What is the recommended management of intraamniotic infection (chorioamnionitis) in a term or near‑term pregnancy, including hospital admission, monitoring, antibiotic regimen (with considerations for beta‑lactam allergy), and delivery planning?

Management of Intraamniotic Infection (Chorioamnionitis)

Admit the patient immediately, start broad-spectrum IV antibiotics (ampicillin 2g IV then 1g every 4 hours plus gentamicin weight-based dosing) as soon as the diagnosis is made, and proceed to delivery without delay—antibiotics alone cannot cure the infection. 1

Diagnosis and Urgency

• Do not wait for maternal fever to make the diagnosis—intraamniotic infection can present without fever, particularly at earlier gestational ages, and treatment must begin when any sign of infection appears (maternal tachycardia >100 bpm, fetal tachycardia, purulent cervical discharge, uterine tenderness, or maternal leukocytosis). 1

• The clinical deterioration can be catastrophic: the median interval from first infection signs to maternal death is only 18 hours, making immediate recognition and treatment life-saving. 1, 2

• Never delay antibiotic initiation waiting for amniocentesis results or laboratory confirmation—clinical bedside assessment drives management. 1

Antibiotic Regimen

Standard regimen (no allergy):

• Ampicillin 2g IV loading dose, then 1g IV every 4 hours until delivery, PLUS
• Gentamicin loading dose (typically 5-7 mg/kg) followed by weight-based maintenance dosing every 8-24 hours depending on institutional protocol. 1

Non-severe penicillin allergy:

• Cefazolin 2g IV loading dose, then 1g IV every 8 hours until delivery, PLUS
• Gentamicin (same dosing as above). 1

Severe penicillin allergy (anaphylaxis, angioedema, severe rash):

• Clindamycin 900 mg IV every 8 hours until delivery, OR

• Vancomycin 1g IV every 12 hours until delivery, PLUS

• Gentamicin (same dosing as above). 1

• This broad-spectrum coverage addresses the polymicrobial nature of intraamniotic infection (aerobic and anaerobic organisms including Group B Streptococcus and E. coli). 1

Delivery Planning

• Proceed to delivery immediately after starting antibiotics—the infection cannot be eradicated by antimicrobials alone and requires evacuation of the infected uterine contents. 1, 3

• The route of delivery is determined by standard obstetric indications (cervical exam, fetal presentation, prior uterine surgery), not by the presence of infection itself. 1

• Cesarean delivery offers no fetal advantage and increases maternal morbidity (higher rates of endometritis, wound infection, pelvic abscess, and hemorrhage). 1, 4, 5

• Intraamniotic infection alone is rarely, if ever, an indication for cesarean section. 4, 5

Postpartum Antibiotic Continuation

• After vaginal delivery: Discontinue antibiotics once delivery is complete—no postpartum continuation is needed. 1

• After cesarean delivery: Add clindamycin 900 mg IV every 8 hours (or metronidazole 500 mg IV every 8 hours) for anaerobic coverage and continue the full regimen until the patient is afebrile for 24 hours. 1

• One study showed shorter hospital stays with abbreviated postpartum antibiotic courses, but current guidelines support treatment until clinical improvement. 6

Neonatal Management

Well-appearing newborns:

• Obtain limited evaluation: blood culture and complete blood count with differential. 1
• Start empirical IV antibiotics immediately: ampicillin (for GBS coverage) plus gentamicin or another agent active against E. coli. 1
• The CBC is more sensitive when drawn 6-12 hours after birth, but do not delay antibiotic initiation waiting for this timing. 1
• Discontinue antibiotics if blood culture remains negative at 48 hours and the infant remains clinically well. 1

Newborns with any sign of sepsis (respiratory distress, temperature instability, poor feeding, lethargy, hypotonia):

• Perform full diagnostic work-up: blood culture, CBC with differential, chest radiograph if respiratory symptoms present, and lumbar puncture if the infant is hemodynamically stable. 1
• Begin broad-spectrum empirical antibiotics immediately (ampicillin plus gentamicin or cefotaxime). 1
• Notify neonatal providers at delivery so they can prepare for immediate evaluation. 4, 5

Common Pitfalls to Avoid

• Waiting for fever: Maternal fever may be absent, especially in preterm gestations—treat based on other clinical signs. 1, 7

• Delaying antibiotics for test results: Amniocentesis, cultures, or laboratory values should never postpone treatment initiation. 1

• Attempting conservative management: Expectant management with antibiotics alone fails—delivery is mandatory. 1, 3

• Performing cesarean for infection alone: This increases maternal morbidity (wound infection, endometritis, hemorrhage) without neonatal benefit. 1, 4

• Underestimating the speed of deterioration: Maternal sepsis can progress to death within 18 hours of initial signs; aggressive early treatment is non-negotiable. 1, 2

Monitoring During Treatment

• Initiate antibiotics within 3 hours of fever recognition, or within 1 hour if septic shock is suspected. 1

• Obtain blood cultures before antibiotic administration when feasible, but do not delay treatment. 1

• Monitor maternal vital signs closely for signs of septic shock (hypotension, tachycardia, altered mental status, oliguria). 1

• Anticipate increased risk of postpartum hemorrhage (uterine atony occurs more frequently with chorioamnionitis) and have uterotonics readily available. 4, 5

• Women with chorioamnionitis have a 2-3 times higher risk of cesarean delivery due to dysfunctional labor patterns. 6, 4