Postpartum Antibiotics for Non-Institutional Delivery
For women who delivered in a non-institutional setting without complications, routine antibiotic prophylaxis is not recommended, as the evidence shows minimal benefit for uncomplicated vaginal births and antibiotics are not a substitute for proper infection prevention measures. 1
When Antibiotics Are NOT Indicated
Routine prophylaxis after uncomplicated vaginal delivery in non-institutional settings should be avoided, as the evidence demonstrates little to no reduction in urinary tract infections (RR 0.25,95% CI 0.05 to 1.19) or wound infections (RR 0.78,95% CI 0.31 to 1.96), and indiscriminate use contributes to antimicrobial resistance. 1
Women who had planned home births or non-institutional deliveries without labor complications, membrane rupture, or fever do not require prophylactic antibiotics. 1
When Antibiotics ARE Indicated
Group B Streptococcus (GBS) Considerations
If the woman was GBS-positive during pregnancy (35-37 weeks screening) but did not receive adequate intrapartum prophylaxis (at least 4 hours of IV antibiotics before delivery), she remains at standard postpartum risk but the newborn requires evaluation. 2
Postpartum antibiotics for the mother are not indicated solely for inadequate GBS prophylaxis; focus should be on neonatal evaluation. 2
Signs of Postpartum Infection Requiring Treatment
If postpartum endometritis develops (fever >38°C, uterine tenderness, foul-smelling lochia):
First-line treatment: IV clindamycin 900 mg every 8 hours PLUS gentamicin 5 mg/kg once daily until the patient is afebrile for 24-48 hours, then discontinue without oral antibiotics. 3, 4
This combination is the gold standard, most cost-effective, and allows once-daily gentamicin dosing. 4
Alternative: Ampicillin-sulbactam or piperacillin-tazobactam if the above regimen is unavailable. 4
If wound infection develops (episiotomy or perineal laceration):
Cephalexin 500 mg orally four times daily for 7 days is appropriate for mild infections. 5, 6
For severe infections with systemic symptoms: IV cefazolin 1-2 g every 8 hours or the clindamycin-gentamicin regimen above. 2, 3
If urinary tract infection/pyelonephritis develops:
Cephalexin 500 mg orally four times daily for 7-10 days for cystitis. 5, 6
For pyelonephritis: IV ceftriaxone 1-2 g daily until afebrile for 24 hours, then oral cephalexin to complete 10-14 days. 5, 6
If mastitis develops (breast tenderness, erythema, fever):
Dicloxacillin 500 mg orally four times daily for 10-14 days (covers Staphylococcus aureus). 5
If MRSA suspected or penicillin-allergic: Trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily (safe postpartum, avoid if breastfeeding jaundiced newborn). 6
Critical Pitfalls to Avoid
Never use amoxicillin-clavulanic acid in the immediate postpartum period as it is associated with increased risk of neonatal necrotizing enterocolitis. 7
Do not prescribe tetracyclines (doxycycline) or fluoroquinolones (ciprofloxacin) to breastfeeding mothers due to fetal/infant toxicity concerns. 5, 6
Avoid prophylactic antibiotics "just in case" for non-institutional deliveries, as this contributes to antimicrobial resistance without proven benefit. 1
If the woman develops fever >38°C within 24 hours of delivery, evaluate for endometritis, urinary tract infection, mastitis, and wound infection before starting empiric antibiotics. 3, 4
Monitoring Considerations
All breastfed infants should be monitored for gastrointestinal effects (diarrhea, candidiasis) when mothers receive antibiotics. 6
If treatment failure occurs (persistent fever after 48-72 hours of appropriate antibiotics), investigate for septic pelvic thrombophlebitis, wound abscess, or resistant organisms. 3, 4
Antibiotics in breast milk may cause falsely negative cultures if the infant requires sepsis evaluation. 6