Obstetric Antibiotic Guidance

Clinical features

Signs of sepsis with no obvious localising symptoms

Investigations

Please ensure cultures are sent from likely sites of infection. Consider:

• Blood cultures
• High vaginal swab
• Wound swab
• Urine- MSU or CSU
• CXR and sputum culture
• Throat swab for bacterial culture.
• Viral throat swab if  respiratory symptoms present

Treatment

Antenatal 

Cefuroxime 1.5g TDS IV

Plus

Metronidazole 500mg TDS IV

SEVERE PENICILLIN ALLERGY:

Clindamycin 900mg TDS IV

Plus

Gentamicin Dosing as per calculator 

Postnatal 

Co-amoxiclav 1.2g TDS IV

MILD PENICILLIN ALLERGY

Cefuroxime 1.5g TDS IV

Plus

Metronidazole 500mg TDS IV

SEVERE PENICILLIN ALLERGY

Clindamycin 900mg TDS IV

Plus

Gentamicin Dosing as per calculator

Clinical features

• Abdominal pain
• Rapid onset of sepsis and development of organ dysfunction
• Septic shock including renal failure and acute respiratory distress syndrome
• Rash
• Sore throat
• Often family member will have URTI

Treatment

Initial empirical treatment is likely to be as for sepsis of unknown origin. However, if the patient is at high risk of Group A Strep or there are particular signs and symptoms which are suggestive of this then consider addition of:

IV clindamycin 1.2g QDSin discussion with microbiology.

If either mother or baby develops suspected or confirmed Group A Strep during the first 28 days of life, antibiotics should be administered

Microbiology will report to infection control team

All patients with Group A Strep should be placed in isolation with contact precautions until they have received a minimum of 48hrs of effective antibiotics

Clinical features

• Lower abdominal pain
• Cramping / tightening
• Uterine tenderness
• Offensive liquor

Treatment

Cefuroxime 1.5g TDS IV

Plus

Metronidazole 500mg TDS IV

If very systemically unwell consider addition of IV gentamicin (as per calculator)

HOWEVER – will also need to consider need for delivery

Total duration: 7 days (may be able to consider IV to oral switch when improving

Clinical Features

• Lower abdominal pain
• Uterine tenderness
• Offensive/heavy lochia

Investigations

Send a high vaginal swab

Treatment

Systemically well   

Co-amoxiclav 625mg TDS PO

Mild penicillin allergy:

Cefalexin 500mg TDS PO

Plus

Metronidazole 400mg TDS PO

Severe penicillin allergy:

Discuss with Microbiology

Systemically unwell  

Co-amoxiclav 1.2g TDS IV

True penicillin allergy:

Clindamycin 900mg TDS IV

Plus

Gentamicin (as per calculator)

Duration: 7 days

Clinical features

• Pain
• Purulent discharge
• Dehiscence

Dehiscence likely to heal by 2ry intention. Very rarely requires re-suturing

Treatment

Systemically well    

Co-amoxiclav 625mg TDS PO

True penicillin allergy:

Clindamycin 300mg QDS PO

Systemically unwell 

Co-amociclav 1.2g TDS IV

True penicillin allergy:

Clindamycin 900mg TDS IV

Total duration: 7 days

Clinical features

• Erythema
• Warmth
• Swelling
• Tenderness
• Palpable collection

Wound swab if purulent discharge (not skin swab)

Treatment

Systemically well      

Flucloxacillin 1g QDS PO

True penicillin allergy:

Clindamycin 300mg QDS PO

Systemically unwell 

Flucloxacillin 1-2g QDS IV (higher dose in more unwell patients or increased BMI)

True penicillin allergy:

Clindamycin 900mg TDS IV

Total duration: 7 days

Clinical features

• Breast engorgement
• Pain
• Erythema
• Palpable lump

If palpable lump doesn’t respond to breast being emptied or pointing - consider breast abscess.

Arrange ultrasound scan and discussion with breast surgeons.

Treatment

Systemically well    

Flucloxacillin 1g QDS PO

True penicillin allergy:

Clindamycin 300mg QDS PO

Systemically unwell   

Flucloxacillin 1-2g QDS IV (higher dose in more unwell patients or increased BMI)

True penicillin allergy:

Clindamycin 900mg TDS IV

Total duration: 7 days

Clinical features

• Dysuria
• Lower abdominal pain
• Frequency
• Haematuria
• Flank pain / tenderness
• Urinary nitrites

Leucocytes are a common finding and unless symptomatic should not have treatment empirically but an MSU sent.

If Group B Streptococcus in any urine culture during pregnancy - should be treated with IV antibiotics in labour.

Treatment

Systemically well 

Nitrofurantoin 50mg QDS PO (avoid in third trimester)

Or

Cefalexin 500mg TDS PO

Systemically unwell      

ANTENATAL

Cefuroxime 750mg TDS IV (1.5g TDS IV for severe infection)

POSTNATAL

Amoxicillin 1g TDS IV

Plus

Gentamicin (as per calculator)

Gentamicin (monotherapy)

Total duration: 7 days

Clinical features

• Cough
• Green/yellow sputum
• Tachypnoea
• Pleuritic pain

Send sputum sample if possible

Send a viral throat swab

Treatment

Systemically well    

Amoxicillin 1g TDS PO

PLUS consider adding Clarithromycin 500mg BD PO if community acquired pneumonia and benefit outweighs risk

True penicillin allergy:

Consider Clarithromycin as above; otherwise discuss with Microbiology

Systemically unwell 

Amoxicillin 1g TDS IV

PLUS consider adding Clarithromycin 500mg BD PO if community acquired pneumonia and benefit outweighs risk

True penicillin allergy:

Vancomycin IV Dose as per calculator

PLUS Consider Clarithromycin as above; otherwise discuss with Microbiology

Total duration: 7 days

Clinical features

• Cough
• Sore throat
• Malaise
• Fever

May have GI symptoms

Check whether vaccinated

Take a viral throat swab

Treatment

Oseltamivir 75mg BD PO

Duration: 5 days

• Single IV dose
  • Consider repeat dosing in major haemorrhage
• If MRSA colonised, then give IN ADDITION to the antibiotics below a single dose of Teicoplanin post-cord clamping:
  • Booking weight < 70kg - 400mg
  • Booking weight 70kg or over - 800mg

Perineal tears

Cefuroxime 1.5g

PLUS

Metronidazole 500mg

Severe cephalosporin or penicillin allergy:

Clindamycin (900mg for booking BMI < 30, otherwise 1200mg, as for C-section)

PLUS

Gentamicin (see below)

MROP

May be required - discuss with surgeon

Antibiotic choice and dose as for perineal tears

Group B Streptococcus (GBS) is recognised as the most frequent cause of early illness (<7 days of age) in newborns and a cause of puerperal sepsis. ~21% of pregnant women carry GBS.  1:2000 newborns are diagnosed with GBS infection.

Newborns acquire GBS through vertical transmission. They are colonised as they pass through the birth canal. Colonised babies are asymptomatic; EoGBS occurs when the colonising bacteria become invasive.

Guidance on screening, risk factors, care of the neonate and midwifery care are available in the full departmental version of this guidance. 

Treatment

Antenatal

Women who are symptomatic of an infection should receive treatment

A positive MSSU with GBS should be treated (as per sensitivities from Microbiology result, using antibiotics appropriate in pregnancy and considering allergies).

If GBS is detected on a vaginal swab, treatment with oral antibiotics is not indicated as such treatment does not lower the likelihood of colonisation at the time of labour.

Intrapartum

• Immediate augmentation of labour should be offered to women known to be colonised with GBS presenting with an SRM >37wks, and they should be offered immediate intrapartum antibiotic prophylaxis (IAP)
• Women who have been detected to be colonised in pregnancy should be offered IAP when presenting in labour
• Women who are pyrexial (38^°C or greater) in labour should be offered a broad-spectrum antibiotic regimen, as per local protocol, which should cover GBS
• ALL women in confirmed preterm labour (with or without a history of preterm ruptured membranes) should receive IAP

Administer antibiotics as soon as possible after the onset of labour

First Choice

BENZYLPENICILLIN IV

3g loading dose and then 1.5g, 4-hourly, until delivery

Penicillin allergy (mild, i.e. no anaphylaxis, angioedema, respiratory distress or urticaria)

CEFUROXIME IV

1.5g loading dose followed by 750mg every 8 hours

Penicillin allergy (severe)

If GBS isolate is known to be sensitive to clindamycin, prescribe this

CLINDAMYCIN IV

900mg loading dose followed by 600mg every 12 hours

If GBS isolate is known to be resistant to clindamycin or the sensitivities are not known, prescribe teicoplanin

TEICOPLANIN IV

12mg/kg (based on most recent weight and rounded to nearest 100mg). Maximum dose 800mg.

Dosed 12 hourly for first 3 doses, then 24 hourly

It is important to give this slowly. Give over 3-5 minutes as a slow IV bolus or over 30 minutes as an IV infusion

Waterbirth

Women colonised with GBS can have a waterbirth. However it is essential that women understand that the IV access required for IAP will be removed after each dose of IAP in line with infection control policies, while she is using the pool

C-section

Women undergoing caesarean section in the absence of membrane rupture do not require antibiotic prophylaxis for GBS. Routine pre-operative antibiotics will be administered