Summarizing use of antimicrobial agents (AMA) in Obstetrics & Gynaecology

Summarizing use of antimicrobial agents (AMA) in Obstetrics & Gynaecology
S. no. Clinical condition / procedure Common pathogens Preferred AMA Alternate AMA Comments
1. Vaginal delivery:
For GBS (Group B Streptococcus) prophylaxis in women who do not know their GBS status in the following situations:
  • Preterm labour (< 37 wks)
  • Prolonged rupture of membranes (>18 hrs)
  • Fever during labour or chorioamnionitis
  • History of the previous baby with GBS infection
  • Bladder or kidney infection due to GBS
 Group B Streptococci Ampicillin Cefazolin ;
If allergic, vancomycin 		Not recommended routinely for normal vaginal delivery Delivery is considered akin to drainage of an abscess as the fetus and placenta is removed which are the nidus of infection  
2. 3rd or 4th degree Perineal tear Gram positive
S. aureus, Gram negative
Enterobacteriaceae
Anaerobes 		Cefoxitin or cefotetan Cefazolin plus metronidazole OR cefuroxime plus metronidazole OR amoxicillin-clavulanic acid if allergic, clindamycin Prophylaxis is considered to prevent adverse outcomes arising from infection e.g. fistulas
3. Preterm pre-labour rupture of membranes Gram positive GBS
Gram negative: Enteric gram-negative bacilli, Ureaplasma, mycoplasma Anaerobes (including G. vaginalis)		 Ampicillin followed by oral amoxycillin PLUS oral erythromycin  If erythromycin 333 mg is not available, use erythromycin stearate  ­­­­
4. Caesarean delivery Gram positiveaerobes:GBS, Staphylococci, Enterococci   Cefazolin + azithromycin   If allergic, clindamycin + gentamicin Only single dose recommended
5. Rescue cervical encerclage Vaginal flora Inj ampicillin   Only single dose recommended To prevent ascending infection from  vaginal flora to exposed membranes
6. Puerperal sepsis / Septic abortion / chorioamnionitis Gram positive: Streptococci (A, B, D), S.aureus
Gram negative: E.coli, Enterobacteriaceae including
Klebsiella,
Enterobacter,
Citrobacter,
Pseudomonas aeruginosa,
Proteus mirabilis,
Gardnerella vaginalis,
Bacteroides
Clostridium perfringens, Anaerobes 		 Inj. piperacillin-tazobactam Clindamycin + gentamicin 
If the patient is in septic shock, consider imipenem/meropenem with or without amikacin plus  vancomycin, or to cover MRSA       		   Usually polymicrobial  
7. Hysterectomy (AH, VH, laparoscopic) and surgeries for pelvic organ prolapse and/or stress urinary incontinence Polymicrobial: Gram-positive: Staphylococci, Gram Negative: Enterococci, aerobic gram-negative, Anaerobes Bacteroides  spp, Cefazolin Cefuroxime +/- metronidazole OR   If allergic to cephalosporin, use clindamycin  + gentamycin Only single dose recommended
In AH & LH, the vagina is opened at end of procedure & exposure to vaginal flora is brief. In VH, there is greatercolonisation of the surgical site. In AH for cancer with resection of upper vagina, there may be colonization with anaerobes. In such cases, metronidazole 500 mg IV may be added.
If BV is suspected, oral metronidazole 500mg BD for 7 days is given, beginning at least 4 days  pre-op
8. Laparoscopy (uterus and/or vagina not entered) / Hysteroscopy / Ectopic pregnancy Skin commensals: S. aureus Cefazolin  Cefuroxime
If allergic, use clindamycin 		Only single dose recommended
9. Abortions (medical and surgical) Chlamydia, Neisseria gonorrhoeae Azithromycin plus metronidazole Doxycycline plus metronidazole No prophylaxis for missed / incomplete abortion
10. HSG Chlamydia, Neisseria gonorrhoeae Doxycycline   Doxycycline  continued twice daily for 5 days if there is a history of PID  or fallopian tubes are  dilated at the procedure
11. Pelvic Inflammatory disease
(mild to moderate)		 N. gonorrhoeae, C. trachomatis and anaerobes.  E. coli, Bacteroides GBS, GAS, S. aureus NACO based:
Tab. Cefixime
PLUS
Tab. Metronidazole
PLUS
Cap. Doxycycline		 CDC based:
Levofloxacin
with
Metronidazole OR Ceftriaxone
plus
Doxycycline with or without
Metronidazole
  •  
12. Pelvic Inflammatory disease
(severe) eg turbo-ovarian abscess, pelvic abscess		   Cefotetan
 PLUS

doxycycline 
  •  
Cefoxitin 
PLUS
Doxycycline 
  • OR Clindamycin  PLUS gentamicin   Or Piperacillin-tazobactam/imipenem (for severely ill patients)
 An attempt should be made to obtain cultures and de-escalate based on that.
Duration is two weeks but can be extended depending upon the clinical situation. Antibiotics may be altered after obtaining culture reports of pus/or blood
13. Vaginal candidiasis C. albicans,
C. glabrata,
C. tropicalis 		Tab Fluconazole
OR
local
Clotrimazole 		Miconazole, nystatin vaginal tablets/creams     Treat for 7 days in pregnancy, diabetes Recurrent infections: 150 mg Fluconazole  on day 1,4,7 then weekly for 6 months
14. Vaginal trichomoniasis T. vaginalis Tab.Secnidazole  OR Tab. Tinidazole
OR  Tab. Metronidazole 		      Alcohol avoided during treatment and 24 hours after metronidazole or 72 hours after completion of tinidazole to reduce the possibility of a disulfiram-like reaction. Partner treatment essential
15. Bacterial vaginosis Overgrowth of anaerobes (Gardnerella vaginalis) Metronidazole 
OR

Metronidazole gel
OR clindamycin Cream
Secnidazole 
OR Tinidazole

OR Tinidazole OR clindamycin 
OR clindamycin 
ovules 		Refrain from sexual activity or use condoms during the treatment. Clindamycin cream is oil-based and might weaken latex condoms