Ampicillin added to regimen with sepsis syndrome or suspected enterococcal infection Clindamycin + aztreonam Gentamicin substitute for renal insuficiency Extended-spectrum penicillins Piperacillin, piperacillin tazobactam, ampicillin/sulbactam, ticarcillin/clavulanate Cephalosporins Cefotetan, cefoxitin, cefotaxime
Vancomycin Added to other regimens for suspected Staphylococcus aureus infections Metronidazole + Metronidazole has excellent anaerobic coverage ampicillin + gentamicin Carbapenems Imipenemlcilastatin, meropenem, ertapenem .eserved for special indications therapy, some add ampicillin to the clindamycin-gentamicin regimen, either initially or if there is no response by 48 to 72 hours (Brumfield, 2000).
Many authorities recommend that serum gentamicin levels be periodically monitored. At Parkland Hospital, we do not routinely do so if the woman has normal renal function. Oncedaily dosing and multiple-dosing with gentamicin both provide adequate serum levels, and either method has similar cure rates (Livingston, 2003). Because of potential nephrotoxicity and ototoxicity with gentamicin in the event of diminished glomerular iltration, some have recommended a combination of clindamycin and a second-generation cephalosporin to treat such women. Others recommend a combination of clindamycin and aztreonam, which is a monobactam compound with activity similar to the aminoglycosides.
The spectra of 3-lactam antimicrobials include activity against many anaerobic pathogens. Some examples include cephalosporins such as cefoxitin, cefotetan, cefotaxime, and ceftriaxone, as well as extended-spectrum penicillins such as piperacillin, ticarcillin, and mezlocillin. 3-Lactam antimicrobials are inherently safe and, except for allergic reactions, are free of major toxicity. The 3-lactamase inhibitors clavulanic acid, sulbactam, and tazobactam have been combined with ampicillin, amoxicillin, ticarcillin, and piperacillin to extend their spectra. Metronidazole has superior in vitro activity against most anaerobes. This agent given with ampicillin and an aminoglycoside provides coverage against most organisms encountered in serious pelvic infections. Metronidazole is also used to treat Clostridium dficile colitis.
lmpenem and similar antimicrobials are in the carbapenem family. hese ofer broad-spectrum coverage against most organisms associated with metritis. Imipenem is used in combination with cilastatin, which inhibits its renal metabolism. Preliminary indings with ertapenem indicated suboptimal outcomes (Brown, 2012). It seems reasonable from both a medical and an economic standpoint to reserve these drugs for serious nonobstetrical infections.
Vancomycin is a glycopeptide antimicrobial active against gram-positive bacteria. It is used in lieu of 3-lactam therapy for a patient with a type 1 allergic reaction and given for suspected infections due to Staphylococcus aureus and to treat C diicile colitis (Chap. 54, p. 1048).
The use of periprocedural antimicrobial prophylaxis is com mon in obstetrics. Even so, no rigorous studies have evalu delivery or manual removal of the placenta (Chongsomchai, 2014; Liabsuetrakul, 2017). But, as discussed, antimicrobial prophylaxis at the time of cesarean delivery has remarkably reduced the postoperative pelvic and wound infection rates.