Endometritis 2

MEDICATION
After making the diagnosis of endometritis and excluding other sources of infection, broad-spectrum antibiotics should be promptly initiated. Improvement will be noted within 48-72 hours in nearly 90% of women treated with an approved regimen. For mild cases following vaginal delivery, an oral agent may be adequate.
Drug Category: Antibiotics -- A combination therapy with clindamycin and an aminoglycoside is considered the criterion standard by which most antibiotic clinical trials are judged.
A combination regimen of ampicillin, gentamicin, and metronidazole provides coverage against most of the organisms that are encountered in serious pelvic infections.
Doxycycline should be used if Chlamydia is the cause of the endometritis.
Ampicillin sulbactam can be used as monotherapy. Single-agent therapies have been found to be efficacious in 80-90% of patients.
Drug Name
Clindamycin (Cleocin) -- Used in combination with gentamicin. Lincosamide useful as a treatment against serious skin and soft tissue infections caused by most staphylococci strains. Also effective against aerobic and anaerobic streptococci, except enterococci.Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome where preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.
Adult Dose
900 mg IV q8h
Pediatric Dose
20-40 mg/kg/d IV divided q6-8h
Contraindications
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Interactions
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficileAmerican Academy of Pediatrics states that clindamycin is compatible with breastfeeding
Drug Name
Gentamicin (Gentacidin, Garamycin) -- Aminoglycoside antibiotic used for gram-negative bacterial coverage. Used in combination with either clindamycin or in combination with metronidazole and ampicillin.Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution. Dose may be given IV or IM.
Adult Dose
1.5 mg/kg IV q8h
Pediatric Dose
2-2.5 mg/kg/d IV q8h
Contraindications
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occurCoadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; data are lacking concerning use while breastfeeding
Drug Name
Ampicillin (Omnipen, Marcillin) -- Used in combination with gentamicin and metronidazole. Interferes with bacterial cell-wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms.
Adult Dose
2 g IV q6h
Pediatric Dose
50-200 mg/kg/d IV divided qid
Contraindications
Documented hypersensitivity
Interactions
Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Drug Name
Metronidazole (Flagyl) -- Used in combination with gentamicin and ampicillin. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.
Adult Dose
500 mg IV q6h
Pediatric Dose
15-30 mg/kg/d IV divided bid/tid
Contraindications
Documented hypersensitivity
Interactions
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathyAmerican Academy of Pediatrics states that metronidazole should be used with caution while breastfeeding
Drug Name
Ampicillin/sulbactam sodium (Unasyn) -- Has been found to be efficacious as monotherapy in 80-90% of patients. Drug combination that uses a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Adult Dose
3 g IV q6h
Pediatric Dose
1.5-3 g IV q8h
Contraindications
Documented hypersensitivity
Interactions
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; compatible with breastfeeding
Drug Name
Doxycycline (Bio-Tab, Doryx, Vibramycin) -- Used if Chlamydia is the cause of the endometritis. Inhibits protein synthesis and thus bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria.
Adult Dose
100 mg IV/PO q12h
Pediatric Dose
<8>8 years: 1-2 mg/lb q12h
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy
D - Unsafe in pregnancy
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclinesAmerican Academy of Pediatrics states that doxycycline is compatible with breastfeeding
Drug Name
Ertapenem (Invanz) -- Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.
Adult Dose
1 g qd for 14 d if given IV and 7 d if given IM; infuse over 30 min if given IV
Pediatric Dose
Not established
Contraindications
Documented hypersensitivity to drug or amide type anesthetics
Interactions
Probenecid may reduce renal clearance of ertapenem and increase half-life but benefit is minimum and does not justify coadministration
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Pseudomembranous colitis may occur; seizures and CNS adverse reactions may occur; when using with lidocaine to administer intramuscularly, avoid inadvertent injection into blood vessel FOLLOW-UP
In/Out Patient Meds:
Patient may be discharged home without antibiotic therapy after being afebrile for at least 24 hours and with a benign physical examination.
Further outpatient therapy has proved to be unnecessary.
Complications:
Wound infection
Peritonitis
Adnexal infection
Parametrial phlegmon
Pelvic abscess
Pelvic hematoma
Septic pelvic thrombophlebitis
Prognosis:
Nearly 90% of women treated with an approved regimen note improvement in 48-72 hours. MISCELLANEOUS
Medical/Legal Pitfalls:
Prophylactic antibiotics reduce the incidence of postpartum febrile morbidity in patients undergoing cesarean delivery.
Single-agent cephalosporin therapy of the first- or second-generation type is considered the best choice.
BIBLIOGRAPHY