How to treat endometritis?

Treatment of Endometritis

Endometritis should be treated with broad-spectrum antibiotics that cover Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci, with the recommended regimen being cefoxitin plus doxycycline for hospitalized patients or clindamycin plus gentamicin for severe cases. 1, 2

Diagnosis of Endometritis

Before initiating treatment, confirm the diagnosis based on:

Minimum Criteria

• Uterine/adnexal tenderness
• Cervical motion tenderness 1

Supporting Criteria

• Oral temperature >101°F (>38.3°C)
• Abnormal cervical or vaginal mucopurulent discharge
• Presence of white blood cells on saline microscopy of vaginal secretions
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein
• Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 1

Definitive Criteria (if needed)

• Endometrial biopsy with histopathologic evidence of endometritis
• Transvaginal sonography showing thickened, fluid-filled tubes with or without free pelvic fluid
• Laparoscopic abnormalities consistent with pelvic inflammatory disease 1

Treatment Regimens

Inpatient Treatment (Recommended for Severe Cases)

First-line regimen:

• Cefoxitin 2g IV every 6 hours OR cefotetan 2g IV every 12 hours
• PLUS Doxycycline 100mg orally/IV every 12 hours 2

Alternative regimen:

• Clindamycin 900mg IV every 8 hours
• PLUS Gentamicin loading dose IV/IM (2mg/kg) followed by maintenance dose (1.5mg/kg) every 8 hours 2

Continue parenteral therapy for at least 24-48 hours after clinical improvement, then transition to oral therapy to complete 10-14 days total treatment 2.

Oral Continuation Therapy

• Doxycycline 100mg orally twice daily to complete 10-14 days total
• OR Clindamycin 450mg orally 4 times daily to complete 10-14 days total 2

Outpatient Treatment (For Mild to Moderate Cases)

• Cefoxitin 2g IM as a single dose OR ceftriaxone 500mg IM as a single dose
• PLUS Doxycycline 100mg orally twice daily for 14 days
• WITH Metronidazole 500mg orally twice daily for 14 days 2, 3

Criteria for Hospitalization

Hospitalization is recommended when:

• Surgical emergencies (e.g., appendicitis) cannot be excluded
• Patient is pregnant
• Patient does not respond clinically to oral antimicrobial therapy
• Patient is unable to follow or tolerate an outpatient regimen
• Patient has severe illness, nausea and vomiting, or high fever
• Patient has a tubo-ovarian abscess 1, 2

Management of Complications

Pelvic Abscess Management

• For patients with pelvic abscesses, antibiotic therapy alone may be insufficient
• Consider surgical drainage or image-guided drainage if:
  • No clinical improvement within 72 hours of antibiotic therapy
  • Abscess is large or well-defined 2

Follow-up and Partner Treatment

• Reevaluate patients within 72 hours to ensure clinical improvement 2
• Sex partners should be referred for evaluation and empirically treated with regimens effective against C. trachomatis and N. gonorrhoeae 2

Important Considerations

• Treatment should be initiated as soon as the presumptive diagnosis is made to prevent long-term sequelae 1
• The combination of clindamycin and gentamicin has been shown to be more effective than other regimens in treating endometritis 4
• Regimens with good activity against penicillin-resistant anaerobic bacteria (like Bacteroides fragilis) are superior to those with poor activity 5, 4
• Inadequate duration of therapy can lead to treatment failure; a full 10-14 days of total antibiotic treatment is essential 2

Emerging Treatments

While not yet standard of care, research suggests that vaginal microbiota transplantation (VMT) may be a promising noninvasive approach for endometritis treatment in the future, particularly for cases associated with microbial imbalance 6.