Medication Summary
Antibiotics are the mainstay of treatment. Pain medications also are important, because patients often have discomfort. Patients with septic pelvic thrombophlebitis must undergo anticoagulation therapy, and they should receive broad-spectrum antibiotics.
Antibiotics
Class Summary
Antibiotic coverage for Bacteroides, group B and A streptococci, Enterobacteriaceae organisms, and Chlamydia trachomatis in endometritis is suggested. Wound and episiotomy site infections require broad-spectrum antibiotics as well, because of the polymicrobial nature of the local flora. Consider coverage primarily for Staphylococcus aureus infection in postpartum mastitis.
Cefoxitin
Second-generation cephalosporin indicated for gram-positive coccal and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin. Must be used with clindamycin or doxycycline and an aminoglycoside for the treatment of endometritis, for which it is a drug of choice. Particularly important in early postpartum (first 48 h) infections.
Doxycycline
Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Must be used with other drugs for endometritis. Used often for outpatient therapy for late postpartum (48 h to 6 wk after delivery) treatment.
Gentamicin (Garamycin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used with an agent against gram-positive organisms in treatment of endometritis. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous and adjusted on the basis of CrCl and changes in volume of distribution. Gentamicin may be given IV/IM.
Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it binds preferentially to the 50S ribosomal subunit, causing bacterial growth inhibition. Must be used with other drugs in the treatment of endometritis. Second drug of choice, after dicloxacillin, in postpartum mastitis.
Dicloxacillin
Bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. Primary drug of choice used for postpartum mastitis to cover S aureus.
Metronidazole
Used with heparin and third-generation parenteral cephalosporin in the treatment of septic pelvic vein thrombophlebitis to cover streptococci and Bacteroides and Enterobacteriaceae species.
Cephalexin
First-generation cephalosporin used to cover S aureus in mastitis. Encourage the mother to continue breastfeeding to shorten duration of symptoms. Another DOC for postpartum mastitis.
