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In the puerperal phase, streptococcal toxic shock syndrome is a relatively uncommon occurrence. However, there has been a rise in the prevalence of more aggressive strains of Group A Streptococcus (GAS), leading to significant maternal morbidity and mortality. In this report, we present a case of a postpartum patient who developed streptococcal toxic shock syndrome with substantial inflammation shortly after delivery. The patient presented on the second postpartum day with hypotension, high fever, hypogastric tenderness and anaemia. After timely workup and appropriate antibiotic therapy, the patient fully recovered. Culture studies confirmed Gram-positive septicaemia with the presence of Streptococcus pyogenes in both the patient's blood and a previously inserted intrauterine device (IUD). This case underscores the importance of maintaining a high index of suspicion for GAS as the cause of puerperal infections despite its rarity. This results in prompt administration of antibiotics and source control, preventing consequences and avoiding mortality., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objective: To describe the intrapartum and postpartum use of non-study antibiotics in low- and middle-income countries (LMICs) during the double-blinded NICHD Global Network Azithromycin in Labor (A-PLUS) trial., Design: The antibiotic use sub-study was a planned prospective, observational sub-study of the A-PLUS trial., Settings: The study was carried out in hospitals or health centres affiliated with eight sites of the Global Network for Women's and Children's Health Research (Global Network) in seven countries: Bangladesh, Pakistan, India (two sites), Kenya, Zambia, The Democratic Republic of the Congo (DRC) and Guatemala., Population: Totally, 29 278 pregnant women enrolled in the A-PLUS trial., Methods: We collected data on 29 278 pregnant women admitted to a facility for delivery related to non-study antibiotic use overall and during three time periods: (1) in the facility prior to delivery, (2) after delivery until facility discharge and (3) after discharge to 42 days post-partum., Main Outcome Measures: Non-study antibiotic use overall and for treatment or prophylaxis by the site during the three time periods., Results: Of the 29 278 women in the study, 5020 (17.1%; 95% CI 16.7%-17.6%) received non-study antibiotics in the facility prior to delivery, 11 956 (40.8%; 95% CI 40.3%-41.4%) received non-study antibiotics in the facility after delivery, and 13 390 (47.6%; 95% CI 47.0%-48.2%) women received non-study antibiotics after delivery and after facility discharge. Antibiotics were prescribed more often among women in the Asian and Guatemalan sites than in the African sites. In the three time-periods, among those receiving antibiotics, prophylaxis was the indication in 82.3%, 97.7% and 90.7% of the cases, respectively. The type of antibiotics used varied substantially by time-period and site, but generally, penicillin-type drugs, cephalosporin-type drugs and metronidazole were used more frequently than other types., Conclusions: Across the eight sites of the Global Network, in the facility before delivery, and in the post-partum periods before and after facility discharge, antibiotics were used frequently, but use was highly variable by site and time-period., (© 2024 John Wiley & Sons Ltd.)

Importance: Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care., Objective: To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario., Evidence Acquisition: Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed., Results: These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B Streptococcus prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens., Conclusions: Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B Streptococcus , we recommend 1-time dose of metronidazole 500 mg IV., Relevance: Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.

Objective: To assess the efficacy of antibiotic usage for the treatment of puerperal metritis (PM) and its association with reproductive performance, a retrospective cohort study including a total of 9168 records of cows from a dairy farm in Argentina was run., Material and Methods: Cows having a PM3 (metricheck, scale 0-3) and treated with ceftiofur (ceftiofur crystalline free acid, 6.6 mg/kg) at 0-21 days postpartum (p. p.) (n = 2688), and cows having a PM 1-2 and not treated with an antibiotic at 0-21 days p. p. (n = 6480) were included in the study. All cows were reexamined with metricheck to assess the clinical cure (vaginal discharge [VD] score 0), partial cure (VD score similar or lower than previous), no cure (VD score higher than previous). Cows with a metricheck VD1-3 after 0-21 days p. p. were diagnosed as clinical endometritis (CE) 1-3. The occurrence of PM1-3, cure rate, calving to conception interval, the hazard of pregnancy, odds for non-pregnancy, and odds for CE were analyzed using SAS software., Results: A total of 8876 PM1-3 records were included, 2435 records of PM3 treatments with ceftiofur (27.43 %), and 6441 records of PM1-2 (72.57 %) with no treatment. Cows having PM1 and PM2 became pregnant 14 and 12 days earlier than cows with PM3 (p < 0.001). The PM3 ceftiofur treated cows had a clinical cure of 24.85 % (PM0); 53.63 % had a partially cure; and 18.52 % no cure. Conversely, cows with PM1-2 had a 51.96 %, 20.70 %, and 24.53 % cure rate, respectively (p < 0.001). Cows having complete cure became pregnant 13 and 11 days earlier than cows having partial cure and no cure (p < 0.001). Cows that had PM3 during the first 21 days p. p. had twice the chances of developing CE compared to cows having PM1-2 (41.28 % vs. 24.14 %, p < 0.001). After 21 days p. p., less than 1 % of cows with clinical cure developed CE compared to 63.32 % that developed CE with partial cure, and 38.21 % with no cure (p < 0.001)., Conclusion and Clinical Relevance: After ceftiofur treatment, 78 % of cows were cured when measured by disappearance of fetid VD but only 25 % of cows had clinical cure when measured by appearance of a clear VD. The cows that remained with clinical metritis had more chances of having CE after 21 days p. p. and had more days open than cows with clear normal VD., Competing Interests: The authors confirm that they do not have any conflict of interest., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To suggest options for oral and intramuscular antibiotic treatment of early postpartum endometritis in low-resource community settings where intravenous antibiotics are unavailable., Data Sources: Studies were identified through MEDLINE from inception through December 2014. Search terms included [("anti-bacterial agents [MeSH]" or "anti-infective agents [MeSH]") and ("endometritis [MeSH]" or "puerperal infection [MeSH]")]. A second search using the terms [("endometritis or endomyometritis or puerperal infection) and ("antibiotics or antimicrobials or anti-bacterial agents or anti-infective agents)"] was also used. Additionally, all references from selected articles were reviewed, a hand-search of a subject matter expert library was conducted, and a search of ClinicalTrials.gov was performed., Methods of Study Selection: We conducted a systematic review of the literature in two phases. Phase I provides a summary of clinical cure data from prospective studies of oral and intramuscular antimicrobial regimens as well as summarizes evidence from trials of intravenous antimicrobials. Phase II is a quantitative analysis of pathogens from intrauterine postpartum endometritis samples. Based on these results, and with consideration of existing recommendations for antibiotic use during breastfeeding, we suggest oral and intramuscular antimicrobial options for the treatment of early postpartum endometritis after vaginal delivery in low-resource settings., Tabulation, Integration, and Results: Reports involving oral or intramuscular antimicrobial treatment of postpartum endometritis are rare and of generally poor quality. Antimicrobial trials of postpartum endometritis treatment and intrauterine microbiology studies suggest five antimicrobial regimens may be effective: oral clindamycin plus intramuscular gentamicin, oral amoxicillin-clavulanate, intramuscular cefotetan, intramuscular meropenem or imipenem-cilastatin, and oral amoxicillin in combination with oral metronidazole., Conclusion: This review provides suggestions for oral, intramuscular, and combined antimicrobial regimens that may warrant additional study. Experimental trials should consider clinical effectiveness, safety and side effects profiles, and feasibility of community-based treatment.

The aim of the study is to describe a case report of Lyell syndrome (toxic epidermal necrolysis) involving 63% of body surface which has been associated with antibiotic therapy of mild peurperal endometritis in woman 3 weeks postpartum. Lyell syndrome is a severe life-threatening condition developing due to idiosyncrazy (alergic reaction type IV), most commonly after administration of drugs. Incidence quoted in literature is around 1:1-2000000. Illness severity can be assessed using a SCORTEN scoring system, which predicts patient mortality based on seven independent factors. Lyell syndrome is a very rare but potentially lethal complication of antibiotic treatment.

Background: Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during the labor process and cause infection. This is more common following cesarean birth. The condition warrants antibiotic treatment., Objectives: Systematically, to review treatment failure and other complications of different antibiotic regimens for postpartum endometritis., Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014) and reference lists of retrieved studies., Selection Criteria: We included randomized trials of different antibiotic regimens after cesarean birth or vaginal birth; no quasi-randomized trials were included., Data Collection and Analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy., Main Results: The review includes a total of 42 trials, and 40 of these trials contributed data on 4240 participants.Regarding the primary outcomes, seven studies compared clindamycin plus an aminoglycoside versus penicillins and showed fewer treatment failures (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.46 to 0.90). There were more treatment failures in those treated with an aminoglycoside plus penicillin when compared to those treated with gentamycin/clindamycin (RR 2.57, 95% CI 1.48 to 4.46). There were more treatment failures (RR 1.66, 95% CI 1.01 to 2.74) and wound infections (RR 1.88, 95% CI 1.08 to 3.28) in those treated with second or third generation cephalosporins (excluding cephamycins) versus those treated with clindamycin plus gentamycin. In four studies comparing once-daily with thrice-daily dosing of gentamicin, there were fewer failures with once-daily dosing. There were more treatment failures (RR 1.94, 95% CI 1.38 to 2.72) and wound infections (RR 1.88, 95% CI 1.17 to 3.02) in those treated with a regimen with poor activity against penicillin-resistant anaerobic bacteria as compared to those treated with a regimen with good activity against penicillin-resistant anaerobic bacteria. There were no differences between groups with respect to severe complications and no trials reported any maternal deaths.Regarding the secondary outcomes, three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, found no differences in recurrent endometritis or other outcomes. Four trials that compared clindamycin plus aminoglycoside versus cephalosporins identified fewer wound infections in those treated with clindamycin plus an aminoglycoside (RR 0.53, 95% CI 0.30 to 0.93). There were no differences between groups for the outcomes of allergic reactions. The overall risk of bias was unclear in the most of the studies. The quality of the evidence using GRADE comparing clindamycin and an aminoglycoside with another regimen (compared with cephalosporins or penicillins) was low to very low for therapeutic failure, severe complications, wound infection and allergic reaction., Authors' Conclusions: The combination of clindamycin and gentamicin is appropriate for the treatment of endometritis. Regimens with good activity against penicillin-resistant anaerobic bacteria are better than those with poor activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen is associated with fewer side-effects. Following clinical improvement of uncomplicated endometritis which has been treated with intravenous therapy, the use of additional oral therapy has not been proven to be beneficial.

We investigated the prevalence of postpartum infections among women giving birth during 1 year in a population-based observational/questionnaire study at seven hospitals in the southeast region of Sweden. Of the women >99% (n = 11,124) received a questionnaire to inquire if they had endometritis, mastitis, or wound, urinary tract or any other infection within 2 months postpartum and whether they received antibiotics for this. Prevalence rates for infections and antibiotic treatment were estimated. The response rate was 60.1%. At least one infectious episode was reported by 10.3% of the women and 7.5% had received antibiotics. The prevalence for infections with and without antibiotics were, respectively, mastitis 4.7% and 2.9%, urinary tract infection 3.0% and 2.4%, endometritis 2.0% and 1.7%, wound infection 1.8% and 1.2%. There was no inter-county difference in infection prevalence. Clinical postpartum infections in a high-resource setting are relatively common., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To perform culture and sensitivity for pathogens causing puerperal and postoperative wound sepsis and determine the frequency of Methicillin Resistant Staphylococcus aureus (MRSA) in such infections., Study Design: Observational study., Place and Duration of Study: Obstetrics and Gynaecology Ward, Jinnah Postgraduate Medical Centre, Karachi, from December 2008 to May 2010., Methodology: All patients presenting with puerperal sepsis or postoperative wound infection were enrolled. Pus was collected for culture and sensitivity using standard technique. Two samples were taken from each patient; one before starting the treatment and one at the end of treatment. Ames transport medium was used. Empirical treatment with triple regimen (Ampicillin, Metronidazole and Gentamicin) was started immediately to cover Gram positive as well as negative bacteria in addition to anaerobic infection. After receiving the sensitivity report, antimicrobial agent were changed accordingly. Samples from ward and theater staff and environment were also taken to look for possible mode of transmission. Data was recorded on a proforma. Discrete variables are expressed as percentages., Results: Staphylococcus aureus was the most frequent organism isolated in 34.6% cases. Methicillin sensitive Staphylococcus aureus was seen in 20% cases and methicillin resistant Staphylococcus aureus was seen in 14.6%. Out of these 14.6% MRSA, (17) 77% was associated with puerperal sepsis and rest (5) 23% was associated with postoperative wound infection. It showed best sensitivity to vancomycin., Conclusion: Staphylococcus aureus and E. coli were common causative agent of postoperative infections and puerperal sepsis.

The objective of this study was to compare two strategies for screening and subsequent treatment of acute puerperal metritis (APM) in dairy cows. Therefore, we conducted a study on 79 cows with APM (cows with an enlarged uterus with fetid watery red-brown vaginal discharge and fever >39.5 °C) and 114 healthy control cows. Cows with APM were divided into two groups (treated, N = 67 cows; not treated, N = 12 cows). The treated animals were further subdivided into two groups (treated between Day 1 and 4 post partum, N =12 and treated between Day 5 and 10, N = 55). Serum haptoglobin concentrations, milk yield, cure rate, prevalence of endometritis, and cervical diameter on days in milk (DIM) 21 to 27 were compared between the groups. Cows were defined as cured when their rectal temperature was <39.5 °C 4 days after treatment and fever did not rebound over 39.4 °C until the end of the screening period which was DIM 10. The results of this study did not show any significant differences in cure rates, milk yield, or serum haptoglobin concentrations on DIM 2, 5, and 10 and subsequent uterine health (DIM 21-27). Considering this study as a proof of concept study, we conclude that there might not be a negative effect after a screening and treatment protocol beginning at DIM 5 and leaving early APM cows untreated. This hypothesis needs to be confirmed by a larger field study. Furthermore, antimicrobial therapy could be avoided in 12 of 55 cows (21.8%) in group 2 because of the protocol implementing treatments after DIM 5. These cows did not show signs of APM during the following 5 days. Therefore, these animals were considered as self-recovered leading to a cure rate of at least 21.8% (12 of 55 cows)., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Acute puerperal metritis (APM) is one of the most common diseases during the puerperal period. Systemic administration of ceftiofur for 5 consecutive days has been shown to be effective for treatment of APM. The objective of this study was to determine concentrations of ceftiofur derivatives in serum, endometrial tissue, and lochia of cows with fever postpartum or APM 4 to 6d after treatment with a single subcutaneous dose of 6.6 mg of ceftiofur crystalline free acid (CCFA)/kg of estimated BW at the base of the ear. In the first experiment, samples from CCFA-treated cows with fever postpartum or APM (n=42) were taken on d 4, 5, or 6 after treatment. Concentrations of ceftiofur derivatives were quantified using an HPLC assay. Concentrations of active ceftiofur metabolite desfuroylceftiofuracetamide (DCA) were greatest at d 4 after treatment with CCFA in all samples, but they were considerably lower than the concentrations of DCA in healthy postpartum cows treated with the same dose of CCFA. The concentrations of DCA in serum, endometrial tissue, and lochia were affected by odor of vaginal discharge before treatment with CCFA. Mean concentrations of DCA could be detected above the reported minimal drug concentrations (minimum inhibitory concentrations, MIC) required to inhibit relevant pathogens such as Escherichia coli and Arcanobacterium pyogenes in serum on all days and in endometrial tissue and lochia only on d 4 in CCFA-treated cows with fetid vaginal discharge before treatment. In the second experiment, samples from CCFA-treated cows with APM (n=8) were taken on d 0 (before treatment) and d 4, 5, and 6 after treatment. Mean concentrations of DCA in serum and lochia were similar on d 4 to 6 in both laboratories. Furthermore, determined concentrations of DCA from both laboratories were correlated for serum and lochia. Mean concentrations of DCA could be detected above the reported MIC in serum and lochia only on d 4. Our 2 experiments demonstrated that in postpartum cows with fever postpartum or APM concentrations above the MIC for relevant bacteria (>0.5 μg/mL or >0.5 μg/g) of DCA could be sustained only for 4 (serum: 15/17; endometrial tissue: 2/17; lochia: 1/16) to 5d (serum: 10/13; endometrial tissue: 1/13; lochia: 2/12) after a single treatment with CCFA only in a certain proportion of cows. Overall, our data provide first pharmacological evidence that a single subcutaneous administration of 6.6g of CCFA/kg of BW might not be sufficient to efficaciously treat APM in postpartum dairy cows., (Copyright © 2013 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Background: The aim of the study was to test the effect of two treatments in cases of acute puerperal metritis (APM) and clinical metritis (CM)., Methods: Cows with APM and CM (n = 40)) were matched according to plasma fibrinogen levels (Fb) into three groups. Two negative control groups D (n = 11) and E (n = 17) were composed of healthy cows. The proportion of animals with APM and CM was similar within the groups. Treatment was started on the 3rd day postpartum (PP). In group A (n = 15), intramuscular (i.m.) administration of ceftiofur was used for five days in combination with flunixin for three days. Group B (n = 15) received i.m. administration of ceftiofur for five days followed by two injections of prostaglandin F2α, with an interval of 8 h, on the 8th day PP. Group C (n = 10) served as a control group with no treatment. The general health status, body temperature (BT) and vaginal discharge were evaluated daily. Endometrial biopsies for bacteriology were taken once a week for seven weeks PP. Blood samples for the analysis of acute phase proteins were collected once a week for six weeks PP. Samples for progesterone analysis were taken twice a week for seven weeks PP. Fertility performance data were recorded., Results: The area under the curve of BT was higher in group B than in group D cows (P < 0.05). No differences were found for vaginal discharge. There were no differences in bacterial growth, start of ovarian activity or serum amyloid-A or fibrinogen levels among the groups. The haptoglobin concentration was higher in the first and second weeks PP in group B compared with the other groups (P < 0.05). The number of days open was higher in group A than in both groups B and D (P < 0.05). The pregnancy rate after the first two services was higher (P < 0.05) in groups B and D than in groups A and C. The number of services per pregnancy was lower in group B than in group C (P < 0.05)., Conclusions: Regardless of more severe uterine inflammation found in animals from group B, these cows showed the same fertility parameters as healthy animals.

Gas in an infected organ generally indicates a severe infection, often requiring surgery; however, data are lacking as to post-cesarean gas-forming uterine infection. A 27-year-old Japanese primigravida underwent a difficult cesarean section, after which a high fever continued. Computed tomography (CT) revealed marked gas in the uterine anterior myometrium. Diagnosing this condition as post-cesarean uterine scar infection, we recommended surgical intervention, that is, hysterectomy or at least drainage; however, the patient refused it. Considering the patient's desire and lack of organ-failure signs, we employed intensive antibiotic treatment for 6 weeks. Serial CT indicated a gradual decrement in the gas amount and she recovered completely after 8 weeks. This case suggests that surgical procedure may not always be necessary for post-cesarean gas-forming uterine infection and CT may be useful to detect/follow this condition., (© 2010 The Authors. Journal of Obstetrics and Gynaecology Research © 2010 Japan Society of Obstetrics and Gynecology.)

The aim of the study was to compare the effect of two acute puerperal metritis (APM) treatment protocols on uterine condition during the late puerperal period (5th to 7th week). Late gestation healthy cows (n = 21) were divided randomly in three equal groups. Parturitions were induced. Treatments of APM were started on the third day postpartum (PP). Group A was treated with an oxytocin analogue carbetocin for three days and intrauterine administration of cephapirin between days 15 and 17. Group B was given intramuscular injection of ceftiofur for five days followed by two injections of prostaglandin F2alpha, at an interval of 12 h, on the eighth day PP. Group C served as the control group with no treatment. Body temperature was recorded daily for 14 days PP. Uterine biopsies for bacteriology, and uterobrush samples for cytology, were taken once a week from the 5th to 7th week postpartum. No differences were found in body temperature on day 14 PP, presence of bacteriological infections and disappearance of uterine inflammatory signs diagnosed by cytological examination between experimental groups.

Background: Postpartum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labor and birth. Antibiotic treatment is warranted., Objectives: The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's trials register (30 January 2004)., Selection Criteria: Randomized trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected., Data Collection and Analysis: We abstracted data independently and made comparisons between different types of antibiotic regimen based on type of antibiotic and duration and route of administration. Summary relative risks were calculated., Main Results: Thirty-eight trials with 3983 participants were included. Fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with the other regimen (relative risk (RR) 1.44; 95% confidence interval (CI) 1.15 to 1.80). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.94; 95% CI 1.38 to 2.72). In three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, no differences were found in recurrent endometritis or other outcomes. In four studies comparing once daily with thrice daily dosing of gentamicin there were fewer failures with once daily dosing. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea., Reviewers' Conclusions: The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin- resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

The aim of the study was to identify the species of microorganisms isolated from the uterus of healthy cows (control group) and cows affected with puerperal metritis (PM) before and after an experimental therapy with an immunomodulator and antibiotics versus commonly applied methods (antibiotic + beta-blocker or antibiotic + PGF2alpha). Examinations were carried out on 110 cows with PM in three farms with similar system of rearing and nutrition. The control group consisted of 21 cows without postpartum disturbances. Smears from the uterus were taken before treatment and then at 21st day of observation. Escherichia coli and other species of Enterobacteriaceae family were isolated from 48.2% of PM cows and 47.6% of healthy cows. The degree of Arcanobacterium pyogenes infection was statistically lower in healthy than in sick cows (9.5% versus 30.0%). Streptococcus sp. was isolated from 13.6% of PM cows and from 16% of control ones. Staphylococci were isolated from 10% of PM and from 30% of control cows. Other bacteria species were isolated from about 10% of the examined cows. The best elimination of infections (66%) was noted in cows treated with the intrauterine antibiotic in combination with PGF2alpha i.m. injection. Examination showed that species of bacteria in the postparturient uterus were similar in healthy and sick cows. However, Arcanobacterium pyogenes was isolated 3 times more often from the sick animals. This pathogen was identified in 11 cows out of 19 (57.9%) culled subsequently because of infertility after the metritis puerperalis was clinically cured.

Cows without signs of clinical mastitis were evaluated by the California Mastitis Test at calving (Day 0). Milk samples from 117 of 184 quarters (64 cows) were positive by this test for mastitis and were submitted for bacterial culture and determination of somatic cell counts. Cows with infected quarters were randomly allocated to treatment with cephapirin sodium by intramammary infusion or to be untreated as controls. Two and 4 weeks following calving, milk was again sampled from the infected quarters and tested. By the 4-week evaluation, the quarters treated with cephapirin sodium had significantly (P < or = .05) fewer positive bacterial cultures and somatic cell counts were significantly (P < or =.05) reduced compared with untreated control quarters.

Background: Post-partum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labour and birth. Antibiotic treatment is warranted., Objectives: The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group's trials register and the Cochrane Controlled Trials Register. Date of last search: June 2001., Selection Criteria: Randomised trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected., Data Collection and Analysis: Data were abstracted independently by the reviewers. Comparisons were made between different types of antibiotic regimen, based on type of antibiotic and duration and route of administration. Summary relative risks were calculated., Main Results: Forty-seven trials were included. Overall the studies were methodologically poor. In the intent-to-treat analysis, fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with another regimen (relative risk (RR) 1.32; 95% confidence interval (CI) 1.09-1.60). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.53; 95% CI 1.10-2.13). In four studies that compared continued oral antibiotic therapy after intravenous therapy, no differences were found in recurrent endometritis or other outcomes. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea., Reviewer's Conclusions: The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

Retention of the fetal membranes and post-partal endometritis (RFM) are common problems in dairy cows. Treatment often includes manual removal of the placenta in combination with antibiotic treatment. Earlier studies have shown that cows with endometritis post-partum have a strong tendency to recover spontaneously. The present study focused on treatments of post-partal endometritis with the prostaglandin synthesis inhibitor, flunixin (F) either alone or combined with oxytetracycline (T). The study was conducted in two experiments, using 12 primiparous cows in each. As a model for RFM, premature parturition was induced in late pregnant heifers by injecting PGF2alpha (25 mg i.m.) twice with a 24 h interval. In each experiment the cows were set into four groups and treated with either T (10 mg/kg BW i.m. once daily), F (2.2 mg/kg BW p.o. twice daily), a combination of T and F (dosage, as above) or conservatively (group 0, no drugs). The treatment periods lasted from days 11-14 post-partum in experiment I (groups T1, F1, TF1 and 0) and from days 3-6 post-partum in experiment 2 (groups T2, F2, TF2 and 0). Jugular vein blood samples were collected for analyses of flunixin and total white blood cells. Uterine biopsies were collected twice weekly for investigation of endometrial microbiology. Rectal palpation and ultrasonographic examinations were performed three times weekly for investigations of uterine involution and ovarian activity. No attempts were made to remove the placentas manually. The experiment lasted until day 56 post-partum. The induction of parturition was successful in all heifers and 22 of 24 animals had RFM. All RFM cows had bacterial endometritis. The predominant bacteria were Escherichia coli alpha-haemolytic streptococci, Fusobacterium necrophorum, Arcanobacterium (Actinomyces) pyogenes, Bacteroides spp., Pasteurella spp. and Proteus spp. Fusobacterium necrophorum and A. pyogenes could be isolated for 3-5 weeks post-partum and E. coli Pasteurella and Proteus could be isolated for 2-3 weeks post-partum. Animals treated with tetracycline after placental shedding (T1 and TF1) had a more rapid recovery from infections with A. pyogenes and F. necrophorum than animals that were not treated with tetracycline. No other genera were affected. Antibiotic treatment before placental shedding (T2 and TF2) did not shorten the uterine infection but altered the bacterial flora, seen as an overgrowth of Proteus spp. (p < 0.05) and increased frequency of Pasteurella (p < 0.05). The alpha-haemolytic streptococci were less common in T2 and TF2 than in other groups (NS). Antibiotic treatment of cows before placental shedding (T2 or TF2, n = 6) postponed detachment of placenta compared to cows were no antibiotics were administered before placental shedding (T1, TF1, F1, F2 and 0, n = 16. 9.8 days pp (median) versus p = 0.004). Neither treatment shortened uterine involution. Flunixin treatments did not seem to influence recovery from infection or uterine involution. It was concluded that early oxytetracycline treatment of retained fetal membranes in the cow did not shorten the uterine involution or uterine infection but it did slow down the detachment process of the retained placenta. Oxytetracycline treatment after placental shedding might shorten the uterine infection but otherwise did not affect the clinical results. Flunixin treatment had no influence on the clinical outcome of the disease.

Objective: The efficacy, safety, and antibiotic-related charges for once-daily gentamicin with twice-daily clindamycin were compared with those of thrice-daily dosing of these antibiotics., Study Design: Patients with puerperal endometritis or with chorioamnionitis in labor assessed to be at risk for endometritis were randomized to receive gentamicin 4 mg/kg intravenously every 24 hours with clindamycin 1200 mg intravenously every 12 hours (experimental arm) or gentamicin 1.33 mg/kg intravenously and clindamycin 800 mg intravenously every 8 hours (conventional dosing interval arm). Primary outcomes included cure rates, mean length of treatment, antibiotic-related charges, and nephrotoxicity. Multiple logistic regression analysis was used to control for confounding variables., Results: There were 135 and 137 patients randomized to the experimental and conventional interval arms, respectively. Cures were obtained in 94.1% and 87.6% of patients in the experimental and conventional arms, respectively (p = 0.06). The experimental arm had mean antibiotic charges of $250.79 versus $442.49 in the conventional arm (p < 0.0001). There was no permanent nephrotoxicity in either group., Conclusions: Once-daily gentamicin dosing with twice-daily clindamycin dosing is as efficacious and safe as the thrice-daily dosing of gentamicin and clindamycin for peripartum uterine infection. The experimental regimen results in substantial cost savings. The incidence of nephrotoxicity is low.

Objective: To evaluate the efficacy and safety of ampicillin/sulbactam with those of clindamycin/gentamicin., Study Design: A prospective, randomized clinical trial of patients with the diagnosis of postpartum endometritis. Intravenous ampicillin, 2.0 g, combined with 1.0 g sulbactam was administered every six hours or intravenous clindamycin, 900 mg, plus gentamicin, 1.5 mg/kg (not to exceed 150 mg unless gentamicin levels were obtained) every eight hours. Endometrial and blood specimens were obtained for culture and antibiotic susceptibility testing., Results: One hundred twenty-nine hospitalized women with the diagnosis of endometritis were enrolled. Both treatment regimens were equally effective. At the end of treatment, 42 of 51 (82%) ampicillin/sulbactam-treated patients achieved clinical cure in comparison to 47 of 56 (84%) patients in the clindamycin/gentamicin group. Respective bacterial eradication rates of 86% and 84% for each treatment group were seen. Both antibiotic regimens were well tolerated, with no statistically significant difference in the incidence of adverse experiences., Conclusion: The two antibiotic regimens were equally effective for a clinical cure, bacterial eradication and incidence of adverse experiences.

Objective: To evaluate whether once-daily gentamicin dosing is as effective as the traditional 8-hour regimen for the treatment of postpartum endometritis., Methods: Postpartum women with endometritis were randomized to receive gentamicin 5 mg/kg as a single daily dose or 1.75 mg/kg every 8 hours. All subjects also received clindamycin. Each participant had a peak serum gentamicin level of at least 5.0 micrograms/mL within the first 24 hours. The dosing regimens were compared by analyzing the number of hours that patients were febrile, the length of hospital stay, occurrence of complications, pharmacy costs, and nursing time required to administer the regimens., Results: The study group (n = 62) and the control group (n = 65) were similar in demographic characteristics and the presence of endometritis risk factors. No differences were found between the groups in the number of patients who completed therapy without complications, required changes in antibiotics, or required readmission for endometritis. The groups did not differ in the number of hours that patients remained febrile after the start of therapy or in the length of hospital stay. No patient in the study group had an initial peak serum concentration less than 5.0 micrograms/mL, whereas 24 patients in the control group had initial peak serum concentrations less than 5.0 micrograms/mL and required dose adjustment, a statistically significant difference (P < .001). Pharmacy costs averaged $16.12 +/- 5.68 for the study group and $41.75 +/- 17.41 for the control group, also a significant difference (P < .001). Nurse tasking time averaged 13.62 +/- 2.56 minutes for the study group and 28.06 +/- 8.77 minutes for the control group (P < .001)., Conclusion: In patients with postpartum endometritis, once-daily gentamicin dosing provides consistently high peak serum levels of gentamicin, requires less nurse tasking time, costs less, and is as effective as the 8-hour dosing regimen.

We discussed the current situation of the intractable bacterial infections in the gyneco-obstetrical field and the countermeasures especially to puerperal fever and pelvic abscess (polymicrobial infection). It is very important to select the proper antibiotics for the treatment, it must be according to the pathobacteriological manifestations of the individual case. We must fix the attention to the infections caused by MRSA.

One of the main mechanisms of generalization of infection in purulent-inflammatory processes of the abdominal cavity, retroperitoneal space and pelvis minor is translocation of the pathogenic microflora of the intestine in the lymphatic system via regional lymphatic nodes with subsequent rupture into the systemic circulation. Endolymphatic administration of antibacterial agents into the peripheral lymphatic vessel favours saturation of the reticuloendothelial structures of the lymph nodes by the antibiotic agent that increases their barrier function and, thus, prevents generalization of the infection and development of polyorganic insufficiency.

Three different antibiotic regimens (trospectomycin plus azteonam, clindamycin plus azteonam, and triple antibiotics-ampicillin plus clindamycin plus gentamicin) were all effective in treating patients with postcesarean endometritis. Patients are frequently cured clinically despite the fact that the offending organisms may be isolated in post-treatment cultures. Treatment of postcesarean endometritis without obtaining endometrial cultures is acceptable gynecologic practice. Obtaining post-treatment cultures is clearly not cost effective nor clinically beneficial. Drug treatment efficacy should be evaluated by clinical response. This communication is the first to report the new antibiotic, trospectomycin, in the treatment of postcesarean endometritis. Further clinical trials are currently underway.

A prospective, multicenter, open-label randomized trial was conducted to compare the efficacy and tolerability of imipenem-cilastatin (I-C) monotherapy with clindamycin+aminoglycoside (C+A) combination therapy. Forty-nine patients were able to be evaluated for clinical efficacy in the treatment of postpartum endometritis. Twenty-three patients received I-C and 26 received C+A therapy. The two groups were statistically similar for demographic and clinical variables upon entry into the study. The results of therapy were categorized as cured, improved, or failed. The use of I-C resulted in an overall clinical response rate (cured and improved) of 91%, compared with an overall response rate with C+A of 73% (P = 0.15). Patients categorized as improved comprised 56.5% of those in the I-C group and 38.5% of those in the C+A group. Patients categorized as failed comprised 8.7% of those in the I-C group and 26.9% of those in the C+A group. Overall, these data support the use of I-C for the treatment of appropriate patients with postpartum endometritis.

Puerperal uterine infection, or endomyometritis, occurs more commonly after cesarean section than after vaginal birth. With the rate of cesarean delivery almost 25% of all births in this country, such infection is relatively common. The classic therapy for postcesarean endomyometritis is the combination of clindamycin and an aminoglycoside, usually gentamicin or tobramycin. This regimen has requisite antimicrobial activity against the aerobes and anaerobes of the cervicovaginal flora that usually cause this illness. In the last decade, however, the availability of broad-spectrum beta-lactam antibiotics has enabled the clinician to combat postcesarean infection with single-agent antimicrobial chemotherapy, or monotherapy. "Higher-generation" cephalosporins such as cefoxitin, cefotetan, and moxalactam, as well as the semisynthetic penicillins ticarcillin, piperacillin, and mezlocillin, have all been used alone in the therapy for postpartum infection. The addition of a beta-lactamase inhibitor to this class of drugs now offers a further resource to the practitioner if beta-lactamase-mediated antibiotic resistance arises in the patient population being treated.

Ninety-two patients with puerperal infection admitted to Siriraj Hospital from April 1, 1980 to March 1, 1983 were studied. The treatment in this study was both medical and surgical, blood transfusion was given in some cases with low hematocrit level. The medical treatment alone was based on the causative organisms which were detected by cervical & intrauterine swab, smear & gram stain and cultures. PGS & Kanamycin were the most frequently used antibiotics which were intended to treat both gram-positive and gram-negative bacteria and adjunctive chloramphenicol for anaerobes. The surgical procedures which were performed in combination with medical treatment included total abdominal hysterectomy, uterine curettage, appendectomy and drainage of subdiaphragmatic abscess. The result of the treatment was satisfactory, 96.7 per cent improved after therapy with slight morbidity in some patients.

The sites of infection and causative organisms found at the Department of Obstetrics and Gynecology of the University of Tübingen are reviewed. About 10% were wound infections, and 10% of all organisms were anaerobes. The principles of treatment of obstetrical and gynecological infections by surgery and chemotherapy are discussed. In cases of mixed infections, good antibiotic coverage of both aerobes and anaerobes should be provided.

The incidence of intrauterine infections following premature rupture of the membranes is high in indigent populations. In 1970 a prospective study was carried out to determine the value of prophylactic antibiotics in preventing puerperal endometritis in such patients. Penicillin and kanamycin were administered when the patients went into labor or when a move was made toward delivery by induction of labor or cesarean section. Antibiotics were continued for two days postpartum. Puerperal endometritis was significantly decreased. Six-year follow-up has shown no problems with masked infections, superinfections or changes in the antibiotic resistance patterns of cultured pathogens.

Piperacillin (PIPC) was administered to patients with obstetrical and gynecological infectious diseases and we studied its clinical effect and tissue distribution. 1. Clinical results. PIPC was administered to 26 patients at a dose of 2--4 g per day (twice a day) by dripping infusion over a period of 3--10 days (total 8--30 g). These included 16 cases with intrauterine infection, 1 with adnexitis, 4 with pelvic inflammatory disease and 5 with infections of the external genitalia. The clinical results were excellent in 11 cases, good in 13 cases and poor in 2 cases so that the overall efficacy rate was 92.3%. For bacteriological study 33 strains were isolated from 20 patients. These included Gram positive bacteria (6 strains), Gram negative bacteria (23 strains) and anaerobes (4 strains). After PIPC treatment 32 strains (including S. epidermidis 4 strains, E. coli 12 strains, K. pneumoniae 3 strains, E. aerogenes 2 strains, P. aeruginosa 2 strains and anaerobes 4 strains, etc.) disappeared except for 1 strain of K. pneumoniae which persisted. The disappearance rate was 97.0%. The only side effect observed was a slight case of malaise during the first administration day, however the relationship between the appearance of this symptom and the drug was unclear. No adverse reaction in laboratory findings was observed. 2. Tissue distribution. We determined the tissue concentration from 90 to 240 minutes after dripping infusion for 1 hour at a dose of 2 g. PIPC concentrations in these tissues including the endometrium, myometrium, cervix uteri, portio vaginalis, oviduct and ovary showed the highest level (18.0--11.7 micrograms/g) at 90 minutes after the beginning of administration. These values were 48.6--31.6% in respect to the uterine arterial blood level (37 micrograms/ml at 90 minutes after infusion).

Despite the widespread use of prophylactic antibiotics, postpartum endometritis remains a common complication following cesarean section. Metritis is generally polymicrobial and responds to a wide variety of antibiotic regimens. During the past decade, single agents have been shown to be safe and efficacious. The pathogenesis, diagnosis, and treatment options for endometritis are reviewed.

The total cost to the patient is an important consideration in the selection of antimicrobials for prevention and treatment of post-cesarean section endomyometritis. We compared the cost to the patient of commonly used therapeutic and prophylactic agents in a theoretical model population of 450 women who were delivered by cesarean section. Cost of the drug alone on a per gram, per dose, or per day of therapy basis is not an accurate way of estimating the cost eventually paid by the patient. The therapeutic efficacy, frequency of administration, and need for ancillary services for each treatment regimen affect significantly the patient's costs.

To assess the effect of broad-spectrum antibiotic therapy upon vaginal colonization, we collected vaginal specimens for culturing at the end of therapy from 50 patients treated for postcesarean section endometritis. Infected patients had participated in a double-blind therapy protocol and had received either clindamycin plus gentamicin or cefamandole plus placebo. Repeat vaginal culturing was performed 6 weeks later. Similar vaginal specimens for culturing were collected from 25 control patients who also had undergone cesarean section but had not received antibiotics. Of 26 patients treated with cefamandole, 16 (62%) developed vaginal colonization with isolates resistant to that drug; of 24 patients treated with clindamycin-gentamicin, two (8%) developed isolates resistant to these agents (p less than 0.001). Among 25 control patients, there was only one isolate resistant to cefamandole and none resistant to clindamycin-gentamicin. Compared to controls, more antibiotic-treated patients developed isolates resistant to cefamandole (p = 0.001) and to clindamycin-gentamicin (p = 0.06). Colonization did not persist, and there were no late infections in this population.

Certain infections, such as UTI, may have an increased incidence during pregnancy owing to physiological changes. Between 2 and 10% of pregnant women have covert or asymptomatic bacteriuria which is associated with an increased incidence of acute symptomatic UTI in later pregnancy if left untreated. Thus antenatal screening to detect the presence of bacteriuria is justified. Most women will remain abacteriuric throughout the remainder of pregnancy after a single course of antibiotic therapy but a small percentage will fail to respond or have recurrent UTIs. Maternal infection with certain organisms, namely those which resist phagocytosis, may result in transplacental infection of the fetus in utero. Congenital syphilis is preventable and antenatal serological screening is usually routinely performed. Listeriosis following maternal infection in pregnancy is less predictable and the epidemiology of L. monocytogenes remains unclear. Genital tract carriage of sexually transmitted organisms, such as N. gonorrhoeae or C. trachomatis, may also be detected during pregnancy and antibiotic therapy will be indicated to eradicate such organisms and prevent maternal and neonatal morbidity. Antibiotic therapy during pregnancy will not, however, eradicate carriage of GBS from the genital tract, although carriage status at term can now be reliably predicted by using enriched culture techniques and swabbing multiple sites on more than one occasion. Where carriage is confirmed, the administration of intrapartum antibiotics to the mother appears a useful approach in the prevention of early onset neonatal GBS disease. Broad spectrum intrapartum antibiotics may also be indicated when there are complications, such as prolonged labour or premature rupture of membranes, which are associated with a higher incidence of maternal postpartum endometritis and morbidity than in women following uncomplicated vaginal delivery. Serious postnatal sepsis and shock is fortunately now rare. The pharmacokinetics of antibiotics in late pregnancy and the puerperium are altered and maternal serum levels may be reduced by 10-50%. Most antibiotics cross the placenta and are excreted in breast milk. Some agents, such as the beta-lactams, are considered safe in pregnancy and breast-feeding women while other antibiotics are contraindicated owing to risk of toxicity (often rare) or teratogenicity (often theoretical). Caution is necessary with many agents which may cause side effects or toxicity although this does not necessarily contraindicate their use in pregnancy.(ABSTRACT TRUNCATED AT 400 WORDS)

Standard antimicrobial therapy for postpartum endometritis usually consists of several days of intravenous antibiotics followed by up to ten days of oral therapy. In an effort to decrease the length of hospitalization and duration of antibiotic use, 54 patients were placed on an abbreviated antibiotic protocol. Therapy consisted of intravenous gentamicin and clindamycin until the patient's temperature remained lower than 99.5F for 24 hours, at which time intravenous antibiotics were discontinued and the patient was discharged immediately without oral medication. No morbidity secondary to the abbreviated regimen was observed. Further, the duration of hospitalization and antibiotic therapy of the study group were significantly shorter than similar data from a group of historic controls. These observations suggest that an abbreviated course of antibiotics, based upon the patient's "therapeutic response," may be a safe and cost-effective alternative to the currently practiced therapeutic regimen.

During a 4-month period 265 women delivered by cesarean section were studied to determine what effect membrane rupture has on the incidence and severity of postoperative infection. There was a definite correlation between the duration of ruptured membranes and the incidence as well as severity of postoperative infections. Only 29% of women with intact membranes subsequently developed endometritis with pelvic cellulitis, in contrast to 85% of those whose membranes were ruptured for less than 6 hours. Wound and pelvic abscesses were encountered in less than 1% of women delivered with intact membranes, yet these complications developed in over 30% of women with membranes ruptured for less than 6 hours. The incidence of septicemia was four times greater in those women whose membranes were ruptured for less than 6 hours. Women with endometritis were treated with one of two empirical antimicrobial regimens chosen randomly. Intravenous penicillin and tetracycline was found to be as effective as, and perhaps slightly more effective than, the combination of intravenous penicillin and intramuscular tobramycin.

The physiologic changes of pregnancy and the puerperium and their effect on antibiotic therapy have not received widespread attention. Pregnancy is accompanied by multiple physiologic changes, including increased uterine weight, blood volume, extracellular fluid, endometrial blood flow and renal function changes. Those changes affect therapy for endometritis since it may take several weeks for a return to the pregravid state. Preeclampsia is associated with reductions in intravascular space, increased extravascular space from edema and impaired renal function. Postpartum uterine changes may also complicate drug therapy because of poor antibiotic perfusion. The ideal antibiotic for postpartum endometritis would achieve optimal uterine tissue levels, be administered infrequently, and have adequate activity against anaerobes and minimal toxicity.