Hospital Practice

ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20

Treatment of Postpartum Endometritis

Mark Martens M.D., Sebastian Faro M.D., Ph.D., Hunter Hammill M.D. &
Maurizio Maccato M.D.

To cite this article: Mark Martens M.D., Sebastian Faro M.D., Ph.D., Hunter Hammill M.D.
& Maurizio Maccato M.D. (1990) Treatment of Postpartum Endometritis, Hospital Practice,
25:sup4, 13-19, DOI: 10.1080/21548331.1990.11704111

To link to this article: http://dx.doi.org/10.1080/21548331.1990.11704111

Published online: 17 May 2016.

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Download by: [RMIT University Library] Date: 23 June 2016, At: 16:57
 Treatment of
Postpartum Endometritis
M A R K M ART E N 5, M. D., 5 E BA 5 TI AN FAR 0, M. D., PH. D., H U N T E R HA M M I L L, M. D.,
and MAURIZIO MACCATO, M.D.
University of Texas at Galveston and Bay/or College of Medicine
ecause of the polymicro-
B bial nature of postpartum
endometritis, typically in-
volving gram-negative and
gram-positive aerobic and an-
aerobic bacteria,L2 treatment
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has traditionally focused on
the use of clindamycin plus
an aminoglycoside.s-5 Although
,8-lactam antibiotics, such as
cefoxitin, cefotetan, imipenem,
mezlocillin, ticarcillin, pipera-
cillin, and ticarcillin/clavulanic
acid have been demonstrated
to be as effective as clinda-
mycin plus gentamicin, sin-
gle-agent therapy has not
gained wide acceptance. 6 - 12
Patients with ruptured mem-
branes who have been in labor
for prolonged periods and are
subsequently delivered by ce-
sarean section are at greatest
risk for developing postpartum
endometritis. Antibiotic pro-
phylaxis is commonly used for
these patients. 13·14 If endome-
tritis occurs despite prophy-
laxis, physicians commonly
assume the presence of a more
complex infection and pre-
scribe combination therapy.
Alternatively, when a patient
fails to respond favorably to a
single-agent therapeutic regi-
men, many physicians replace
that agent with clindamycin
plus gentamicin.
This common approach
stems from a lack of under-
standing of the effect of anti-
biotic prophylaxis on vaginal
microflora, 15 a failure to ap-
preciate the spectrum of ac-
tivity of ,8-lactam antibiotics,
In this study, cefoxitin
alone (2 gm, every 8
and failure to obtain culture hours) was generally suf-
specimens from the uterine ficient to cure postpartum
fundus and from venous blood endometritis, even when
as well as other suspected the patient had received
sites of infection. 16 prophylaxis with a /3-
With current practice in lactam antibiotic. When
mind, we undertook to deter- single-agent therapy fails,
mine if 1) cefoxitin would be
addition of ampicillin
effective therapy for postpar-
usually results in a prompt
tum endometritis in patients
who had received a cephalo-
clinical response.
sporin or penicillin for prophy-
laxis; 2) an every-eight-hour
regimen was appropriate for
such use of cefoxitin; and 3)
in patients failing initial ce-
foxitin therapy, cefoxitin could
be continued and supplement-
ed with an agent effective
against the isolated or sus-
pected resistant pathogens.
Patients and Protocol
The presence of one or more
of the following criteria de-
fined eligibility in the study:
an oral body temperature of
Dr. Martens is Director, Division of In-
38° C or higher on two occa- fectious Diseases, and Associate Pro-
sions, at least six hours apart fessor of Obstetrics/Gynecology, Uni-
and 24 hours after delivery; versity of Texas Medical School at
Galveston. Dr. Faro is Professor and
one oral body temperature of Vice Chairman, Department of Obstet-
at least 38.3° C; a white blood rics and Gynecology, and Director, In-
cell count of 14,000/mm3 or fectious Disease Section, Bay/or Col-
higher; a 10% or greater in- lege of Medicine, Houston. Drs.
Hammi/1 and Maccato are Assistant
crease in immature polymor- Professors of Obstetrics and Gynecol-
phonuclear leukocytes from ogy, Bay/or College of Medicine.
13

Table 1. Demographic Data
by Outcome of Postpartum
Patients with Endometritis
Cure Failure
N=45 N=7
(87%) (13%)
Age 24.6±5.6 22.4±3.6
Gravidity 2.3±1.5 2.4±1.3
Parity 1.9±1.1 1.9±0.8
Race
White 31 (69"-b) 5 (71%)
- - ---·-
Black 14 (31%)
---
2 (29"-b)
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baseline sample; tachycardia; a
markedly tender uterus; puru-
lent or foul-smelling lochia.
Fifty-two women entered the
study, having given written
informed consent approved by
the institutional review boards
of the participating hospitals.
None of the four women who
had vaginal deliveries, but 43
of the 48 patients who had
cesarean section deliveries,
received intravenous antibiot-
ic prophylaxis during delivery.
Cefoxitin was administered in-
travenously, 2 gm every eight
hours. Patients were consid-
ered cured if they were afe-
brile and asymptomatic fqr
more than 24 hours after ces-
Table 2. Clinical Characteristics by Outcome of
Postpartum Patients with Endometritis
Route of delivery
Cesarean
- - - - - - - - ------- - - - - - -
Vaginal
Maximum temperature (0 C)
WBC at diagnosis (cells/mm3)
Estimated blood loss (ml)
Operating time (min)
14
sation of cefoxitin without
addition of another antibiotic.
Patients who did not show a
positive response (diminution
of symptoms or absence of
fever) after receiving cefoxitin
for 48 hours were categorized
as "clinical failures"; they were
reexamined to establish that
the original diagnosis was cor-
rect and that there was no new
focus of infection. Ampicillin,
2 gm every six hours, was then
added to their regimen.
Methods
Specimens for culture and
antibiotic susceptibility testing
were obtained from the inner
aspect of the uterine fundus,
venous blood, and urine. Speci-
mens from the uterine fundus
were obtained with an endo-
metrial suction curette (Pip-
elle, Unimar, Wilton, Conn.)Y
placed in an anaerobic trans-
port vial, and processed as pre-
viously described. 5 ·12 Venous
blood was obtained by needle
aspiration, in duplicate, from
the volar aspect of the arms; a
total of 10 ml from each arm
was divided into 5-ml aliquots
and inoculated into one blood
culture bottle for the growth
Cure Failure
42 6
3 1
38.6±0.5 39.1 ±0.4
14,400±3,700 13,700±2,100
688±213 717±281
51±15 52±16
 of aerobic and into another for & r
anaerobic bacteria 12
All isolates were identified
by the Sceptor System (BBL,
The cure rate (for postpartum
Cockeysville, Md.). Anaerobic endometritis) achieved with this
susceptibility testing was per-
formed by both the Sceptor dosage (using 2 gm of cefoxitin
microbroth system (Johnston
Laboratories, Towson, Md.)
every 8 hours) was comparable to
and the spiral gradient end- that achieved when the drug was
point method (SGE) (Spiral
System Instruments, Bethes- administered every six hours in
da, Md. (see Dr. Hill's article,
page 31). For the SGE method,
other studies.
the cefoxitin stock solution
was prepared in 0.1 M sodium
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phosphate buffer. Antibiotic is, 20 (47%) had received cefa-

gradient plates were made on
prereduced Wilkins-Chalgren
agar (60 ml of agar in 15-cm
Petri dishes, achieving an agar
depth of 3.3 mm), and plates
were allowed to dcy in an an-
aerobic environment for one
hour before inoculation. Broth
cultures (brain-heart infusion
agar plus vitamin K1 and he-
min) of the isolates were ad-
justed to a turbidity equiva-
lent to 0.5 MacFarland. Wil-
kins-Chalgren plates without
antibiotic were inoculated to
serve as growth controls. All
plates were incubated for 48
hours at 36° C in an anaero-
zolin, 18 a second- or third-
generation cephalosporin, and
five a penicillin (see Table 3).
In one of the 45 patients
classified as cured, a serous
fluid collected, causing a
wound separation. Among the
seven patients who failed to
respond to initial therapy with
cefoxitin alone, six responded
Table 3.
Antibiotic Prophylaxis in
43 Patients with
Postpartum Endometritis
Cure Failure

bic chamber. Gradient plates Cefazolin (1 gm) 9 1

were interpreted by reading
Cefazolin (1 gmx3) 7
the junction at which growth
Cefazolin (2 gm) 3
ceased. 18- 20
Cefoxitin (1 gm) 2 1

Cefoxitin (2 gm) 6 1
Results
Ceftizoxime (1 gm) 4
Of the 52 patients in the
Cefonicid (1 gm) 2
study, 45 (87%) were cured
and seven required additional Cefotetan (1 gm) 2

antibiotic therapy. The demo- Ampicillin (2 gm) 1 2

graphic and clinical data for Mezlocillin (4 gm) 1
the two groups are presented
Piperacillin (4 gm) 1
in Tables 1 and 2.
No prophylaxis 4 1
Of the 43 patients who had
received antibiotic prophylax-
15
 Table 4. Endometrial Baderiallsolates in Patients
with Postpartum Endometritis*
Gram-Positive
I Gram-Nelf_ative

Aerobes
Streptococcus sp 3 (6%) Acinetobacter
ca/coaceticus 1 (2%)

Streptococcus agalactiae 6 (12%) Citrobacter freundii 1 (2%)

Streptococcus faecalis 18 (35%) Escherichia coli 2 (4%)

Staphylococcus aureus 3 (6%) Enterobacter c/oacae 2 (4%)

Staphylococcus epidermidis 10 (19%) Gardnere/la vagina/is 9 (17%)

I
Lactobacillus 2 (4%) Haemophilus
influenzae 1 (2"..b)

Diphtheroids 7 (13%) Proteus mirabi/is 2 (4%)

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Pseudomonas
aeruginosa 2 (4%)

Klebsiella pneumoniae 1 (2"..b)

Anaerobes

Peptostreptococcus 5 (11%) Porphyromonas

asaccharolytica 5 (10%)

Bacteroides bivius 7 (13%)

Bacteroides fragilis 2 (4%)

Others

Candida albicans 2 (4%)

Ureaplasma urealyticum 28 (54%)

Mycoplasma hominis 12 (23%)

Chlamydia trachomatis 1 (2%)

• Percentages are based on total number of patients (52) in study
Isolates were not cultured in five patients

to ampicillin. A wound infec- Ureaplasma urealyticum,

tion developed in one, and
another patient, diagnosed as
having septic pelvic vein throm-
bosis, required heparin to
achieve resolution of her signs
and symptoms of infection.
There were no adverse reac-
tions to any of the antibiotics
administered.
Bacterial isolates were ob-
tained from endometrial sam-
ples from 4 7 patients (see Ta-
ble 4). Among the 45 patients
cured by cefoxitin alone. the
most frequent isolates were
Streptococcus jaecalis, and
Mycoplasma hominis. No bac-
teria were retrieved from the
specimens of one of the treat-
ment failures and four of the
patients who were cured with
cefoxitin alone.
In susceptibility studies,
none of the 19 anaerobic iso-
lates was resistant to cefoxitin,
clindamycin, metronidazole,
amoxicillin/ clavulanate, or
ticarcillin/clavulanate. One iso-
late of Bacteroidesjragilis was
resistant to cefotetan, cefo-

16
 Table 5. Clinical Failures
Patient Site of
No. Isolation Ort?anism Comments
1 Endometrium Ureaplasma Ampicillin added on
urealyticum day 3

2 Blood Escherichia coli Ampidlin, gentamicin,

clindamycin added
on day 2
Endometrium Staphylococcus
epidermidis
Streptococcus
faeca/is
Urine Citrobacter sp

3 Endometrium S. faecalis Ampicillin added on

S. epidermidis day 2
Bacteroides bivius
U. urealyticum
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4 Endometrium S. faecalis Gentamicin added

U. urealyticum on day 2and
ampicillin added on
day 5

5 Endometrium S. faecalis Ampicillin added on

Diphtheroids day 3 without
S. epidermidis response. Heparin
Klebsiella added on day 5 for
pneumoniae septic pelvic
thrombophlebitis

6 Endometrium S. faecalis Ampicillin added on

S. epidermidis day 2 without
B. bivius response. Wound
Group 8 opened with
Streptococcus defervescence

7 No growth

taxime, and ceftizoxime; two ministered every eight hours

isolates of B. bivius were resist-
ant to cefotaxime, one isolate
of Peptostreptococcus was re-
sistant to cefotetan and cefti-
zoxime, and one isolate of Por-
phyromonas asaccharolytica
was resistant to cefotaxime.
Discussion
Cefoxitin is accepted as a
generally effective agent for
the treatment of postpartum
endometritis. 21 •22 In this inves-
tigation, 2 gm of cefoxitin ad-
was generally effective against
postpartum endometritis in
patients who had received anti-
biotic prophylaxis, even when
that prophylaxis involved the
use of a cephalosporin. The
cure rate achieved with this
dosage was comparable to that
achieved when the drug was
administered every six hours
in other studies.s. 11 ·22 Antibiotic
prophylaxis, especially with a
cephalosporin. may have re-
sulted in selection for S. fae-
cal is, a finding in agreement

17
 Antibiotic susceptibility testing
revealed that all anaerobes
isolated from these patients (with
postpartum endometritis) were
susceptible to cefoxitin.
with other studies. 11
When a patient fails to re-
spond to an initial agent, it is
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customary to replace it with
either clindamycin plus gen-
tamicin or ampicillin plus clin-
damycin plus gentamicin;
nevertheless, all patients in
this study who showed no re-
sponse to cefoxitin did re-
spond when ampicillin was
added. Two were given gen-
tamicin along with ampicillin
alone and one, clindamycin
plus gentamicin in addition
to ampicillin. A review of these
three patients' bacteriologic
findings (see Table 5) suggests
that there was no in vitro
data to support the use of any
of the additional drugs. In
fact, one patient (#4) received
gentamicin on day 2 but
showed no response until
ampicillin was added.
Antibiotic susceptibility test-
ing revealed that all anaerobes
isolated from these patients
were susceptible to cefoxitin.
This finding supports our prac-
tice of not routinely substitut-
ing clindamycin for cefoxitin
to improve anaerobic coverage.
Cefoxitin typically does not
provide adequate coverage for
S.jaecalis, Enterobacter cloa-
cae, or Pseudomonas aerugin-
18
osa. The choice of the proper
additional antibiotic to en-
hance the spectrum provided
by cefoxitin can logically be
based on culture data of the
bacteria isolated from a par-
ticular site of infection. The
laboratory should be able to
determine within 48 hours if
bacterial growth is present
and its gram-stain character-
istics, which can direct the
choice to ampicillin for pre-
sumed S.jaecalis infection or
to gentamicin for presumed
resistant gram-negative infec-
tion. This procedure simpli-
fies the choices of antibiotics
for treatment of postpartum
endometritis.
In summary, single-agent
therapy with cefoxitin was
generally effective for patients
with postpartum endometritis,
even in those who had re-
ceived a ,13-lactam agent for
prophylaxis. For those patients
who failed initial treatment
with cefoxitin, simple addition
of ampicillin generally resulted
in a pro_mpt clinical response.
In most cases, addition of a single
supplemental antibiotic should
be directed toward the pre-
sumed or isolated resistant
pathogenic organism and mul-
tiple antibiotic additions or
changes are not required. D
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19