Treatment of Postpartum Endometritis
Abstract & Commentary
Synopsis: A regimen of clindamycin-gentamicin is an effective treatment for most women with post-cesarean endometritis and the addition of ampicillin or vancomycin will cure 94% of these patients.
Source: Brumfield CG, et al. Am J Obstet Gynecol 2000;182:1147-1151.
To evaluate the efficacy of antibiotic treatment consisting of gentamicin plus clindamycin for post-cesarean endometritis, Brumfield and associates studied the outcomes of 1643 women who delivered at their institution between 1993-1996. Endometritis was diagnosed as a persistent fever more than 104o F 24 hours after delivery, as well as one or more of the following: uterine tenderness, tachycardia, foul-smelling lochia, or an elevated maternal white count. Endometritis was diagnosed in 322 (20%) of the study group. Of that group, 174 patients (54%) were cured with gentamicin and clindamycin—that is, they were afebrile after 48 hours of antibiotic treatment, and had resolution of clinical signs and symptoms of infection. In 129 patients (40%) who remained febrile, ampicillin or vancomycin in penicillin-allergic patients was added to the clindamycin-gentamicin regimen, and these patients were cured. In only 19 (6%) of the 322 women with post-cesarean endometritis did fever persist despite triple antibiotics. In this group, six had a wound complication, 12 were thought to have a resistant organism and responded to an antibiotic program of ampicillin, penicillin G, or vancomycin with chloramphenicol, and one woman had an infected hematoma.
Brumfield et al conclude that a regimen of clindamycin-gentamicin is an effective treatment for most women with post-cesarean endometritis and that the addition of ampicillin or vancomycin will cure 94% of these patients. In women who remain febrile, wound infection, antibiotic resistance, or an infected pelvic hematoma should be suspected.
Comment by Steven G. Gabbe, MD
This prospective investigation by Brumfield et al demonstrates a simple yet effective approach to the treatment of post-cesarean endometritis. The protocol used by these clinicians calls for the prophylactic administration of a first-generation cephalosporin at the time of umbilical cord clamping. Those women diagnosed with endometritis received intravenous gentamicin and clindamycin. Maternal gentamicin levels were obtained only in women with a serum creatinine greater than 1.1 mg/dl. Blood cultures and endometrial cultures were not part of the routine evaluation of these patients. If women remained febrile after 48 hours of antibiotic treatment, ampicillin or vancomycin were added. Ninety-four percent of women treated in his way were cured. Brumfield et al used chloramphenicol in patients suspected to have an antibiotic-resistant organism. Because this agent has been associated with irreversible bone-marrow failure in rare cases, imipenem with cilastatin has been recommended in this setting. Brumfield et al did obtain an abdominal-pelvic CT scan in women who remained febrile despite triple antibiotic treatment and whose pelvic examination suggested a hematoma or abscess, or in women who did not respond to the addition of chloramphenicol. Only five of the 322 patients met these criteria, and only one had a significant abnormality. Of note, Brumfield et al did not use heparin therapy for suspected septic pelvic thrombophlebitis unless an ovarian vein or vena caval thrombus was seen on CT scan.
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