Name
PUERPERAL SEPSIS
DESCRIPTION
DETAIL
CAUSES . The risk of endometritis increases 5-30 fold following Cesarean delivery . Endometritis commonly follows chorioamnionitis . Other infections follow trauma to the perineum, vagina, cervix and uterus . Infection is nearly always polymicrobial and involves organisms that have ascended from the lower genital tract: . Aerobic isolates in 70% - S. faecalis , S. agalactiae, S. viridans , Staphylococcus aureus , E.coli , Klebsiella sp. , Proteus sp. , Gardnerella vaginalis . Anaerobic isolates in 80% - Peptococcus sp. , Peptostreptococcus sp. , Clostridium sp. , Bacteroides bivius , B. fragilis , Fusobacterium sp. . Other - genital mycoplasmas - role in endometritis is unclear . Chlamydia trachomatis - responsible for some late (2-10 days) post-partum endometritis . Range of number of isolates is 1-8 -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS . Fever from other sources . Urinary tract infection . Viral syndrome . Dehydration . Pneumonia . Wound infection . Thrombophlebitis . Thyroid storm . MastitisLABORATORY β’ CBC - interpret with care as physiologic leukocytosis may be as high as 20,000 β’ Blood cultures - if sepsis is suspected β’ Amniotic fluid gram stain - usually polymicrobial β’ Uterine tissue cultures - diffi cult to obtain without contamination β’ Genital tract cultures and rapid test for group B strep - may be done when patient is in labor β’ Note: Diagnosis is usually made clinically IMAGING . If patient is not responsive to antibiotics . CT or MRI for pelvic vein thrombophlebitis . U/S, CT or MRI for abscess, pelvic masses or deepseated wound infection DIAGNOSTIC PROCEDURES Paracentesis or culdocentesis with culture - rarely necessary
TYPENOTES
RISK FACTORS: Cesarean section, Pre-existing chorioamnionitis, Multiple vaginal examinations, Indigent status, Bacterial vaginosis or group B strep colonization of genital tract, Prolonged rupture of membranes, prolonged laborGENERAL MEASURES β’ IV antibiotics and close observation for severe infections β’ Open and drain infected wounds β’ Normalize fluid status β’ Note: Amnioinfusion during labor may decrease infections when membranes have been ruptured for more than 6 hours. SURGICAL MEASURES β’ Curettage of retained products of conception β’ Surgery to establish drainage of abscess β’ Surgery to decompress the bowel β’ Surgical drainage of a phlegmon is not advised unless suppurative DRUG(S) OF CHOICE β’ Cefoxitin 2 gm IV q6hrs. Add ampicillin 2 gm IV q6hrs if clinical failure after 48 hours. β’ Cefotetan 2 gm IV q12hrs. Add ampicillin 2 gm IV q 6 hrs if clinical failure after 48 hours. β’ Piperacillin 4 gm IV q6hrs β’ Ampicillin-sulbactam (Unasyn) 2/1 gm IV q6hr β’ Clindamycin 600-900 mg IV q8hr plus gentamicin 5 mg/kg IV q24hrs (traditional βgold standardβ but may cause nephrotoxicity, ototoxicity, pseudomembranous colitis, diarrhea [in up to 6%] and may require gentamicin peak and trough levels) β’ Note: Base therapy on cultures, sensitivities, and clinical response ALTERNATIVE DRUGS β’ Metronidazole 7.5 mg/kg IV q6hr plus gentamicin 2 mg/kg IV qd (see above) β’ Amoxicillin-clavulanate (Augmentin) 500/125 mg po tid for mild infections as outpatient β’ Clindamycin 300-450 mg po qid for penicillin allergic outpatients with mild infections β’ Note: Consider adding a macrolide antibiotic (for chlamydia coverage) for infections occurring after 48 hours β’ Note: Heparin may be indicated for septic pelvic vein thrombophlebitis - requires 10 days at full anticoagulation PATIENT MONITORING β’ Individualize according to severity β’ IV antibiotics can be stopped when afebrile for 24 - 48 hours β’ Oral antibiotics on discharge are not necessary except in cases of bacteremia PREVENTION/AVOIDANCE β’ Treat chorioamnionitis during labor β’ Treat prophylactically with cefazolin for C/S deliveries after the cord is clamped β’ Avoid unnecessary vaginal exams β’ Avoid retained placental fragments or membranes POSSIBLE COMPLICATIONS β’ Resistant organisms β’ Pelvic abscess β’ Septic pelvic vein thrombosis β’ Septic shock β’ Death EXPECTED COURSE/PROGNOSIS β’ With supportive therapy and appropriate antibiotics most patients improve within a few days β’ If no improvement on antibiotics, consider retained placental fragments or membranes, abscess, wound infection, hematoma, cellulitis, phlegmon or septic pelvic vein thrombosis
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
ULTRA SOUND WHOLE ABDOMEN - FEMALE, COMPLETE BLOOD COUNT, PUS CULTURE TEST, CT SCAN ABDOMEN