What is the recommended antibiotic regimen for an episiotomy wound infection?

Recommended Antibiotic Regimen for Episiotomy Wound Infection

For episiotomy wound infections, a broad-spectrum antibiotic regimen of amoxicillin-clavulanic acid is recommended as first-line therapy, with alternative options including clindamycin plus either piperacillin-tazobactam or ceftriaxone plus metronidazole for more severe infections. 1

Initial Assessment and Management

• Evaluate for systemic signs of infection including fever >38.5°C, tachycardia >110 beats/minute, or erythema extending >5 cm beyond wound margins 2
• Obtain appropriate wound cultures from the base of the debrided wound before starting antibiotics to guide targeted therapy 2
• Ensure adequate surgical debridement of the infected episiotomy site, as this is essential alongside antibiotic therapy 1, 2
• Place a Foley catheter before initiating repair of severely infected wounds requiring surgical intervention 3

Antibiotic Regimen by Severity

Mild to Moderate Infections

• First-line: Amoxicillin-clavulanic acid (oral) 1
• Alternative options: Cloxacillin or cefalexin 1
• For penicillin allergy: Clindamycin 3

Moderate to Severe Infections

• First-line: Piperacillin-tazobactam or ampicillin-sulbactam (IV) 3, 1
• Alternative regimen: Ceftriaxone plus metronidazole (with or without vancomycin if MRSA is suspected) 3, 1
• For suspected MRSA: Add vancomycin, linezolid, or daptomycin 1

Severe Infections with Systemic Symptoms

• Vancomycin plus piperacillin-tazobactam or a carbapenem antimicrobial is recommended 3, 2
• For penicillin allergy: Clindamycin plus either a fluoroquinolone or aztreonam 3

Route of Administration and Duration

• For mild infections: Oral antibiotics for 5-7 days 1
• For moderate infections: Initial IV therapy with transition to oral when clinically improved 3, 2
• For severe infections: IV antibiotics until clinical improvement, typically 7-10 days total 3, 1
• Reassess after 48-72 hours and narrow therapy based on culture results and clinical response 2

Special Considerations

• Preoperative antibiotics should be administered before surgical repair of severely infected episiotomy wounds 3
• According to the American College of Obstetricians and Gynecologists, a second- or third-generation cephalosporin with metronidazole provides adequate coverage for both vaginal and bowel flora 3
• Consider adding gentamicin for broader gram-negative coverage in severe infections 3
• For patients with penicillin allergy, clindamycin is an appropriate alternative 3

Important Caveats and Pitfalls

• Avoid prolonged antibiotic courses as they increase risk of resistance without additional benefit 1, 2
• Ensure adequate anesthesia before surgical debridement of infected episiotomy wounds 3
• Consider surgical site preparation with povidone-iodine or chlorhexidine gluconate before repair of severely infected wounds 3
• Avoid fluoroquinolones when possible in postpartum women who are breastfeeding due to potential risks 1
• Remember that adequate surgical debridement is as important as antibiotic therapy for successful treatment 3, 2
• A Cochrane review found insufficient evidence to recommend routine antibiotic prophylaxis for episiotomy repair after normal birth, highlighting the importance of targeted therapy for established infections 4