Endometritis

Endometritis complicates 20-25% of cesarean sections and occasionally occurs in routine postpartum women.  A combination of Clindamycin-Gentamicin will be effective in 90% of cases.  In unresponsive cases, addition of Ampicillin (for enterococcus) will sometimes be effective.  A search should be made for pelvic abscess in unresponsive patients.  If septic pelvic thrombophlebitis is suspected, a trial of Heparin is indicated.

Clindamycin 900 mg IV q 8 hours
+
Gentamicin IV 2 mg/kg loading dose; then 1.5 mg/kg q 8 hours

(Example: 80 kg patient will be loaded with 160 mg IV Gentamicin, then 120 mg IV q 8 hours)

For Obese Patients > 100 kg.
200 mg loading dose maximum, then 150 mg q 8 hours maintenance maximum

(Example:  150 mg obese patient = 200 mg loading, then 150 mg q 8 hours maintenance)

The above antibiotic combination has been tested most extensively in the literature and has resulted in cure rates exceeding 90% in infected patients.  The increased dosing schedule for Gentamicin reflects the need to give higher doses due to the increased plasma volume and GFR in obstetrical patients. Pharmacy may recommend alternate dosing schedules. Clindamycin + Gentamicin can be mixed together and given in the same IV solutions.  These antibiotics should be continued until the patient is afebrile 24 hours.  There is no need to switch to oral antibiotics and there is also no need to observe the patient’s temperature for one additional day in the hospital.

Serum Gentamicin Levels:  In a healthy patient with normal renal function (serum creatinine less than 1.1 mg/dl), there is no need to order serum Gentamicin levels.  After reviewing the OB literature for the past 15 years, we cannot find one article to support that these levels are beneficial or cost effective in the treatment of endometritis.  The patient’s clinical response remains the best indicator of the efficacy of Gentamicin therapy.

Duration of Therapy:  Treat until afebrile for at least 24 hours (i.e.  <100.4° F).

Therapeutic Failures:  If a patient has not become afebrile by 72 hours or there is not a downward trend of peak temperature elevation within 48 hours after starting Clindamycin + Gentamicin, she should be considered a therapeutic failure.  Ampicillin should be added to her antibiotic regimen.  If the patient is still not improving after 24 hours of triple antibiotics, consider a CT scan to rule out hematoma, abscess, or ovarian vein thrombosis.  A complete physical exam including pelvic exam is indicated to discern the cause of the treatment failure.  Causes of therapeutic failures – pelvic abscess, wound infection, septic pelvic thrombophlebitis, drug fever, pneumonia, resistant organisms etc.  The chief resident and attending physician should be notified so that an alternative treatment plan can be discussed.

An attending physician should be notified ANYTIME a patient has a postpartum fever and treatment is considered.