Antibiotic Guidelines: Obstetric Anti-Infective

Prescribing Guidelines
Classification: Clinical Guideline
Lead Author: Antibiotic Steering Committee
Additional author(s): Kelly Alexander / Frances Garraghan /
Dr Ahmed Qamruddin / Dr Melissa Whitworth / Dr Teresa Kelly
from Central Manchester Foundation Trust Hospitals.
Authors Division: DCSS & Tertiary Medicine
Unique ID: 144TD(C)25(J2)
Issue number: 1
Date approved: Medicines Management Group - May 2014

Contents

Intro

Section

Page

Who should read this document

Key practice points
Background

2
2
2

Empiric treatment for unknown source of maternal infection / sepsis

Pyrexia in labour
Treatment of a secondary postpartum haemorrhage due to retained
products
Group B Haemolytic Streptococcus prophylaxis
Intra-abdominal infections
Urinary tract infections
Post-operative wound infection post delivery
Mastitis / breast abscess
Genitourinary infections
Gentamicin in pregnancy

4
5
6

Standards
Roles and Responsibilities

11
11

Appendix

12

Document control information (Published as separate document)

Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis

14

Guideline

Issue1
June 2014

6
7
8
9
11

11

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 1 of 13

Who should read this document?

This policy applies to all clinical staff involved the prescribing of antimicrobials.

Key Practice Points

The recommendations below consider safety during pregnancy. For ladies who
have given birth, the general Trust antibiotic guidelines may be followed, with
consideration on safety in breast feeding if applicable. Contact Pharmacy or
Medicines Information (ext 65223) for further advice.
When considering treatment with antibacterial agents during pregnancy, the
following factors should be considered: the severity of the maternal infection, the
effects of any fever present on the pregnancy, the effects of failing to treat the
mother, and the potential fetotoxicity of the drugs to be used.
Where possible, the results of culture and sensitivity tests should be available before
making a treatment choice, however treatment should NOT be delayed in patients
who are unwell or septic.
Administration of intravenous broad spectrum antibiotics is recommended
within one hour of suspicion of severe sepsis, with or without septic shock. If
genital tract sepsis is suspected, prompt early treatment with a combination of highdose broad spectrum intravenous antibiotics may be lifesaving.
Breastfeeding
This document is not a resource for determining antibiotic safety in breastfeeding.
Do not assume if potential toxicity in breastfeeding has not been highlighted that the
drug is safe in this situation. Please refer to medicines information for further
information.

Issue1
June 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 2 of 13

Background
Antimicrobial agents are among the most commonly prescribed drugs and account
for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to
individual patients are compromised by the development of bacterial drug resistance.
Resistance is a natural and inevitable result of exposing bacteria to antimicrobials.
Good antimicrobial prescribing will help to reduce the rate at which antibiotic
resistance emerges and spreads. It will also minimise the many side effects
associated with antibiotic prescribing, such as Clostridium difficile infection. It should
be borne in mind that antibiotics are not needed for simple coughs and colds. In
some clinical situations, where infection is one of several possibilities and the patient
is not showing signs of systemic sepsis, a wait and see approach to antibiotic
prescribing is often justified while relevant cultures are performed.
This document provides treatment guidelines for the most common situations in
which antibiotic treatment is required. The products and regimens listed here have
been selected by the Trust's Medicines Management Group on the basis of
published evidence. Doses assume a weight of 60-80kg with normal renal and
hepatic function. Adjustments may be needed for the treatment of some patients.
This document provides treatment guidelines for the appropriate use of antibiotics.
The recommendations that follow are for empirical therapy and do not cover all
clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20%
of cases. Alternative recommendations will be made by the microbiologist in
consultation with the clinical team.
This document refers to the treatment of adult patients (unless otherwise stated).
Please refer to up to date BNF/SPC for a full list of cautions, contra-indications,
interactions and adverse effects of individual drugs.

Issue1
June 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 3 of 13

Guideline
Empiric treatment for unknown source of maternal infection / sepsis

Infection
Maternal
sepsis
(unknown
origin)
Clinically
stable

Maternal
sepsis
Severe
sepsis, septic
shock

IV treatment
Oral treatment
First line
Penicillin allergy
First line
Penicillin allergy
Non-severe delayed:
Co-amoxiclav 1.2g tds
Co-amoxiclav 625mg tds No ideal oral options
plus
plus
Cefuroxime 1.5g tds
consider completion
plus
metronidazole 500mg tds if
metronidazole 400mg tds of IV antibiotic
intra-abdominal collection
Metronidazole 500mg tds
if intra-abdominal
course.
suspected
collection suspected
Clindamycin 450mg
Likely IgE / severe delayed:
IV/po qds plus
Clindamycin 600mg qds
ciprofloxacin 500mg
plus
orally bd may be used
metronidazole 500mg tds
where benefit
plus
outweighs risk.
Gentamicin stat
Choose appropriate route based on clinical condition
Non-severe delayed:
Piperacillin/tazobactam 4.5g
Step down based on
tds
Meropenem 1g tds
culture and sensitivity
plus
Likely IgE / severe delayed: results
metronidazole 500mg tds if
intra-abdominal collections
Clindamycin 600mg qds
suspected
PLUS
metronidazole 500mg tds.
Plus gentamicin IV
First dose of antibiotics should be given within 1 hour.
Consider risk of MRSA and consult microbiology if needed.
Consider a stat dose of gentamicin IV review at 24 hours

Issue1
May 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 4 of 13

Total duration
Review at 24 hours.
If no improvement
discuss with micro
Total course length
7 - 10 days

Review at 24 hours.
If no improvement at
24 hours discuss with
microbiology.

Total course length

7 - 10 days

Pyrexia in labour
Procedure

Pyrexia in
labour
defined as:
38.0 C once
or 37.5 C on
two
occasions 2
hours apart

1st line prophylaxis

Penicillin allergy
Previous / current Post delivery doses
Non-severe
Likely IgE / severe MRSA colonised
delayed:
delayed:
Intrapartum fever (>38C) carries a 1 in 167 risk of early onset group B streptococcus infection in the newborn. It may also indicate
intrauterine infection / chorioamnionitis. Therefore therapy is targeted to cover all of these possibilities. Less common causes include
UTIs symptoms should be investigated.
Temperature should be checked every 4 hours during labour. Once pyrexia has been detected, temperature should be checked hourly.
Investigations: FBC, CRP, blood cultures, urine for culture and sensitivity and a vaginal swab as a minimum. Other investigations e.g,
swabs/pus as directed by Obstetrician. Monitor for other signs of infection; maternal or fetal tachycardia, uterine tenderness and
offensive smelling amniotic fluid
General management: to reduce pyrexia, anti-pyretic (paracetamol), hydration with cold fluids, tepid sponging, reduce ambient
temperature.
Non-infective causes of raised temperature (e.g. misoprostol) are common during labour but usually resolve within 6 hours of delivery
Co-amoxiclav 1.2g IV tds
Cefuroxime 1.5g IV
Clindamycin 600mg Discuss with
Continue antibiotics for 24 hours post
microbiology
(+ metronidazole
IV stat then qds
delivery. If no further episodes of
500mg IV if cplus
pyrexia have occurred and there are
section) tds
IV gentamicin
no other signs of infection stop
antibiotics.
For patients with ongoing signs of infection (raised temperature, CRP, WCC, tachycardia etc.) post delivery antibiotics should be
continued for a minimum of 5 days and investigations performed to identify the source of infection.
For patients with pyrexia in labour associated with a surgical intervention e.g. caesarean section, continue recommended prophylactic
antibiotics for 24 hours post delivery. If no further episodes of pyrexia have occurred and there are no other signs of infection stop
antibiotics.

Issue1
May 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 5 of 13

Treatment of a secondary postpartum haemorrhage due to retained products

Refer to empiric treatment for unknown source of maternal infection / sepsis.
Group B Haemolytic Streptococcus prophylaxis
Procedure

1st line prophylaxis

Group B Haemolytic
Streptococcus
prophylaxis

Benzylpenicillin 3g
IV stat. Then
Benzylpenicillin
1.5g four hourly
until delivery

Issue1
May 2014

Penicillin allergy
Non-severe
Likely IgE / severe
delayed:
delayed:
Clindamicin 900mg IV stat then Clindamycin
900mg eight hourly until delivery

Previous / current
MRSA colonised

Discontinue unless clinical signs

of infection present in patient

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Post delivery doses

Page 6 of 13

Intra-abdominal infections
***NB*** Please note that the following treatment guideline for intra-abdominal infections refer to treatment in pregnant women ONLY. For the
Trust policy on intra-abdominal sepsis in other patient groups, click here.

Intra-abdominal sepsis
1st line

Antibiotics
Co-amoxiclav

Route
IV

Dose
1.2g

Frequency
tds

IV

500mg

tds

IV

4.5g

tds

Discuss with micro

IV

1g

tds

Non-severe delayed:
Meropenem 1g TDS
Likely IgE / severe delayed: Discuss with micro

Add

2nd line
Non- response to first line
Recent ITU admission
Likely pseudomonas
infection
3rd line

Oral continuation

Metronidazole if
collection present
Piperacillin /
tazobactam

Meropenem
Only after
discussion with
microbiology

Co-amoxiclav
Add
Metronidazole if
collection present

Issue1
May 2014

Duration
5-10 days
therapy, but
may be
longer (e.g
liver abscess,
4-6 weeks)

Alternative in penicillin allergy

Non-severe delayed:
Cefuroxime 1.5g IV tds + metronidazole 500mg IV tds
Likely IgE / severe delayed:
Clindamycin 450mg IV/po qds + gentamicin IV

Consider adding gentamicin IV stat if >2 signs and symptoms of sepsis (SIRS)
Review at 24 hours
po
625mg
tds
No ideal oral options consider completion of IV antibiotic
course.
po
400mg
tds
Clindamycin 450mg IV/po qds plus ciprofloxacin 500mg
orally bd may be used where benefit outweighs risk.

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 7 of 13

Urinary tract infections

Antibiotics
Simple cystitis / lower
UTI
1st line
2nd line

Route

Dose

Frequency

Duration

Cefalexin

po

500mg

tds

7 days

Trimethoprim
Nitrofurantoin

po
po

200mg
50mg

bd
qds

7 days

Alternative in
penicillin allergy
See below (if
anaphylaxis)

Comments

NA

Avoid in 1st trimester

Avoid in renal impairment or 3rd
trimester or breast feeding

Clindamycin and macrolides (erythromycin, clarithromycin) are not excreted in the urine therefore are not suitable treatment
Amoxicillin may be used where sensitivities are known.
Co-amoxiclav may be used but cefalexin is preferred as more narrow spectrum

IV therapy
Antibiotics
Pyelonephritis /
Complicated UTI

Co-amoxiclav

Severe uro-sepsis
st
Failure of 1 line
Recent ITU
admission
Culture +ve for
pseudomonas

Piperacillin /
tazobactam (Tazocin)

Oral Phase
Trimethoprim
Cefalexin
Co-amoxiclav
Issue1
May 2014

Route

Dose

Frequency

Duration

Alternative in penicillin
Comments
allergy
IV
1.2g
tds
7-14 days Non-severe delayed:
Cefuroxime 750mg-1.5g tds
Likely IgE / severe
delayed:
Gentamicin IV
Non-severe delayed:
IV
4.5g
tds
Meropenem 1g TDS
Likely IgE / severe
delayed:
Discuss with micro
Consider addition of gentamicin IV stat if >2 signs and symptoms of sepsis (SIRS)
Review at 24 hours
According to cultures and sensitivities
Avoid in 1st trimester
po
200mg
bd
10-14 days
See alternatives
in total
po
500mg
tds
po
625mg
tds
Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 8 of 13

Options for treatment of resistant organisms ESBL / Amp C

Discuss sensitivities with microbiology
Antibiotics
Route
Dose
Frequency
Duration
Fosfomycin
po
3g
Alternate days 3-7 doses
Meropenem

IV

1g

tds

7-14 days

Alternative in penicillin allergy

NA
Non-severe delayed:
Meropenem 1g TDS
Likely IgE / severe delayed: Discuss with
micro

Comments
Unlicensed
Reduce frequency in renal impairment
IV option

Post-operative wound infection post delivery

Procedure
Clean or clean/contaminated
surgery
Contaminated/dirty surgery
1st line

Contaminated/dirty surgery
2nd line:
st
Non-response to 1 line

Oral continuation
MRSA skin colonisation

Antibiotics
Flucloxacillin

Route
IV
po
IV

Dose
1-2g
500mg
1.2g

Frequency
qds
qds
tds

Duration
Total duration 5
to 7 days
According to
response 7-14
days

Alternative in penicillin allergy

Clarithromycin 500mg IV/po bd

Non-severe delayed:
Cefuroxime 1.5g IV tds plus metronidazole
po
625mg
tds
500mg IV tds
Likely IgE / severe delayed: Clarithromycin
500mg IV bd plus metronidazole 500mg IV
tds
Non-severe delayed:
Piperacillin /
IV
4.5g
tds
tazobactam
Meropenem 1g TDS
Likely IgE / severe delayed:
(Tazocin)
Clarithromycin 500mg IV bd + ciprofloxacin
500mg po bd + metronidazole 500mg IV tds
OR Clindamycin 450mg IV/po bd +
ciprofloxacin 500mg po bd
Consider adding IV gentamicin stat if >2 signs and symptoms of sepsis (SIRS)
Review at 24 hours
Modify this according to response & culture / sensitivity results.
Add / substitute (for flucloxacillin) vancomycin IV or teicoplanin if post delivery
Co-amoxiclav

Issue1
May 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 9 of 13

Mastitis / breast abscess

Mastitis / breast abscess
1st line
nd

2 line / mixed infection

Antibiotics
Flucloxacillin

Co-amoxiclav

Issue1
May 2014

Route
IV

Dose
1-2g

Frequency
qds

po
IV

500mg
1.2g

qds
tds

po

625mg

tds

Duration
Total
duration 5 to
7 days.
Up to 2
weeks if
abscess
present or
as clinically
indicated

Alternative in penicillin allergy

Non-severe delayed:
Oral: Cefalexin 500mg po TDS
IV: Cefuroxime 1.5g IV TDS
Likely IgE / severe delayed:
Clarithromycin 500mg IV/po bd
Plus metronidazole 500mg IV / 400mg po
tds for mixed infection or failure to
respond to 1st line

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 10 of 13

Genitourinary infections

Please refer to the Trusts Treatment Management Protocols for Sexually Transmitted Infections.
Gentamicin in pregnancy

Neonatal ototoxicity has not been observed with use of gentamicin in pregnancy however it has
been seen with other aminoglycosides, therefore gentamicin should be used with caution in
pregnancy. Where possible use only a stat dose or the shortest effective course.
For guidance on dosing gentamicin, please refer to the Trust policy on Once Daily Gentamicin
Dosing.
Please note that in pre-eclampsia, gentamicin clearance is reduced and levels should be
checked daily.

Standards

Document the Indication/rationale for antimicrobial therapy, including clinical criteria

relevant to this.

Review and document the patients allergy status

Ensure the choice of antibiotic complies with the antibiotic guidelines and you have
documented any clinical criteria relevant to the choice of agent.

Document a management plan including a stop or review date.

Where relevant, consider drainage of pus or surgical debridement/removal of foreign

material.

Explanation of terms & Definitions

NA

Roles and responsibilities

All clinical staff involved in the prescribing of antimicrobials to adhere to this policy including full
documentation on EPMAR as detailed.

Issue1
May 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 11 of 13

Appendices
Summary of safety information for antibiotics in pregnancy

Antibiotic class
Penicillins

Cephalosporins

Macrolides

Drugs considered safe for routine use in pregnancy

Examples
Safety in
Details
pregnancy
Amoxicillin
First line
Co-amoxiclav
First line
No adverse effects have been
attributed in studies of amoxicillin and
clavulanate in pregnant women.
Pipercillin /
Suitable for use
Limited human data. Animal data
tazobactam
in severe
suggests Non-severe delayed:.
infections.
Cefalexin
First line
Cefotaxime
Ceftriaxone
Cefuroxime
Erythromycin
Second line to
Available data does not indicate an
(excluding
penicillins or
increased risk of congenital
estolate salt)
cephalosporins.
malformations / adverse fetal effects.

Clarithromycin

Metronidazole

Issue1
May 2014

Has been
extensively used
in pregnancy.

Standard treatment for pre-term

premature rupture of membranes

Erythromycin
preferred due to
limited data for
clarithromycin.
Has been
extensively used
in pregnancy.

To date, exposure to during pregnancy

has not been associated with
teratogenic effects.
Mutagenic and carcinogenic in some
animal studies. Available data, in
humans does not indicate an
increased risk of adverse fetal effects.
High dose regimens e.g. 2g stat are
generally not recommended

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 12 of 13

Antibiotic class
Carbapenems

Clindamycin

Fosfomycin

Glycopeptides

Pivmecillinam
(Note this is a
penicillin)

Reserve antibiotic agents or caution in pregnancy

Examples
Safety in
Details
pregnancy
Meropenem
Reserved for serious Limited human data. Animal data
or life-threatening
suggests Non-severe delayed:.
infections.
Ertapenem
No human studies. Animal data
suggests Non-severe delayed:.
Imipenem
Use meropenem
Limited human data suggests Nonsevere delayed:.
May be used in
No reports of congenital defects
pregnancy for
identified.
indicated infections.
Strictly
Number of published reports in humans,
microbiology only
including 1st trimester, without apparent
agent.
harm to newborn
Non-severe delayed:
to fetus, may be
used in pregnancy
for indicated
infections
Vancomycin
May be used in
No reports of congenital defects.
pregnancy for
Potential risk of ototoxicity if
indicated infections
recommended plasma levels exceeded
Ensure strict
monitoring of levels
Microbiology only
Crosses placenta. Limited data in UK
agent.
texts. Extensively used in Scandinavian
countries (first line agent). Cohort
studies do not suggest an increase in
malformations. One cohort study
concluded pivmecillinam was associated
with an increased risk of miscarriage
compared to control (but not a
comparator agent). The study design
did not allow conclusions as to whether
risk was associated with infection or
drug exposure.

Issue1
May 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 13 of 13