What is the recommended treatment for infection after a cesarean section (C-section)?

Treatment of Infection After Cesarean Section

For post-cesarean section infections, the first-line treatment is clindamycin plus gentamicin, which has demonstrated significantly fewer treatment failures compared to other regimens. 1

Diagnosis of Post-Cesarean Infection

• Fever greater than 100.4°F (38.0°C) on more than two occasions more than 6 hours apart after the first 24 hours postpartum
• Common presentations include:
  • Abdominal pain
  • Uterine tenderness
  • Foul-smelling lochia
  • Possible chills, back pain, pelvic spasms, and passing of clots 1

Risk Factors

• Cesarean delivery (especially unplanned) is the most significant risk factor 1
• Other risk factors include:
  • Prolonged labor
  • Prolonged rupture of membranes
  • Multiple vaginal examinations 1

Treatment Algorithm

First-Line Treatment

• Clindamycin (600-900 mg IV every 8 hours) plus Gentamicin (5 mg/kg IV daily) 1
  • This combination provides coverage for aerobic and anaerobic polymicrobial flora including Staphylococcus aureus, intestinal flora, and vaginal flora

For Persistent Fever Despite Appropriate Treatment

• Consider septic pelvic thrombophlebitis
• Continue broad-spectrum antibiotics (clindamycin, gentamicin, and ampicillin)
• Consider imaging with contrast-enhanced CT or MRI to identify filling defects in pelvic veins 1

For Wound Infections

• Drainage of any collections
• Consider broader coverage if MRSA is suspected
• For obese women with surgical site infections:
  • Consider adding oral cephalexin (500 mg) and metronidazole (500 mg) every 8 hours for 48 hours following initial IV treatment 2

Special Considerations

For Severe Infections

• Consider using cefotaxime for severe infections:
  • Dosage: 1-2 grams every 8 hours IM or IV
  • For life-threatening infections: up to 2 grams every 4 hours IV 3

For Obese Patients

• Higher antibiotic doses may be required
• Consider extended post-operative prophylaxis with oral antibiotics 2
• A randomized clinical trial showed that a 48-hour course of oral cephalexin and metronidazole reduced surgical site infection rates from 15.4% to 6.4% in obese women after cesarean delivery 2

Prevention of Post-Cesarean Infections

• Administer antibiotic prophylaxis within 60 minutes before skin incision
• First-generation cephalosporin (e.g., cefazolin) is recommended for all women
• For women in labor or with ruptured membranes, add azithromycin for additional reduction in postoperative infections 4, 1
• Chlorhexidine-alcohol is preferred for abdominal skin cleansing
• Vaginal preparation with povidone-iodine solution should be considered 4

Important Caveats

• Initiate antibiotics immediately upon diagnosis to prevent long-term sequelae 1
• For patients with penicillin allergies, alternative regimens should be considered
• Avoid fluoroquinolones in urological procedures as they have no place for antibiotic prophylaxis in this setting 4
• Single-dose prophylactic regimens administered after cord clamping are as effective as multiple-dose regimens for prevention 5
• Consider testing for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and HIV in patients with suspected endometritis 1

By following this evidence-based approach to treating post-cesarean infections, clinicians can effectively reduce morbidity and improve outcomes for affected women.