eMedicine Specialties > Obstetrics and Gynecology > General Obstetrics

Endometritis: Treatment & Medication

Author: Gema T Simmons, MD, Consulting Staff, Department of Obstetrics and Gynecology, Alegent Health
Contributor Information and Disclosures

Updated: Aug 2, 2009

Treatment

Medical Care

Most cases of endometritis, including those following cesarean delivery, should be treated in an inpatient setting. For mild cases following vaginal delivery, oral antibiotics in an outpatient setting may be adequate.

  • Combination intravenous clindamycin and gentamicin administered every 8 hours has been considered the criterion standard treatment. Recent studies have revealed adequate efficacy with daily dosing as well.
  • Second- or third-generation cephalosporin in combination with metronidazole is another popular choice.
  • Improvement is usually noted within 48-72 hours in nearly 90% of women. Parenteral therapy is continued until the patient has been afebrile for longer than 24 hours. Thereafter, oral antibiotics are not usually necessary.

Surgical Care

Surgical management is not usually necessary in acute endometritis in the obstetric population. Dilatation and curettage may be advised for retained products of conception, however.

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.

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.


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

900 mg IV q8h

Pediatric

20-40 mg/kg/d IV divided q6-8h

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

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 difficile
American Academy of Pediatrics states that clindamycin is compatible with breastfeeding


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

1.5 mg/kg IV q8h

Pediatric

2-2.5 mg/kg/d IV q8h

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non-dialysis-dependent renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

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


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

2 g IV q6h

Pediatric

50-200 mg/kg/d IV divided qid

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction


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

500 mg IV q6h

Pediatric

15-30 mg/kg/d IV divided bid/tid

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
American Academy of Pediatrics states that metronidazole should be used with caution while breastfeeding


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

3 g IV q6h

Pediatric

1.5-3 g IV q8h

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 - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; compatible with breastfeeding


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

100 mg PO/IV q12h

Pediatric

<8 years: Not recommended
>8 years: 1-2 mg/lb PO/IV q12h

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

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

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 tetracyclines
American Academy of Pediatrics states that doxycycline is compatible with breastfeeding


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

1 g qd for 14 d if given IV and 7 d if given IM; infuse over 30 min if given IV

Pediatric

Not established

Probenecid may reduce renal clearance of ertapenem and increase half-life but benefit is minimum and does not justify coadministration

Documented hypersensitivity to drug or amide-type anesthetics

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

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

More on Endometritis

Overview: Endometritis
Differential Diagnoses & Workup: Endometritis
Treatment & Medication: Endometritis
Follow-up: Endometritis
References
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References

  1. Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. May 2007;196(5):455.e1-5. [Medline].

  2. Tita AT, Hauth JC, Grimes A, Owen J, Stamm AM, Andrews WW. Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis. Obstet Gynecol. Jan 2008;111(1):51-6. [Medline].

  3. Tita AT, Rouse DJ, Blackwell S, Saade GR, Spong CY, Andrews WW. Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstet Gynecol. Mar 2009;113(3):675-82. [Medline].

  4. Cunningham FG. Infection and disorders of the puerperium. In: Cunningham GF, MacDonald PC, Leven KJ, et al, eds. Williams Obstetrics. 20th ed. Stamford, Conn: Appleton & Lange; 1997:548-55.

  5. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004;CD001067. [Medline].

  6. Ledger WJ. Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. Dec 2003;29(6):364-73. [Medline].

  7. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. Jun 2007;62(6):393-9. [Medline].

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Further Reading

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Keywords

metritis, endomyometritis, endomyoparametritis, myometritis, Cesarean delivery, C section, pelvic inflammatory disease, PID, retained products of conception, obstetric endometritis, nonobstetric endometritis, salpingitis, Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, group B Streptococcus, Chlamydia, Enterococcus, cesarean delivery, bacterial vaginosis

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Contributor Information and Disclosures

Author

Gema T Simmons, MD, Consulting Staff, Department of Obstetrics and Gynecology, Alegent Health
Gema T Simmons, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Colposcopy and Cervical Pathology, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Anthony Charles Sciscione, DO, Director, Division of Maternal-Fetal Medicine, Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine
Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Antonio V Sison, MD, Medical Director, Ob/Gyn Group, Robert Wood Johnson University Hospital at Hamilton
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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