Approach Considerations
After making the diagnosis of endometritis and excluding other sources of infection, the physician should promptly initiate broad-spectrum antibiotics. Improvement will be noted within 48-72 hours in nearly 90% of women treated with an approved regimen.
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. Pregnant women with symptoms of bacterial vaginosis (BV) should be treated because BV is associated with adverse pregnancy outcomes. Although treatment has not been demonstrated to prevent these outcomes, treatment does reduce signs and symptoms of vaginal infection. [2]
In adolescents who undergo termination of pregnancy, subsequent endometritis with associated salpingitis poses a significant risk of infertility. Therefore, earlier and more aggressive antibiotic therapy is warranted in this group.
Surgical management is not usually necessary in acute endometritis in the obstetric population. Dilation and curettage may be advised for retained products of conception, however. In rare instances of overwhelming infection nonresponsive to conservative therapy, hysterectomy may be necessary as a life-saving intervention. [16]
Antibiotic Therapy
The combination of clindamycin and gentamicin administered intravenously every 8 hours has been considered the criterion standard treatment. Some studies have revealed adequate efficacy with once-daily dosing, as well. [17, 18, 19, 20] The combination of a second- or third-generation cephalosporin with metronidazole is another popular choice.
The CDC 2015 STD treatment guidelines include details of recommended antibiotic regimens. [1, 2]
In teenagers, postabortion endometritis may be caused by organisms that cause pelvic inflammatory disease (PID). The initial treatment regimen in these patients usually includes intravenous cefoxitin and doxycycline, in the same doses as for PID.
A trend toward the use of broad-spectrum monotherapy has emerged; these agents are generally effective in 80-90% of patients. Cephalosporins, extended-spectrum penicillins, and fluoroquinolones are used as monotherapy. [21]
Improvement is 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. If the physical examination findings are benign, the patient may be discharged at that time. Further outpatient antibiotic therapy has proved to be unnecessary. If the patient does not improve in the expected 48- to 72-hour period, reevaluate for complications such as abscess.
Prophylaxis
Prophylactic antibiotics reduce the incidence of postpartum febrile morbidity in patients undergoing cesarean delivery. Current research supports the use of preoperative administration of prophylactic antibiotics. [22, 23, 24, 25] Single-agent therapy with a first- or second-generation cephalosporin (eg, cefazolin) has been considered the best choice.
A joint publication by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) supports the administration of antibiotics prior to skin incision rather than immediately after cord clamping. However, current research is also assessing the use of extended-spectrum regimens with a cephalosporin plus either azithromycin or metronidazole after cord clamping. [26, 27, 28] Head-to-head comparisons between narrow-spectrum prophylaxis given before skin incision and extended-spectrum prophylaxis given after cord clamping still need to be done. [28]
A study by Ward et al found that the combination of cefazolin plus azithromycin when administered before skin incision was significantly more effective than the administration of cefazolin after cord clamping. [29]
A Cochrane database systematic review concluded that the use of vaginal chlorhexidine douching during labor does not prevent endometritis. [30] Preoperative use of povidone-iodine vaginal preparation prior to cesarean delivery appears to decrease the incidence of postcesarean endometritis but does not seem to decrease the overall risk of postoperative fever or wound infection.
A systematic review and meta-analysis by Caissutti et al reported that compared to the control group, vaginal cleansing (most commonly with 10% povidone-iodine) before cesarean delivery significantly lowered the incidence of endometritis (4.5% vs 8.8%; RR 0.52, 95% CI 0.37-0.72; 15 studies, 4,726 participants) and also lowered the risk of postoperative fever (9.4% vs 14.9%; RR 0.65, 95% CI 0.50-0.86; 11 studies, 4,098 participants). [31]
