What is the recommended treatment for postpartum endometritis?

Treatment of Postpartum Endometritis

The recommended first-line treatment for postpartum endometritis is intravenous clindamycin plus gentamicin, which has demonstrated superior efficacy compared to other antibiotic regimens. 1, 2

Definition and Etiology

• Postpartum endometritis is an infection of the endometrial lining that occurs after delivery, most commonly following cesarean section, when vaginal organisms invade the endometrial cavity during labor and delivery 1
• The condition is typically polymicrobial, involving aerobic, facultative, and obligate anaerobic gram-negative bacteria as well as gram-positive bacteria 3
• Major risk factors include prolonged labor with ruptured membranes (>6 hours), cesarean delivery, and bacterial vaginosis 3, 4

Recommended Treatment Regimens

First-Line Therapy

• Clindamycin plus gentamicin is the gold standard treatment for postpartum endometritis 2, 1
  • This combination provides excellent coverage against penicillin-resistant anaerobic bacteria, which is crucial for successful treatment 1
  • Once-daily dosing of gentamicin has shown fewer treatment failures compared to thrice-daily dosing 1

Alternative Regimens

• Ticarcillin/clavulanate has shown similar cure rates to clindamycin plus gentamicin 3
• Cefoxitin has demonstrated efficacy in clinical trials with comparable results to other regimens 3, 5
• FDA-approved cefoxitin has shown effectiveness in preventing endometritis in high-risk cesarean deliveries, with significant reduction in infection rates compared to placebo (5.2% vs 27.6%) 5

Treatment Considerations

• Regimens with good activity against penicillin-resistant anaerobic bacteria are significantly more effective than those with poor activity (treatment failure 1.94 times more likely with poor coverage) 1
• Continued oral antibiotic therapy after clinical improvement with intravenous antibiotics has not been proven to provide additional benefit 1, 6
• Treatment can be discontinued once the patient is afebrile without continuing oral antibiotics 2
• Treatment failure occurs in approximately 10% of cases and should trigger investigation for other infectious complications 2

Special Considerations

Wound Infections

• Clindamycin plus aminoglycoside regimens have shown fewer wound infections compared to cephalosporin regimens (RR 0.53,95% CI 0.30 to 0.93) 1
• Genital mycoplasmas, which are usually resistant to penicillins and cephalosporins, are commonly isolated from infected wounds following cesarean section 7

Treatment Failure

• If treatment failure occurs, investigate for:
  • Wound infection, which is a common cause of antimicrobial failure 7
  • Other infectious complications 2
• Prolonged fever of undetermined etiology may require extended antibiotic therapy, with or without heparin 2

Prevention

• Prophylactic antibiotics reduce the risk of postpartum endometritis by approximately 60% 2
• Intravenous antibiotics should be administered within 60 minutes before cesarean delivery skin incision 4
• Vaginal preparation with povidone-iodine solution before cesarean delivery in women in labor or with ruptured membranes reduces the risk of infectious complications, including endometritis (from 8.3% to 4.3%) 4

By following these evidence-based recommendations, clinicians can effectively manage postpartum endometritis and reduce associated maternal morbidity.