
Es ist wichtig, den häufigen „maternity blues“ von der Post-partum-Depressionen und der Puerperalpsychose abzugrenzen.
Childbirth and the postpartum period constitute an exciting yet challenging time for the mother, newborn, and family members. This includes physiological, physical, and psychosocial changes which many new mothers transition through uneventfully. However, this period can also pose overwhelming challenges with associated health issues. Hence, the importance of effective prenatal, intrapartum, and postpartum anticipatory guidance cannot be overemphasized.
Background:
Post-caesarean section infection is a cause of maternal morbidity and mortality. Administration of antibiotic prophylaxis is recommended for preventing infection after caesarean delivery. The route of administration of antibiotic prophylaxis should be effective, safe and convenient. Currently, there is a lack of synthesised evidence regarding the benefits and harms of different routes of antibiotic prophylaxis for preventing infection after caesarean section.
Objectives:
The aim of this review was to assess the benefits and harms of different routes of prophylactic antibiotics given for preventing infectious morbidity in women undergoing caesarean section.
Search methods:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 January 2016) and reference lists of retrieved studies.
Selection criteria:
We included randomised controlled trials (RCTs) comparing at least two alternative routes of antibiotic prophylaxis for caesarean section (both elective and emergency). Cross-over trials and quasi-RCTs were not eligible for inclusion.
Data collection and analysis:
Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data from the included studies. These steps were checked by a third review author.
Main results:
We included 10 studies (1354 women). The risk of bias was unclear or high in most of the included studies.All of the included trials involved women undergoing caesarean section whether elective or non-elective. Intravenous antibiotics versus antibiotic irrigation (nine studies, 1274 women) Nine studies (1274 women) compared the administration of intravenous antibiotics with antibiotic irrigation. There were no clear differences between groups in terms of this review's maternal primary outcomes: endometritis (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.70 to 1.29; eight studies (966 women) (low-quality evidence)); wound infection (RR 0.49, 95% CI 0.17 to 1.43; seven studies (859 women) (very low-quality evidence)). The outcome of infant sepsis was not reported in the included studies.In terms of this review's maternal secondary outcomes, there were no clear differences between intravenous antibiotic or irrigation antibiotic groups in terms of postpartum febrile morbidity (RR 0.87, 95% CI 0.48 to 1.60; three studies (264 women) (very low-quality evidence)); or urinary tract infection (RR 0.74, 95% CI 0.25 to 2.15; five studies (660 women) (very low-quality evidence)). In terms of adverse effects of the treatment on the women, no drug allergic reactions were reported in three studies (284 women) (very low-quality evidence), and there were no cases of serious infectious complications reported (very low-quality evidence). There was no clear difference between groups in terms of maternal length of hospital stay (mean difference (MD) 0.28 days, 95% CI -0.22 to 0.79 days, (random-effects analysis), four studies (512 women). No data were reported for the number of women readmitted to hospital. For the baby, there were no data reported in relation to oral thrush, infant length of hospital stay or immediate adverse effects of the antibiotics on the infant. Intravenous antibiotic prophylaxis versus oral antibiotic prophylaxis (one study, 80 women) One study (80 women) compared an intravenous versus an oral route of administration of prophylactic antibiotics, but did not report any of this review's primary or secondary outcomes.
Authors' conclusions:
There was no clear difference between irrigation and intravenous antibiotic prophylaxis in reducing the risk of post-caesarean endometritis. For other outcomes, there is insufficient evidence regarding which route of administration of prophylactic antibiotics is most effective at preventing post-caesarean infections. The quality of evidence was very low to low, mainly due to limitations in study design and imprecision. Furthermore, most of the included studies were underpowered (small sample sizes with few events). Therefore, we advise caution in the interpretation and generalisability of the results.For future research, there is a need for well-designed, properly-conducted, and clearly-reported RCTs. Such studies should evaluate the more recently available antibiotics, elaborating on the various available routes of administration, and exploring potential neonatal side effects of such interventions.
Im Wochenbett finden Uterusrückbildung mit Wundheilung und Laktationsbeginn statt. Die Subinvolutio uteri kann über eine Endometritis/Endomyometritis zur Puerperalsepsis oder gar zum Toxic-shock-Syndrom (TTS) durch Streptococcus pyogenes oder Staphylococcus aureus führen.
Jedes Fieber, eine plötzlich auftretende Verschlechterung des Allgemeinzustands oder gar ein „systemic inflammatory response syndrome“ (SIRS) müssen abgeklärt und behandelt werden, um nicht zur schweren Sepsis oder septischen Schock zu führen. Auch an eine septische Ovarialvenenthrombose ist zu denken. Bei Sepsismanifestationen sollten großzügig die operative Entfernung des Infektionsherdes, eine hochdosierte antibiotische Kombinationstherapie und ggf. intensivmedizinische Maßnahmen erfolgen.
Auch Harnverhalt, Harnwegsinfektionen, Urininkontinenz oder Hämorrhoidalbeschwerden kommen im Wochenbett vor.
Es ist wichtig, den häufigen „maternity blues“ von der Post-partum-Depressionen und der Puerperalpsychose abzugrenzen.
The postpartum period (typically the first six weeks after delivery) may underscore physical and emotional health issues in new mothers. A structured approach to the postpartum office visit ensures that relevant conditions and concerns are discussed and appropriately addressed. Common medical complications during this period include persistent postpartum bleeding, endometritis, urinary incontinence, and thyroid disorders. Breastfeeding education and behavioral counseling may increase breastfeeding continuance. Postpartum depression can cause significant morbidity for the mother and baby; a postnatal depression screening tool may assist in diagnosing depression-related conditions. Decreased libido can affect sexual functioning after a woman gives birth. Physicians should also discuss contraception with postpartum patients, even those who are breastfeeding. Progestin-only contraceptives are recommended for breastfeeding women. The lactational amenorrhea method may be a birth control option but requires strict criteria for effectiveness.
Supplemental material accompanying the article. Part I, overview of model; part II, overview of model parameterization, calibration, performance; part III, overview of costs and estimates; part IV, supplemental results; part V, references.
(0.53 MB PDF)
Maternal and Perinatal Morbidity and MortalityEvidence-Based Operative ConsiderationsPotential Risks of Repeat Cesarean DeliveryInfluence of Different Patient Populations on Cesarean Delivery RatesCurrent Indications for Cesarean DeliveryCase Presentation 1Case Presentation 2Case Presentation 3References
The management of critically ill obstetric patients presents a challenge for the critical care physician because they have significant physiological differences compared to the average patient admitted to the intensive care unit (ICU) [1, 2]. The fact that two lives are endangered simultaneously makes this challenge even greater. Besides, obstetric infections are more commonly related to emotional, moral, legal, social and sanitary factors compared to other severe infections and are significantly dependent on the economic and technical development, community patterns and traditions of each country.
Objective: To elaborate and establish a protocol for dosing and monitoring aminoglycosides and vancomycin in adult hospitalized patients. Method: We reviewed a selection of articles and consensus guides of various scientific societies and groups of experts published in the last ten years, and elaborated a consensus protocol approved by the Infections Commission. Results: Protocol for dosing and monitoring of: 1) Aminoglycosides: The administration of aminoglycosides in a unique daily dose and the monitoring of trough concentrations seem to decrease the toxicity risk, while peak concentrations above the Minimal Inhibition Concentration (MIC) of the causing bacteria (Cmax/MIC > 10), are related to a probable increase in therapeutic efficacy based on pharmacokinetic and pharmacodynamic (PKJPD) parameters. 2) Vancomycin: Vancomycin's dosage pattern adjusted for trough concentrations has the purpose of achieving the index PK/PD value that better correlates with therapeutic efficacy, in the area under the 24-h curve (AUC24h)/MIC higher than 400. Conclusions: The implementation and development of a dosing and monitoring protocol for aminoglycosides and vancomycin in adult hospitalized patients could improve treatment optimization for these antibiotics.
Fifty adult women with postpartum endometritis were randomly assigned to receive either ampicillin (AMP) or cefotaxime (CFX) in a double-blind fashion. Treatment success rates were 19 of 23 (82.6%) in the AMP group versus 19 of 22 (86.3%) in the CFX group. Four failures in the AMP group and two in the CFX group were attributed to pelvic abscess formation. Mean total postpartum hospital charges for the CFX group were 4,822.84 ± 3,337.28 in the AMP-treated patients (P < 0.012). One excess failure in the ampicillin group contributed to the overall difference in hospital charges. Although study antibiotic costs were significantly higher for the cefotaxime group, overall hospitalization charges were not greater. Antibiotic charges alone do not predict overall charges for treatment of postpartum endometritis.
Ninety-eight patients with a diagnosis of postpartum endometritis were randomized in an open comparative study involving piperacillin and clindamycin/gentamicin. Six patients receiving piperacillin and three patients receiving clindamycin/gentamicin failed to respond to therapy. There was no significant difference in the failure rate between the two groups. Piperacillin was found to be suitable for the treatment of postpartum endometritis that develops following delivery by cesarean section.
OBJECTIVE: Comparison between two therapeutics schedules Gentamicin plus and Pefloxacine plus metronidazol in the post-cesarean section endometritis. DESIGN: One open randomized clinical trial was started. There were 71 women, who were undergone to urgency cesarean section in the Institute Materno Infantil, from September 1st 1993 to August 31th 1994 who developed endometritys. The diagnostic was done with three of nine criteria's that we used in the septic ward in our Hospital. They were randomized in two groups of treatment, clindamicyn plus gentamicin or Pefloxacine plus Metronidazol. We studied the therapeutic efficacy between the regimens with the comparison of time of the fever effervescence, clinical curse, therapeutic falls and complications. The safety of the treatments were studied too. Statistical comparisons was done with t student for continuos variables and chi square for discrete variables (a0.05). RESULTS: The safety was studied in 68 patients who assisted to control on 5th day of treatment and the efficacy in 63 patients who assisted to controls on 7th day. The endometrial cultures showed anaerobic microorganisms in 48% of the patients and there was 1.9 microorganisms per patient. There was not differences between two therapeutic regimens about effervescence fever (p = 0.94), improvement rate (p = 0.49), complications (p = 0.44) and safety (0.94). The antibiotic accuracy to aerobic germens was high for the two regimens studied, although we did not find b lactamic resistance in the four cases of N gonorrhoeae. CONCLUSIONS: Clindamycin-Gentamicin regimen was too successful like the association Pefloxacine-Metronidazol in the treatment of post-cesarean endometritis, showed the last regimen to be an alternative therapeutic, especially in cases of severe infection or fault on the first regimen.
OBJECTIVE: Our purpose was to compare the efficacy and safeiy of gcntamicin even 8 hrs with gentamicin administered every 24 In-s tor the treatment ol'postcesarean endometrilis. STUDY DESIGN: Patients with [he clinical diagnosis of postoperative endometritis were randomi/ed to receive clindanivcin 900 ing IV cverv 8 hrs in combination with either geniamicin 1.f> ing/kg (2 ing/kg loading dose) IV even- 8 hrs (Group 1 ) or gentainicin 5 in/kg IV even- 24 hrs (Group 2). Prioi to the initiation ol antibiotic therapy etidometrial, urine, and blood cultures were obtained. If patients rlid not respond to antibiotic theiapy ampicillin '2 g IV everv (> hrs was added to the regimen. Therapeutic success was defined as a decrease in temperature and uterine tenderness within 48 hrs of therapy with complete resolution by the end of treatment. Therapeutic fail'ire was defined as a change in antibiotic therapy within the first 'M\ hrs, peisistenl iever and meriue tetidei ness alter 48 hrs of therap\, or the addition of heparin. Patients white count and serum creatinine were monilorec: dailv during iherajn. Nephiotoxicitv was defined as an increase in serum creatinine of >0.5> mg/dl. above theii baseline value. RESULTS: One hundred patients were i;mdomi/ed into the study protocol. Kightv five were included for' analvsis (44 in Group 1 and 41 in Group 2). There was no difference with respect to age, race. gravidity, paritv. hrs of ruptured membranes, hrs of labor, or indication for cesarean between the two groups. Thirtv three (75.0%)patients in Group I and 29 (70.7%) patients in Group 2 responded to therapv (p > 0.05%). The number of hospital davs (5.7 ±2.2 vs 5.4 ± 2.5). days of antibiotics (3.0 ±2.3 vs 3.3 ± 1.96 and postoperathc days (5 ±2.4 vs 5 ±2.0) uas similar be-lueen the two groups (p > 0.051. No patients in either group experienced nephroloxicity. CONCLUSION: Cienlaniicin administered evry 24 hrs is as eilectivc and safe lor the treatment ol postcesarean endometritis as gentainicin administered eve rv 8 lirs when given in conjunction with the standard regimen ol clindatnvrn with or without ampicillin.
OBJECTIVE: The null hypothesis is that once daily gentamicin is as efficacious, safe and cost effective as thrice daily gentamicin in the treatment of postpartum endometritis. STUDY DESIGN: Patients with puerperal endometritis or with chorioamnionitis in labor and assessed to be at risk for endometritis were randomized to receive gentamicin 4 mg/kg IV every 24 hours with clindamycin 1200 mg IV ever)- 12 hours (experimental arm) or gentamicin 1.33 mg/kg [V and clindamycin 800 mg IV every 8 hours (traditional arm). The primary outcomes were cure rates, mean length of treatment, mean cost, and nephrotoxicity. Sample size calculations indicated that 272 women were needed for an 80% power and a p-value of 0.05 to determine a significant difference between treatment groups. RESULTS: There were 134 patients randomized to the experimental arm and 137 patients randomized to the traditional arm. Cures (no additional antibiotics required) were obtained in 94.0% of the patients in the experimental arm and 87.6% of the patients in the traditional arm (p=0.067). The mean length of treatment was 2.1 days and 2.5 days in the experimental and treatment arms respectively (p=0.01). The experimental arm had an average cost of 442.49 per patient in the traditional arm (p = .0001). There was no nephrotoxicity. CONCLUSION: Once daily gentamicin with twice daily clindamycin is as efficacious as the three times daily dosing of gentamicin and clindamycin in this study population. The experimental regimen results in a shorter mean length of treatment and significantly reduces the cost of treatment. No nephrotoxicitv was noted in either treatment regimen.
Sixty-seven patients diagnosed with post-cesarean-section endometritis were studied in a prospective comparative randomized trial of sulbactam/ampicillin, a new beta-lactamase inhibitor drug combination, versus treatment with metronidazole/gentamicin. The success rate was 91% for each antibiotic regimen. Mycoplasma spp. or Ureaplasma spp. were isolated from all treatment failures. Endometrial cultures revealed 2.3 aerobes as well as anaerobes per patient, with Enterococcus faecalis, Bacteroides bivius, and Escherichia coli tthe most frequently reported bacterial isolates in 64, 40, and 28% of all patients, respectively. Positive blood cultures were noted in 11 (15%) patients with Mycoplasma sp. the most commonly found isolate (45.5%). Sulbactam/ampicillin appears to be safe and equally effective as a metronidazole/aminoglycoside drug regimen in the treatment of postpartum endometritis.
A prospective randomized study of the treatment of postpartum endometritis was conducted with 43 patients. The bacterial origin of the infection was determined by uterine aspiration. Treatment was successful in 17 of the 19 patients receiving ampicillin (12 g/d) and in 21 of the 24 patients receiving clindamycin (2.4 g/d) plus gentamicin (5.1 mg/kg daily).
A total of 120 patients who were to be delivered by cesarean section and who were at high risk of postoperative infection received three doses of either cefamandole, cephalothin or placebo perioperatively. Maternal serum levels for both antibiotics were in the therapeutic range. Although both drugs reduced the incidence of febrile morbidity and endometritis, only cefamandole significantly reduced the fever index. Risk factors for postoperative infections were the presence of ruptured membranes, labor, and internal fetal monitoring. Cefamandole beneficially influenced all risk factors while cephalothin was able to reduce only the risk of ruptured membranes. When a new method for obtaining endometrial tissue was utilized, 50% of cultures were negative. There was no difference in the organisms isolated from patients with and without endometritis.
A random comparison of clindamycin-gentamicin (C-G) and penicillin-gentamicin was made in 200 women who developed endomyometritis following cesarean section. All pretreatment profiles indicated similar populations. The clinical response was more favorable in the women receiving clindamycin-gentamicin. The implications of these results upon clinical practice is discussed.
During a 4-month period 265 women delivered by cesarean section were studied to determine what effect membrane rupture has on the incidence and severity of postoperative infection. There was a definite correlation between the duration of ruptured membranes and the incidence as well as severity of postoperative infections. Only 29% of women with intact membranes subsequently developed endometritis with pelvic cellulitis, in contrast to 85% of those whose membranes were ruptured for less than 6 hours. Wound and pelvic abscesses were encountered in less than 1% of women delivered with intact membranes, yet these complications developed in over 30% of women with membranes ruptured for less than 6 hours. The incidence of septicemia was four times greater in those women whose membranes were ruptured for less than 6 hours. Women with endometritis were treated with one of two empirical antimicrobial regimens chosen randomly. Intravenous penicillin and tetracycline was found to be as effective as, and perhaps slightly more effective than, the combination of intravenous penicillin and intramuscular tobramycin.
Three different antibiotic regimens (trospectomycin plus azteonam, clindamycin plus azteonam, and triple antibiotics-ampicillin plus clindamycin plus gentamicin) were all effective in treating patients with postcesarean endometritis. Patients are frequently cured clinically despite the fact that the offending organisms may be isolated in post-treatment cultures. Treatment of postcesarean endometritis without obtaining endometrial cultures is acceptable gynecologic practice. Obtaining post-treatment cultures is clearly not cost effective nor clinically beneficial. Drug treatment efficacy should be evaluated by clinical response. This communication is the first to report the new antibiotic, trospectomycin, in the treatment of postcesarean endometritis. Further clinical trials are currently underway.
The hypothesis of the study is that cefotetan and cefoxitin will be equally efficacious and safe in the treatment of post-cesarean section endometritis.
In a double-blind, randomized manner 140 patients with post-cesarean section endometritis were treated with cefotetan, 2 gm intravenously every 12 hours, or cefoxitin, 2 gm intravenously every 6 hours. They were followed prospectively for clinical response and side effects. Cure rates between the two groups were compared with the chi 2 test.
The cure rates were 83% for cefotetan and 79% for cefoxitin (p = 0.56). No patient required a change in therapy due to adverse effects, and no abnormal bleeding occurred.
In this study cefotetan and cefoxitin appeared equally effective in treating endometritis with no difference in side effects or complications.
A prospective, randomized, double-blind trial was done to compare the efficacy of cefoxitin (2 grams given intravenously every six hours) with ceftizoxime (2 grams given intravenously every 12 hours) in the treatment of postpartum endometritis. Thirty-eight patients received cefoxitin and 43 received ceftizoxime. Demographic variables (age, gravidity, parity and estimated gestational age) and risk factors (cesarean section, operating time, duration of ruptured membranes and labor, number of vaginal examinations and internal monitoring) were not statistically different in the two antibiotic groups. In the cefoxitin group, eight of 38 patients failed initial antibiotic therapy and six of 43 patients in the ceftizoxime group failed (p = 0.399). In the univariate analysis, abdominal wound infection (p = 0.003) and higher gestational age (p = 0.008) were associated with failure of the antibiotic. With multiple logistic regression, only abdominal wound infection was associated with failure of the antibiotic (p = 0.0002). We conclude that cefoxitin and ceftizoxime are equally effective in the therapy of postpartum endometritis and that abdominal wound infection is primarily responsible for persistent fever and, therefore, failure of the antibiotic in patients with postpartum endometritis.
A prospective, multicenter, open-label randomized trial was conducted to compare the efficacy and tolerability of imipenem-cilastatin (I-C) monotherapy with clindamycin+aminoglycoside (C+A) combination therapy. Forty-nine patients were able to be evaluated for clinical efficacy in the treatment of postpartum endometritis. Twenty-three patients received I-C and 26 received C+A therapy. The two groups were statistically similar for demographic and clinical variables upon entry into the study. The results of therapy were categorized as cured, improved, or failed. The use of I-C resulted in an overall clinical response rate (cured and improved) of 91%, compared with an overall response rate with C+A of 73% (P = 0.15). Patients categorized as improved comprised 56.5% of those in the I-C group and 38.5% of those in the C+A group. Patients categorized as failed comprised 8.7% of those in the I-C group and 26.9% of those in the C+A group. Overall, these data support the use of I-C for the treatment of appropriate patients with postpartum endometritis.
An open, randomized, comparative study of intravenous ciprofloxacin versus gentamicin and clindamycin was performed on women with postpartum endometritis. Ciprofloxacin alone successfully eradicated the infections in 35 of 49 patients (71%), while the combination of gentamicin/clindamycin cured 41 of 48 (85%) (P = .15). The microbiology and antibiotic sensitivity of the endometrial isolates confirmed the poor activity of ciprofloxacin against anaerobic bacteria and less-than-optimal activity against Streptococcus faecalis. Ciprofloxacin, when used alone, may not be suitable for the treatment of postpartum endometritis.
One hundred thirty-six patients were enrolled in a randomized, double-blind, placebo-controlled trial of oral antibiotic therapy (amoxicillin) versus placebo following successful intravenous (IV) antibiotic therapy for postpartum endometritis. No subjects were readmitted to the hospital for recurrent endometritis and there were no wound infections or recurrent fevers. Minor side effects were seen in 10% of those taking amoxicillin and 14% of those taking placebo. Compliance was fair; only 52% of those taking amoxicillin and 65% of those taking placebo completed therapy. The lack of infectious complications in this high-risk population suggests that oral antibiotic therapy is unnecessary after successful IV antibiotic therapy for endometritis.
To describe the microbiologic etiology of post-cesarean endometritis developing after perioperative cephalosporin prophylaxis, endometrial samples were obtained from 27 women with a triple-lumen catheter. The women were assigned in a double-blind, randomized fashion to receive either ticarcillin/clavulanate, 3.1 g, or cefoxitin, 2 g, administered every six hours, until the clinical signs of infection resolved. A total of 149 microorganisms (84 facultative and 65 obligate anaerobes) were recovered from 26 women, for a mean of 5.5 isolates per specimen. One endometrial specimen was sterile. Bacteroides and Peptostreptococcus species were the most frequent isolates, followed by Gardnerella vaginalis, Enterococcus, facultative gram-negative rods and Mycoplasma hominis. Each of the isolates was tested for beta-lactamase activity. At least one beta-lactamase-producing isolate was recovered from 56% of the specimens. Susceptibility testing of endometrial isolates demonstrated that 96% of 118 potential pathogens (Gardnerella, Bacteroides, Peptostreptococcus, enterococci and streptococci) were susceptible to ticarcillin/clavulanate. By comparison, 86% of these isolates were susceptible to cefoxitin in vitro. Women who were treated with ticarcillin/clavulanate were less likely to have a temperature greater than 38 degrees C for two or more days (8% vs. 57%, P = .01). Also, there was a trend toward a decreased duration of uterine tenderness in the ticarcillin/clavulanate group, but it did not attain statistical significance (60% vs. 86%, P = .4). However, the overall clinical success rate with these single-agent treatments was not different for the two groups (77% vs. 79%, P = 1.0).(ABSTRACT TRUNCATED AT 250 WORDS)
Sixty-eight patients with postpartum endomyometritis were enrolled in this open randomized comparative study. Forty-two patients received ampicillin/sulbactam and 26 received clindamycin. The cure rates were similar in the two groups: 83% in the ampicillin/sulbactam group and 88% in the clindamycin group. The most frequent endometrial bacterial isolates were Bacteroides bivius, Streptococcus faecalis, Escherichia coli, and Ureaplasma urealyticum. Bacteremia was present in 15 of 68 (22%), the most frequent isolates being Mycoplasma (four cases) and B bivius (three cases). Clindamycin-resistant species were S faecalis, E coli, and Proteus mirabilis. There were seven treatment failures in the ampicillin/sulbactam group; only one isolate (an E coli) was resistant to ampicillin/sulbactam. In a significant number of these failures, Mycoplasma was isolated. Ampicillin/sulbactam and clindamycin were found to be equally efficacious in the treatment of postpartum endometritis.
Endometritis is the commonest postpartum complication and is one of the leading causes of maternal morbidity, if not mortality. The object of the present clinical trial was to assess the efficiency of single-agent therapy with Amox-CA (Augmentin) (formulation which includes a beta-lactamase inhibitor), against standard treatment which necessarily combines two or three antibiotics depending on the clinical severity of the case. 101 patients were evaluated in this comparative prospective randomized study. The mild forms were defined by a temperature between 37.9 and 38.4 degrees C and the severe forms by a temperature of more than 38.5 degrees C (which alone required treatment with three antibiotics). The time until the return of apyrexia and the clinical cure rate, as well as duration of treatment, were identical in both groups. Tolerance was good: no side effect requiring discontinuation of treatment occurred. In the population value, the use of a single-agent therapy with amoxycillin/clavulanic acid is not significantly different from a double or triple-agent regimen, and the convenience is increase.
Predictors of postpartum endometritis were identified in 607 asymptomatic, laboring women. One hundred (16.5%) developed postpartum endometritis. Multivariate analysis using stepwise logistic regression identified cesarean delivery (relative risk 12.8; P less than .0001) as the dominant overall predictor. In patients with cesarean delivery (N = 124), prophylactic antibiotics (relative risk 0.54; P less than .0002) and high-virulence bacteria or Mycoplasma hominis (relative risk 1.4; P less than .01) predicted the incidence of endometritis, and in patients with vaginal delivery (N = 483), "bacterial vaginosis organisms" (relative risk 14.2; P less than .001) and aerobic gram-negative rods (relative risk 4.2; P less than .01) predicted endometritis. Despite significant associations found on univariate analysis, clinical variables such as duration of labor, rupture of membranes, and internal monitoring were not predictive of endometritis in the multivariate analysis. Our findings show that cesarean delivery and certain organisms, such as bacterial vaginosis or high-virulence organisms, predict endometritis, and that clinical variables may be facilitators rather than predictors of endometritis.
Patients with serious soft-tissue infections in obstetrics and gynecology are frequently treated with parenteral antibiotics until afebrile and clinically well for 48-72 hours, and then discharged on a broad-spectrum oral antibiotic. To evaluate the efficacy of this type of management, we designed a prospective, randomized single-blinded study comparing a group of patients who received oral antibiotics after hospital discharge (N = 80) with a group who did not (N = 83). No significant differences in age, race, parity, diagnosis, or pathogen isolated were observed between the patients in the two groups. No significant difference was noted in delayed morbidity between those who did and those who did not take oral antibiotics (P greater than .06). In light of the cost of oral antibiotics and the chance of drug-induced side effects, the data suggest that oral antibiotics after parenteral antibiotics are not indicated.
A randomized, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of dual topical therapy with zinc chloride spray and magnesium hydroxide ointment in healing incisional wounds. The participants were 100 obstetric and gynecologic patients with abdominal and perineal incisional wounds; 85 completed the treatment regimen, 15 were lost to follow-up. Spray and ointment were applied twice daily and dressings were changed at each application for seven consecutive days. The condition of the wound (the length of the incision, the presence and extent of dehiscence, and signs of infection, such as inflammatory changes and purulent discharge) as well as the degree of pain experienced by the patient were evaluated and recorded on the first, fourth, and seventh days. A more marked decrease in the size of the wound, a shorter healing time, a better control of infection, less dehiscence, and more effective pain control were observed in patients in the treatment group as compared with those in the placebo group. No side effects were noted in patients in either group. The dual topical therapy with zinc chloride spray and magnesium hydroxide ointment proved to be safe and effective in accelerating wound healing in obstetric and gynecologic patients.
In an open, randomized clinical study, the safety and efficacy of sulbactam/ampicillin was compared to that of cefotetan in 95 hospital patients with gynecologic or obstetric infections. Sulbactam/ampicillin (1 g:2 g), was administered intravenously every 8 h to 46 patients, and cefotetan (2 g) was administered intravenously every 12 h to 49 patients. All 23 patients with obstetric infections and 18 of the 23 patients with gynecologic infections treated with sulbactam/ampicillin were evaluated as cured. All 21 patients with obstetric infections and 23 of the 28 patients with gynecologic infections treated with cefotetan were evaluated as cured. No side effects requiring discontinuation of therapy or reduction of the dose administered, were observed.
One hundred fifty-two women who received cefazolin prophylaxis and subsequently developed postpartum endometritis were randomized to treatment with either ticarcillin/clavulanic acid (75) or clindamycin-gentamicin (77). Bacteria isolated from the endometrium were predominantly facultative anaerobic bacteria. The ratio of facultative anaerobes to obligate anaerobes was 3:1. Nineteen percent of the women were bacteremic, with mycoplasma the organism most frequently isolated from venous blood specimens. Cure rates were similar for both groups: ticarcillin/clavulanic acid 85% and clindamycin-gentamicin 81%. The advantages of ticarcillin/clavulanic acid are an increased spectrum of activity against beta-lactamase-producing bacteria, less toxicity, and lower cost.
To evaluate the safety and efficacy of an abbreviated course of antibiotic therapy in postpartum endomyometritis, 109 patients with endomyometritis were randomized to three study groups. All were treated with clindamycin and tobramycin until afebrility and clinical signs of disease were absent. Patients in group I received antibiotics for greater than or equal to 24 hours, group II received therapy for greater than or equal to 48 hours, and group III received antibiotic therapy for greater than or equal to 48 hours that preceded a 7-day course of oral Augmentin. The groups were similar in size and in demographic and clinical parameters. Two patients from each group required a third antibiotic, and no patient required rehospitalization. Group III required more days of antibiotic therapy than did group I, 2.9 versus 2.1 days (p less than 0.01), and cost $412.00 more per patient. This data strongly suggest that a short course of antibiotic therapy is efficacious and safe and would result in substantial monetary savings.
To characterize the flora of early postpartum endometritis and the clinical features of women with specific organisms, endometrial cultures for facultative and anaerobic bacteria, genital mycoplasmas, and Chlamydia trachomatis were taken with a triple-lumen sampling device. More than one organism was recovered from 80% of the women. Over 60% of the women had Gardnerella vaginalis and/or anaerobes associated with bacterial vaginosis isolated from the endometrium; these women were more likely to have severe illness and to develop a wound infection than were other women. Genital mycoplasmas were isolated frequently, but specific antibiotic therapy was not required for clinical cure in the 10% of patients who had Ureaplasma urealyticum only. Chlamydia trachomatis was infrequently isolated, but C trachomatis commonly remained after therapy.
Thirty-six hospitalized patients, 18 in each of two groups, with postpartum upper genital tract infection were enrolled in a randomized, prospective study comparing treatment with sulbactam/ampicillin, to treatment with clindamycin/gentamicin. One (5.5%) clinical failure was reported in each group. Side effects were minimal in both groups and did not warrant discontinuation of treatment. The in vitro activity of ampicillin versus sulbactam/ampicillin (1:2) was evaluated and these data were compared with data from other drugs commonly used for aerobic and anaerobic infections. Sulbactam eliminated resistance to ampicillin in all anaerobic and most aerobic isolates.
The clinical efficacy and safety of sulbactam/ampicillin versus metronidazole/gentamicin were compared in 39 patients with severe pelvic infections. 30 patients had severe acute pelvic inflammatory disease with peritonitis, 3 tubo-ovarian abscesses, 4 endomyometritis, and 2 posthysterectomy pelvic cellulitis. Aerobic and anaerobic cultures from the sites of infection yielded 259 micro-organisms from 38 patients; an average of 6.8 bacteria per infection (3.9 anaerobes and 2.9 aerobes). The most frequent isolates were Bacteroides spp. (21), B. bivius (13), B. disiens (8), Fusobacterium spp. (9), Peptostreptococcus anaerobius (15), P. asaccharolyticus (8), anaerobic Gram-positive cocci (17), Gardnerella vaginalis (24), Neisseria gonorrhoeae (14), α-haemolytic streptococci (6) and Escherichia coli (3).
Clinical cure was noted in 19 of 20 patients treated with sulbactam/ampicillin and 16 of 19 treated with metronidazole/gentamicin. The sulbactam/ampicillin failure was a patient with pelvic inflammatory disease with a positive Chlamydia trachomatis culture who required antichlamydial therapy. The metronidazole/gentamicin failures included a patient with a tubo-ovarian abscess requiring surgical drainage and 2 patients with pelvic inflammatory disease requiring antichlamydial treatment. No adverse haematological, renal, or hepatic effects were noted with either regimen.
The clinical efficacy and safety of ampicillin/sulbactam versus metronidazole-gentamicin were evaluated in a comparative, randomized, prospective study. Forty-four patients were enrolled: 22 received the ampicillin/sulbactam regimen, and 22 received the metronidazole-gentamicin combination. There were 33 cases of severe acute pelvic inflammatory disease, two tuboovarian abscesses, five cases of endomyometritis, and two cases of posthysterectomy pelvic cellulitis. Aerobic and anaerobic cultures from the infection sites yielded 447 microorganisms from 44 patients (an average of 10 bacteria per infection; 6.4 anaerobes and 3.7 aerobes). The most frequent isolates were Bacteroides sp., 54; Bacteroides bivius, 17; black-pigmented Bacteroides, 12; Bacteroides disiens, 11; Fusobacterium, 13; Peptostreptococcus anaerobius, 24; Peptostreptococcus asaccharolyticus, 21; anaerobic gram-positive cocci, 34; Gardnerella vaginalis, 29; Neisseria gonorrhoeae, 17; alpha-hemolytic streptococci, 15; and Escherichia coli, five. Clinical cure was noted in 19 of 20 patients treated with ampicillin/sulbactam and 18 of 21 patients treated with metronidazole-gentamicin. One treatment failure occurred in the ampicillin/sulbactam group in a patient who required antichlamydial therapy and had a complex left adnexal mass consistent with an abscess. The cases of metronidazole-gentamicin failure included two patients initially diagnosed as having tuboovarian abscesses who required a change in antibiotic therapy to control the infections. The third patient had postabortion endomyometritis that did not respond to metronidazole-gentamicin therapy within 48 hours, and required a change of medication. No adverse hematologic, renal, or hepatic effects were noted in either group of patients.
In a prospective, randomized study of 96 patients after cesarean section who had endomyometritis, there was a therapeutic cure in 35 of 47 (74.5%) patients who received mezlocillin, in comparison with 42 of 49 (85.7%) patients who received clindamycin and gentamicin (p = 0.17). Only wound infections in the study population were predictive for therapeutic outcome. Four of the five patients who received mezlocillin and none of the three patients who received clindamycin and gentamicin with wound infections were associated with therapeutic failures. This suggests mezlocillin may not be as effective as clindamycin and gentamicin in successfully treating wound infections. The number of vaginal examinations in patients sectioned for cephalopelvic disproportion was associated with increased febrile morbidity, suggesting that an excessive number of vaginal examinations should be avoided in the laboring patient.
Two hundred eighty-seven women were treated in a multicenter, randomized, comparative study to compare the safety and efficacy of cefotetan every 12 hours with that of cefoxitin every 6 or 8 hours in the treatment of acute obstetric and gynecologic pelvic infections. The most frequent primary diagnoses in both groups were endometritis and pelvic inflammatory disease; 24 of these patients were also bacteremic. The mean duration of treatment was 5.2 and 5.4 days for the cefotetan and cefoxitin groups, respectively, and the total doses administered were 18.1 and 32.1 gm, respectively. The rate of clinical failure for the cefotetan group was 8.5% and 12.2% for the cefoxitin group. Laboratory and clinical adverse reactions were infrequent and none was serious; both antimicrobials were well tolerated. These results suggest the administration of cefotetan provided adequate clinical and bacteriologic effectiveness in the treatment of hospital- and community-acquired, polymicrobial obstetric and gynecologic pelvic infections.
The clinical efficacy and safety of cefotetan was assessed in two multicenter clinical trials involving 335 evaluable patients hospitalized with obstetric and gynecologic infections. In Study I, cefotetan was compared with moxalactam and in Study II, cefotetan was compared with cefoxitin. The clinical response rate in Study I was 67 of 70 patients for cefotetan (96 percent) and 33 of 34 patients (97 percent) for moxalactam. In Study II, the clinical response rate was 138 of 147 patients in the cefotetan group (94 percent) and 76 of 84 patients in the cefoxitin group (91 percent). For the patients with bacteriologic response data, 196 of 205 cefotetan patients (96 percent), 23 of 24 moxalactam patients (96 percent), and 70 of 75 cefoxitin patients (93 percent) had a satisfactory bacteriologic response. Cefotetan was well tolerated and produced no major adverse reactions. The mean amount of cefotetan given was lower than that of moxalactam or cefoxitin.
Ticarcillin disodium/clavulanate potassium was compared to clindamycin/gentamicin in the treatment of post-cesarean-section endometritis in 133 evaluable patients. All patients received three 1-g doses of cefazolin for prophylaxis. There was no statistically significant difference in the cure rates between the ticarcillin disodium/clavulanate potassium group (84%) and the clindamycin/gentamicin group (81%). Bacteremia occurred in 21% of the patients, with Mycoplasma the most frequent isolate. Ticarcillin disodium/clavulanate potassium was found to be as efficacious as clindamycin/gentamicin in the treatment of postpartum endometritis.
Sixty women with the diagnosis of puerperal endometritis were randomized to receive either moxalactam (n = 29) or the combination of clindamycin and tobramycin (n = 31) as therapy for their infection. Endometrial bacteriology consisted of mixed flora, both aerobic and anaerobic gram-positive and gram-negative organisms. Clinical cure was achieved in 27 (93%) of the moxalactam-treated patients and 28 (90%) of those given combination therapy. The two failures of moxalactam therapy were associated with enterococcal infection. Failures of clindamycin/tobramycin therapy were due to enterococcal infection, abscess formation, and moderately severe diarrhea. This study indicates that moxalactam is as effective and safe as the combination of clindamycin/tobramycin for the treatment of postpartum endometritis.
Sixty-two patients who had postpartum endometritis were treated with clindamycin in combination with either aztreonam or the aminoglycoside gentamicin. Currently, the combination of clindamycin and an aminoglycoside constitutes a treatment of choice for this condition. Our results suggest that aztreonam can be substituted for an aminoglycoside in the treatment of postpartum endometritis with similar clinical outcomes.
The direct and indirect costs associated with either moxalactam or clindamycin plus gentamicin as treatment for endomyometritis after emergent cesarean section were compared in an open, randomized prospective trial of 114 patients. A total of 58 patients were assigned to receive moxalactam, 2 g intravenously (i.v.) every 8 h for 5 doses, followed by 2 g every 12 h and prophylactic vitamin K (10 mg) intramuscularly, and 56 patients were assigned to receive clindamycin (600 mg) i.v. every 6 h plus gentamicin (1.5 mg/kg) i.v. every 8 h. Prothrombin times were measured in moxalactam-treated patients, and patients treated with clindamycin plus gentamicin had urinalyses and blood urea nitrogen and serum creatinine determinations performed before and after treatment. Also, gentamicin levels in serum were determined as clinically indicated. A satisfactory treatment response was defined as the resolution of signs and symptoms of endomyometritis within 3 days of the start of antibiotic therapy. Satisfactory responses were demonstrated in 78% of the moxalactam-treated patients and 84% of patients treated with clindamycin plus gentamicin. Mean hospital costs for laboratory tests (4.53) and mean patient charges for laboratory tests (27.81) and medications (421.82) were significantly higher in patients treated with clindamycin plus gentamicin (P less than 0.05), while mean medication costs to the hospital were greater in the moxalactam group (195.68; P less than 0.05). However, total patient charges and total hospital drug-associated costs were not significantly different for the two group. In this tudy, moxalactam was similar in efficacy and, despite its higher acquistion cost, was comparable in total hospital costs and patient charges to clindamycin plus gentacmicin in treating endomyometritis.
Cefotetan is a recently introduced cephamycin antibiotic for parenteral administration, with a broad spectrum of antibacterial activity. Its elimination half-life of three hours or more allows a twice-daily dosage schedule. A noncomparative trial of cefotetan yielded a satisfactory clinical response in the treatment of all of ten patients with pelvic infection. Subsequently, we did a prospective, randomized comparative study of 53 patients with pelvic infections treated with either cefotetan (2 gm IV every 12 hours) or cefoxitin (2 gm IV every six to eight hours). Both drugs showed similar clinical efficacy and antimicrobial activity (100% [n = 36] with cefotetan and 94% [n = 17] with cefoxitin, the difference not statistically significant). A mean of 21.3 gm of cefotetan was required, as compared with 34.4 gm of cefoxitin, a statistically significant difference (P less than .001). Use of cefotetan is therefore more cost effective.
Cefoxitin, a cefamycin derivative, has demonstrated activity against a broad spectrum of aerobic and anaerobic bacterial pathogens. The efficacy and safety of cefoxitin were compared with that of the combination of clindamycin and gentamicin in the treatment of postcesarean section infection. Ninety-eight patients were evaluated. Cefoxitin cured 36 of 48 patients (75%); clindamycin/gentamicin cured 38 of 50 (76%) (P greater than .05). Febrile degree hours and length of hospital stay did not differ between the two study groups. No patient experienced abscess formation or septic pelvic thrombophlebitis. Both therapies were well tolerated. In the authors' experience, cefoxitin as a single agent was as effective in the treatment of postoperative pelvic infection as the combination of clindamycin and gentamicin.
Thirty-four patients with pelvic inflammatory disease, postoperative, postabortal and postpartum infections were randomized to intravenous therapy with either 500 milligrams of imipenem and cilastatin sodium every six hours or 2 grams of moxalactam every eight hours for a minimum of four days. One patient in the moxalactam group was nonevaluable because of protocol noncompliance; three more patients had no bacteriologic pathogen isolated (two in the moxalactam group and one patient in the imipenem/cilastatin group). The two groups were similar with respect to age, diagnosis, etiologic agents and duration of therapy. Of the 17 evaluable patients in the imipenem/cilastatin group, all were complete clinical cures. Three patients in the imipenem/cilastatin group had persistence of at least one bacteriologic pathogen despite clinical cure and apparent laboratory evidence of susceptibility. Of the 13 evaluable patients in the moxalactam group, eight were complete clinical cures. Two more patients in that group were clinically improved enough to be discharged on oral antibiotics. There were three clinical failures in the moxalactam group, all of whom had group D streptococcus resistant to moxalactam. An additional three patients in the moxalactam group had other resistant organisms isolated despite clinical cure. Both drugs were well tolerated and no serious complications or side effects occurred in either group. Despite small numbers, our data suggest that imipenem and cilastatin is a more appropriate agent for initial treatment of obstetric and gynecologic infections than moxalactam.
The efficacy of mezlocillin versus cefoxitin versus clindamycin plus gentamicin was evaluated in 152 patients with postpartum endometritis. There were no statistically significant differences in rate of cure among the three groups (87% with mezlocillin, 82% with cefoxitin, and 92% with clindamycin-gentamicin). There were no severe adverse reactions observed in any of the three treatment regimens. Mezlocillin is as safe and effective as cefoxitin and clindamycin-gentamicin for treatment of postpartum endometritis.
Serum levels of tobramycin were determined with an enzyme immunoassay technique in 20 puerperal women with postcesarean endometritis who were being treated with metronidazole-tobramycin. Ideal dosing was then calculated to attempt to provide peak serum levels between 5 and 8 micrograms/mL and trough serum levels less than 2 micrograms/mL. In eight patients, therapeutic serum levels could not be attained even at doses greater than the package-insert recommendation of 3 mg/kg/d. Therapeutic levels were achieved in five patients with doses between 3 and 5 mg/kg/d and in seven patients only at doses above the maximum recommended daily dose of 5 mg/kg. The puerperal patient appears to usually require much higher dosages of tobramycin than usual, and serum levels must be monitored for therapeutic reasons rather than for toxicity.
A protected, triple-lumen transcervical culture method was used to recover organisms from the endometrium. At least one facultative
or one anaerobic species of bacteria was recovered from 82% of the patients, and genital mycoplasmas were recovered from 76%
of the women with endometritis. Bacteria together with genital mycoplasmas were present in 61% of the women, bacteria alone
were present in 20%, genital mycoplasmas alone were present in 16%, and Chlamydia trachomatis was isolated from 2% of the patients. The most common organisms included Gardnerella vaginalis, Peptococcus spp., Bacteroides spp., Staphylococcus epidermidis, group B Streptococcus, and Ureaplasma urealyticum. A randomized, double-blind regimen of either piperacillin or cefoxitin was equally successful in treating the postpartum
endometritis.
A randomized comparison of aztreonam (2 g intravenously every eight hours) versus gentamicin (1.5 mg/kg intravenously every eight hours), each with clindamycin (600 mg intravenously every six hours), was performed in 119 patients with endometritis after cesarean section. Patients in both groups had similar risk factors. Genital cultures revealed an average of 3.0 isolates per specimen. Eighty-five aerobic gram-negative rods were isolated from 57 (48%) patients. All were susceptible to both aztreonam and gentamicin. Of 133 anaerobic isolates, 131 (98%) were susceptible to clindamycin. The failures in the aztreonam group were associated with a wound abscess and with an enterococcal bacteremia. Of the six failures in the gentamicin group, two were associated with persistent isolation of enteric bacilli. In the other four failures, no explanation was evident. Side effects occurred in four patients, (three diarrhea, one allergic reaction). All were self-limited and appeared to be due to clindamycin. No patient showed nephrotoxicity. When used in combination with clindamycin, aztreonam gave clinical results similar to gentamicin.
New third generation cephalosporins have been recommended as single agent antibiotic therapy in the treatment of postoperative infections. This study compares the new third generation cephalosporin ceftizoxime with cefoxitin, clindamycin and gentamicin in the treatment of postcesarean section endomyometritis. The results indicate that the clindamycin and gentamicin regimen is more efficacious in the treatment of severe infection after cesarean section than either ceftizoxime or cefoxitin regimens. Therefore, the results of this study suggest caution in substituting single drug antibiotic therapy with cefoxitin or the third generation cephalosporins for the standard clindamycin and gentamicin regimen in the treatment of postcesarean section endomyometritis until more clinical data are available.
A new single-antibiotic combination of ticarcillin and clavulanic acid was compared with the standard two-drug regimen of clindamycin and gentamicin in the treatment of post-cesarean endomyometritis. The regimens were as follows: 3 g of ticarcillin plus 100 mg of clavulanic acid intravenously every four hours; or 600 mg of clindamycin intravenously every six hours plus 3 to 5 mg/kg per day of gentamicin intramuscularly. The prospective randomized schedule was calculated such that half the patients were assigned to each treatment group. The diagnosis of endomyometritis was based upon an elevated oral temperature of 100.4 degrees F or higher on any two occasions, excluding the first 24 hours after delivery, uterine tenderness, and the absence of other foci of infection. Lochial discharge was foul in most cases. Forty-seven patients were treated. Treatment was successful in all patients who received clindamycin and gentamicin; ticarcillin plus clavulanic acid failed in two of 23 (9 percent) patients. Patients in whom treatment failed did not appear to be different from those in whom treatment was successful on demographic variables or in terms of risk factors for endomyometritis. The difference between the treatment failure rates was not statistically significant. This study suggests that the single-drug combination of ticarcillin plus clavulanic acid is effective in the treatment of post-cesarean endomyometritis when compared with the standard regimen of clindamycin and gentamicin.
Using a system of random selection in patients with severe obstetric-gynecologic infections. parenteral penicillin-kanamycin was given to 23 women and cltndamycin-kanamycin was given to 21. Therapeutic response to the two antibiotic regimens was similar; no significant differences were noted in either the posttreatment fever index or the numbers of women requiring other therapy. There was a failure of response to the pwenicillin-kanamycin regimen in those women with Bacleroides fragilir infection and to the clindamycin-kanamycin regimen in some of the women with an Enlerococ. cus infection. The implications of these findings for the future selection of antibiotics for patients with severe ohstetric-gynccologlc infections arc discussed. © 1974 The American College of Obstetricians and Gynecologists.
One hundred and twenty-six patients with female genital tract infections were treated with intravenous mezlocillin (16 g/day)
in a prospective, multicentre, clinical trial. Clindamycin (2 g/day) was added if patients failed to improve within 48 h of
mezlocillin therapy. Cure was noted in 84.3%, improvement in 4.8%, and failure in 7.9%.
Using the same basic protocol, but with the addition of randomization and blinding, mezlocillin and ampicillin (8 g/day) were
compared in 48 and 51 postpartum patients, respectively. No significant differences between mezlocillin and ampicillin treated
patients were demonstrable. Side-effects were minimal and insignificant.
We conclude that mezlocillin is an effective drug for the treatment of female genital tract infections and that mezlocillin
and ampicillin are equally effective in the treatment of postpartum genital tract infections.
A double-blind comparison of clindamycin plus gentamicin versus moxalactam plus placebo was performed for the treatment of endomyometritis after cesarean section delivery. Entry criteria were uterine tenderness, temperature greater than or equal to 101 degrees F, and leukocytosis. Uterine specimens were obtained for culture via a single-lumen transcervical catheter. Bacteremia occurred in 10% of patients. Among the 57 patients treated with clindamycin plus gentamicin, there were two clinical failures and four side effect failures (diarrhea in two, allergic reaction in two). Among the 56 patients in the moxalactam group, there were four clinical failures and one side effect failure (diarrhea). Both regimens had good cure rates, with no significant differences in cures or postoperative hospital stay.
Infections in the upper genital tract continue to be one of the leading causes of serious morbidity for obstetric and gynecologic
patients. The polymicrobial, mixed aerobic and anaerobic isolates recovered from women with such infections demand broad-spectrum
antimicrobial activity. In the past, combination therapy has been given in order to attain this coverage. In a multicenter
open study, cefotaxime was used for treatment of endomyometritis after cesarean section, pelvic cellulitis after hysterectomy,
and acute pelvic inflammatory disease. The drug effected a clinical cure in 93% of 104 women. In a randomized comparative
study conducted at one center, cefotaxime cured 97% of 36 cases of post-cesarean section endomyometritis; clindamyclin plus
gentamicin cured 94% of 18 cases of the same infection. There was no evidence of significant alteration in hematopoietic,
hepatic, or renal function with either regimen. Cefotaxime appears to be a safe, extremely effective antimicrobial drug that
is ideally suited for single-agent treatment of serious soft-tissue pelvic infections in obstetric or gynecologic patients.
One hundred eighteen women who developed endomyometritis after cesarean section in Parkland Memorial Hospital were treated with parenteral cefotaxime sodium. The requirement for additional antimicrobial therapy was significantly higher at an initial daily dose of 3 g/day (16.4%) than when the dose was 6 g/day (4.8%) (P less than .05). The latter clinical efficacy and the observed in vitro susceptibility of 88% of isolates indicate that cefotaxime is well suited for single-agent parenteral therapy for this polymicrobial pelvic infection. Subsequently, 120 women with the same diagnosis were randomly treated with cefotaxime or clindamycin and gentamicin. Patient populations, surgical variables, in vitro microbiologic data, and side effects were similar for both groups. Clinical success observed was also similar: it was 97.5% for women given cefotaxime and 95% for women given clindamycin and gentamicin.