Obstetrics and Gynaecology



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Antenatal Infections / Prophylaxis / Sepsis

Differentials

  • Chorioamnionitis
  • Listeriosis / Septic miscarriage
  • Pre-term Pre-labour Rupture of Membranes (PPROM)
  • Severe Life-Threatening Antenatal Sepsis – Source Unclear
  • Urinary tract infection, e.g. cystitis, pyelonephritis

Tests to send

Bloods

  • FBC, CRP, U&E, LFTs, Coag and lactate (if systemically unwell)

Microbiology

  • Blood cultures
  • Urine C&S
  • HVS (if PROM)
  • Sputum C&S
  • Viral nose/throat swab (if influenza suspected)

Pause before prescribing

  • Check computer system for history of resistant organisms, e.g. MRSA, ESBL
  • Checks patient’s allergy status and stage of pregnancy

Comments

Indication

Obstetrics - Chorioamnionitis / Sepsis - Source Unclear 18,21-23

First Line Antimicrobials

Benzylpenicillin 2.4g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-TRI-axone 2g daily IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 900mg TDS IV

AND

Gentamicin 5mg/kg once daily IV

Note : If GBS resistant to clindamycin has been isolated, replace clindamycin with vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV AND metronidazole 500mg TDS IV.

Comments

  • If the patient does not respond to initial empiric treatment or is severely unwell, contact Consultant Microbiologist for advice.

Indication

Obstetrics - Listeriosis / Septic Miscarriage 18,21

First Line Antimicrobials

Amoxicillin 2g four hourly IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

Penicillin Allergy Alternatives

Vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

Indication

Obstetrics - Pre-term Pre-labour Rupture of Membranes (PPROM) 21,23

First Line Antimicrobials

Prophylactic antibiotics recommended if > 20 weeks gestation, clinically well and no evidence of chorioamnionitis or maternal sepsis:

Benzylpenicillin 2.4g QDS IV x 48 hrs (8 doses) AND Azithromycin 1g STAT PO

Followed by: Amoxicillin 250mg TDS PO x 5 days

Penicillin Hypersensitivity

Azithromycin 1g STAT PO

Comments

  • If the patient has systemic signs of sepsis, then manage as per chorioamnionitis guidelines.
  • Microbiological Investigations:
    • HVS for culture
    • Low vaginal swab and rectal swab for Group B Streptococcus
    • First void urine for Chlamydia trachomatis and Neisseria gonorrhoeae
    • Urine for microscopy and culture

Duration

Duration as outlined above.  Duration should not extend beyond labour to the post-partum period.

Indication

Obstetrics - Severe Life-Threatening Antenatal Sepsis – Source Unclear 18,21,22

Definition of Severe Sepsis: Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion

First Line Antimicrobials

Meropenem 1g TDS IV

AND

Clindamycin 1.2g QDS IV

NB. Use meropenem with great caution and close clinical monitoring if history of immediate-onset or severe penicillin hypersensitivity – approximately 1% risk of immediate-onset hypersensitivity to meropenem in patients with history of immediate-onset penicillin hypersensitivity.

NB. Always contact Consultant Microbiologist for advice and if alternative antimicrobial choice required.

Indication

Obstetrics - Urinary Tract Infections -  Asymptomatic Bacteriuria or Cystitis 18,21,24,25

First Line Antimicrobials

Nitrofurantoin 50mg QDS PO (if < 36 weeks gestation)

OR

Cefalexin 500mg TDS PO (if > 36 weeks gestation)

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Nitrofurantoin 50mg QDS PO (if < 36 weeks gestation)

OR

Cefalexin 500mg TDS PO (if > 36 weeks gestation)

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Nitrofurantoin 50mg QDS PO (if < 36 weeks gestation)

OR

Fosfomycin 3g STAT PO (if > 36 weeks gestation)

Comments

  • Avoid nitrofurantoin if > 36 weeks gestation or if delivery is imminent.
  • If pyelonephritis / systemic infection suspected, refer to the guideline on pyelonephritis / systemic infection . Nitrofurantoin, cephalexin and oral fosfomycin are not appropriate treatment options for pyelonephritis / systemic infection.
  • Always review empiric therapy after 48 hours in conjunction with C&S results.
  • A repeat urine sample must be sent after treatment is complete.

Duration

7 days

Indication

Obstetrics - Urinary Tract Infections – Pyelonephritis 18,21

First Line Antimicrobials

Ceftriaxone 2g daily IV

+/- if severe

Gentamicin 5mg/kg once daily IV

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-TRI-axone 2g daily IV

+/- if severe

Gentamicin 5mg/kg once daily IV

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Contact Consultant Microbiologist for advice.

Comments

  • Contact Consultant Microbiologist for advice if history of ESBL colonisation
  • Always review empiric therapy after 48 hours in conjunction with C&S results.

Duration

10 – 14 days


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Peripartum Infections / Prophylaxis

Indication

Obstetrics - Intrapartum Group B Streptococcus (GBS) Prophylaxis 14-16

First Line Antimicrobials

Benzylpenicillin 3g stat dose by IV infusion, then benzylpenicillin 1.8g IV every 4 hours until delivery

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-UR-oxime 1.5g IV stat, then 1.5g QDS IV until delivery

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 900mg TDS IV

OR

If patient is known to have GBS resistant to clindamycin:

Vancomycin 20mg/kg by IV infusion TDS, max 2g per dose until delivery

(Max rate 10mg/min)

Comments

  • In order to optimise the efficacy of intrapartum prophylaxis, the first dose should preferably be given at least 4 hours before delivery; in general administer intrapartum prophylaxis as soon as possible after the onset of labour.

Indication

Obstetrics - Pyrexia in Labour > 38°C 14,15,18,21-23

First Line Antimicrobials

Benzylpenicillin 3g STAT IV then 2.4g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-UR-oxime 1.5g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 900mg TDS IV

AND

Gentamicin 5mg/kg once daily IV

Note : If GBS resistant to clindamycin is isolated, replace clindamycin with vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV AND metronidazole 500mg TDS IV.

Comments

NB . If the patient does not respond to initial empiric treatment or is severely unwell, contact Consultant Microbiologist for advice.


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Postnatal Infections / Sepsis

Indication

Obstetrics - C-section Wound Infection / Endometritis / Perineal Infection / Pelvic Infection post-ERPC – Mild 18,21

First Line Antimicrobials

Co-amoxiclav 625mg TDS PO

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cefalexin 500mg TDS PO

AND

Metronidazole 400mg TDS PO

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 450mg QDS PO

Comments

  • Send wound swab for C&S and review treatment in conjunction with results when available.

Duration

5 - 7 days

Indication

Obstetrics - C-section Wound Infection / Endometritis / Perineal Infection / Pelvic Infection post-ERPC / Infected Third or Fourth Degree Tear – Moderate to Severe 18,21

First Line Antimicrobials

Co-amoxiclav 1.2g TDS IV

AND

Gentamicin 5mg/kg once daily IV

N.B. Check lab system for resistant organisms (e.g. MRSA, ESBL). If colonised with resistant organisms or at risk of resistance, contact the clinical microbiology team to discuss alternative antibiotic cover.

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-UR-oxime 1.5g QDS IV

AND

Metronidazole 500mg TDS IV

AND

Gentamicin 5mg/kg once daily IV

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 900mg TDS IV

AND

Gentamicin 5mg/kg once daily IV

Duration

Minimum 7 days based on C&S results and clinical response

Indication

Obstetrics - Mastitis – Mild 18,21

First Line Antimicrobials

Flucloxacillin 500mg QDS PO

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cefalexin 500mg TDS PO

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 450mg QDS PO

Duration

7 days

Indication

Obstetrics - Mastitis/Breast Abscess – Severe 18,21

First Line Antimicrobials

Flucloxacillin 2g QDS IV

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-UR-oxime 1.5g QDS IV

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Vancomycin  25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

AND

Clindamycin 900mg TDS IV (Review clindamycin at 48hrs)

Comments

  • Surgical referral essential if breast abscess confirmed .
  • Microbiological Investigations:
    • Blood cultures
    • Breast milk for C&S
    • Breast swab (if discharging abscess) for C&S
    • MRSA screen
  • If patient is MRSA positive, contact Consultant Microbiologist to discuss alternative antibiotic choice.

Indication

Obstetrics - Nipple and Breast Thrush 18,21,34-36

First Line Antimicrobials

Nipple treatment for mother:

Miconazole 2% cream applied to nipples and areolae after each feed for 1 to 2 weeks.  It is not necessary to wash the cream from the nipples before the next breastfeed - any excess cream should be wiped away.

Oral treatment for baby:

Miconazole oral gel smeared around inside of mouth four times a day after feeds for 2 weeks. NB . Apply the gel in small amounts with a clean finger and do not use a spoon due to the risk of the baby choking on the viscous fluid.

If symptoms of pain do not improve or deep breast pain develops, oral treatment of mother with fluconazole may be necessary in addition to topical treatment: Loading dose fluconazole 200mg PO, followed by 100mg daily PO for a total of 10 days of treatment.

Duration

Topical treatment for mother and baby should continue until 7 days after symptoms have disappeared.

Fluconazole PO: 10 days.

Comments

  • If a mother reports sore nipples during breastfeeding the first action should always be to re-examine and improve attachment. It is imperative that both mother and baby are treated simultaneously, even when there are no signs in the baby’s mouth. Otherwise the baby will re-infect the mother at each feed. Babies frequently show no signs of oral thrush, even though their mothers have the symptoms.

Indication

Obstetrics - Severe Life-Threatening Postnatal Sepsis – Source Unclear 21,37

Definition of Severe Sepsis: Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion.

First Line Antimicrobials

Meropenem 1g TDS IV

AND

Clindamycin 1.2g QDS IV

NB. Use meropenem with great caution and close clinical monitoring if history of immediate-onset or severe penicillin hypersensitivity – approximately 1% risk of immediate-onset hypersensitivity to meropenem in patients with history of immediate-onset penicillin hypersensitivity.

NB. Always contact Consultant Microbiologist for advice and if alternative antimicrobial choice required.

Comments

  • Initiate hospital sepsis pathway and complete Sepsis Six within 1 hour – refer to section number 7.6.
  • Contact Consultant Microbiologist urgently to discuss.


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Malaria in Pregnancy

Indication

Obstetrics - Severe Malaria in Pregnancy 26-29

> 2% of red blood cells parasitised or end organ damage

Likely organisms

P. falciparum

Antimalarial Treatment

First Line Therapy for Severe Malaria – All Trimesters:

Artesunate IV 2.4mg/kg at 0h, 12h, 24h, then daily

**Please note Quinine IV is no longer available (Jul 2019)**

Switch to oral therapy after at least 24 hours of IV therapy, once patient improving and can tolerate oral medication:

Artemether-Lumefantrine (Riamet®) 20mg/120mg, 4 tablets at 0h, 8h, 24h, 36h, 48h and 60h

N.B. Please note the timing of Riamet® doses relates to time from time zero – see worked example below:

  • Time Zero = 18.00 on 12/8/19
  • Next dose due at 8 hours from time zero = 02.00 on 13/8/19
  • Next dose due at 24 hours from time zero = 18.00 on 13/8/19
  • Next dose due at 36 hours from time zero = 06.00 on 14/8/19
  • Next dose due at 48 hours from time zero = 18.00 on 14/8/19
  • Next dose due at 60 hours from time zero = 06.00 on 15/8/19
  • It will take 60 hours total (2.5 days) for administration of full course.

N.B. Contact Pharmacy Department prior to discharge to ensure continuity of supply as Riamet® is not readily available in the community.

OR

Quinine Sulphate 600mg TDS PO to complete total of 7 days PLUS start Clindamycin 450mg TDS PO for 7 days.

Comments

Malaria is a medical emergency.  Always discuss with ID Consultant or Consultant Microbiologist.

Diagnostic tests:

  • Blood for stained thick and thin films – three samples at least 12 hours apart

  • Request percentage parasitaemia on thin blood film.

Admit patient medically if P. falciparum suspected or confirmed.  Start treatment after laboratory confirmation except in severe disease with strong clinical suspicion.  Patients who have taken malaria chemoprophylaxis should not receive the same drug for treatment.

Please see HPSC Clinical Guidelines on the Management of Suspected Malaria for further information, available at www.hpsc.ie .

Always document travel history for the past 12 months – countries and locations visited, travel dates, prophylaxis taken, prior history of malaria and co-morbidities.  Malaria prophylaxis is not 100% effective and having taken prophylaxis does not rule out the possibility of malaria infection.  The incubation period may be from 8 days up to 1 year.

Indication

Obstetrics - Uncomplicated Malaria in Pregnancy 26-29

Likely organisms

P. falciparum or “species not identified” initially

Antimalarial Treatment

1st Trimester of Pregnancy:

Quinine Sulphate 600mg TDS PO PLUS Clindamycin 450mg TDS PO for 7 days

[If patient cannot tolerate PO due to vomiting, consider IV therapy.  Please note Quinine IV is no longer available (Jul 2019).  There is limited evidence for the use of artemisinin derivatives in pregnancy: data for > 250 pregnant women in the first trimester did not show evidence of teratogenic risk and data for > 1,500 pregnant women in the second and third trimester did not find an increased risk of miscarriages, stillbirths or malformations.  The WHO recommends using artemisinin derivatives as medications of choice for malaria in the second and third trimester.   During the first trimester, due to lack of experience, the WHO views artemisinin derivatives as reserve medications that should not be withheld in an individual case where needed. (Reference: Schaeffer C, Peters P, Miller RK. Drugs during pregnancy and lactation, 3rd Edition. UK: Academic Press; 2014). If IV therapy required in the first trimester for uncomplicated malaria, consider Artesunate IV 2.4mg/kg at 0h, 12h, 24h, then daily and switch to PO therapy as above (Quinine/Clindamycin) as soon as the patient can tolerate PO.]

2 nd or 3 rd Trimester of Pregnancy:

Artemether-Lumefantrine (Riamet®) PO 20mg/120mg, 4 tablets at 0h, 8h, 24h, 36h, 48h and 60h

N.B. Please note the timing of Riamet® doses relates to time from time zero – see worked example below:

  • Time Zero = 18.00 on 12/8/19
  • Next dose due at 8 hours from time zero = 02.00 on 13/8/19
  • Next dose due at 24 hours from time zero = 18.00 on 13/8/19
  • Next dose due at 36 hours from time zero = 06.00 on 14/8/19
  • Next dose due at 48 hours from time zero = 18.00 on 14/8/19
  • Next dose due at 60 hours from time zero = 06.00 on 15/8/19
  • It will take 60 hours total (2.5 days) for administration of full course.

N.B. Contact Pharmacy Department prior to discharge to ensure continuity of supply as Riamet® is not readily available in the community.

[If patient cannot tolerate PO due to vomiting, start with Artesunate IV 2.4mg/kg at 0h, 12h, 24h, then daily and change to PO Artemether-Lumefantrine (Riamet®) as soon as patient can tolerate PO].

OR

Quinine Sulphate 600mg TDS PO PLUS Clindamycin 450mg TDS PO for 7 days

If cause of malaria subsequently diagnosed as P. vivax or P. ovale :

To prevent relapse, give chloroquine 310mg PO once weekly until delivery. Once baby delivered, contact ID Consultant for advice on how to complete required treatment to prevent relapse.

Comments

Malaria is a medical emergency.  Always discuss with ID Consultant or Consultant Microbiologist.

Diagnostic tests:

  • Blood for stained thick and thin films – three samples at least 12 hours apart

  • Request percentage parasitaemia on thin blood film.

Admit patient medically if P. falciparum suspected or confirmed.  Start treatment after laboratory confirmation except in severe disease with strong clinical suspicion.  Patients who have taken malaria chemoprophylaxis should not receive the same drug for treatment.

Please see HPSC Clinical Guidelines on the Management of Suspected Malaria for further information, available at www.hpsc.ie .

Always document travel history for the past 12 months – countries and locations visited, travel dates, prophylaxis taken, prior history of malaria and co-morbidities.  Malaria prophylaxis is not 100% effective and having taken prophylaxis does not rule out the possibility of malaria infection.  The incubation period may be from 8 days up to 1 year.

Indication

Obstetrics - Non-falciparum Malaria in Pregnancy 26-29

Likely organisms

P.vivax, P. ovale, P. malariae

Antimalarial Treatment

Treatment of malaria caused by P. vivax, P. ovale, P. malariae - chloroquine-sensitive strains :

Chloroquine 620mg at 0h, then 310mg at 6hr, 24h and 48h

( N.B . Chloroquine base 620mg = chloroquine phosphate 1,000mg = 4 tablets of Avloclor®)

Prevention of relapse if malaria caused by P.vivax or P. ovale :

To prevent relapse, give chloroquine 310mg PO once weekly until delivery. Once baby delivered, contact ID Consultant for advice on how to complete required treatment to prevent relapse.

Treatment of malaria caused by P. vivax resistant to chloroquine :

1st Trimester of Pregnancy:

Quinine Sulphate 600mg TDS PO PLUS Clindamycin 450mg TDS PO for 7 days

AND Discuss with ID Consultant regarding further required treatment to prevent relapse.

2 nd or 3 rd Trimester of Pregnancy:

Artemether-Lumefantrine (Riamet®) 20mg/120mg, 4 tablets at 0h, 8h, 24h, 36h, 48h and 60h

N.B. Please note the timing of Riamet® doses relates to time from time zero – see worked example below:

  • Time Zero = 18.00 on 12/8/19
  • Next dose due at 8 hours from time zero = 02.00 on 13/8/19
  • Next dose due at 24 hours from time zero = 18.00 on 13/8/19
  • Next dose due at 36 hours from time zero = 06.00 on 14/8/19
  • Next dose due at 48 hours from time zero = 18.00 on 14/8/19
  • Next dose due at 60 hours from time zero = 06.00 on 15/8/19
  • It will take 60 hours total (2.5 days) for administration of full course.

N.B. Contact Pharmacy Department prior to discharge to ensure continuity of supply as Riamet® is not readily available in the community.

AND Discuss with ID Consultant regarding further required treatment to prevent relapse.

OR

Quinine Sulphate 600mg TDS PO PLUS Clindamycin 450mg TDS PO for 7 days

AND Discuss with ID Consultant regarding further required treatment to prevent relapse.

Comments

Malaria is a medical emergency.  Always discuss with ID Consultant or Consultant Microbiologist.

Diagnostic tests:

  • Blood for stained thick and thin films – three samples at least 12 hours apart

  • Request percentage parasitaemia on thin blood film.

Admit patient medically if P. falciparum suspected or confirmed.  Start treatment after laboratory confirmation except in severe disease with strong clinical suspicion.  Patients who have taken malaria chemoprophylaxis should not receive the same drug for treatment.

Please see HPSC Clinical Guidelines on the Management of Suspected Malaria for further information, available at www.hpsc.ie .

Always document travel history for the past 12 months – countries and locations visited, travel dates, prophylaxis taken, prior history of malaria and co-morbidities.  Malaria prophylaxis is not 100% effective and having taken prophylaxis does not rule out the possibility of malaria infection.  The incubation period may be from 8 days up to 1 year.


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GBS Antimicrobial Resistance

Benzylpenicillin is the recommended first-line agent for GBS prophylaxis in pregnant patients.

For patients who report penicillin hypersensitivity, ALWAYS check the nature of the reaction to penicillin.

There is limited evidence for the efficacy of alternatives to penicillin to prevent early-onset GBS disease among infants.  Cef-AZ-olin (unlicensed in Ireland) and cef-UR-oxime are both cephalosporins that achieve high intra-amniotic concentrations and are recommended as an alternative to penicillin for intrapartum prophylaxis by the CDC and UK Green Top Guidelines, respectively. 14,15 Clindamycin and vancomycin can be used but are not considered reliable alternatives due to very limited evidence.  In addition, GBS resistance to clindamycin is increasing both nationally and internationally. Therefore, if the penicillin-allergic patient can tolerate cephalosporins (see penicillin hypersensitivity tile), cef-UR-oxime should be administered in preference to either clindamycin or vancomycin.

References

  • Royal College of Obstetricians and Gynaecologists. The Prevention of Early-onset Neonatal Group B Streptococcal Disease. Green-top Guideline No. 36, 3rd Edition, 2017. Available from https://www.rcog.org.uk .
  • Verani JR, McGee L and Schrag SJ. Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC, 2010. Morbidity and Mortality Weekly Report, November 19, 2010 / 59(RR10);1-32. Available from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5910a1.htm?s_cid=rr5910a1_w
  • O’Hanlon M, Ryan D. OLOL GBS resistance data on 52 GBS isolates 2018. On file in OLOL Microbiology Laboratory.
  • Knowles SJ, O’Sullivan NP, Meenan AM, et al.Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG 2014; DOI: 10.1111/1471-0528.12892.


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Other Infections in Pregnancy

Indication

Obstetrics - Bacterial Tonsillitis 18,21

First Line Antimicrobials

Phenoxymethylpenicillin 666mg QDS PO

Penicillin Allergy Alternatives

First trimester: Erythromycin 500mg QDS PO

Second and third trimester: Clarithromycin 500mg BD PO

Comments

The majority of sore throats are viral; most patients do not benefit from antibiotics.

Duration

10 days

Indication

Obstetrics - Influenza (Flu) 18,21,30

First Line Antimicrobials

Oseltamivir 75mg BD

Comments

  • Pregnant women are at increased risk of severe and complicated influenza, including associated hospitalisation and death, compared to non-pregnant women of reproductive age
  • Monitor women carefully for signs of bacterial super-infection (e.g. Group A Streptococcus)
  • Please see https://www.hpsc.ie/a-z/respiratory/influenza/seasonalinfluenza/guidance/ for further information and national guidance on the management of influenza in pregnant patients
  • Pregnant and post-partum contacts in hospital should be given oseltamivir prophylaxis

Duration

5 days

Indication

Obstetrics - Meningitis 18,31

First Line Antimicrobials

Cef-TRI-axone 2g BD IV

AND

Vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

AND

Amoxicillin 2g 4 hourly IV

Penicillin Allergy Alternatives

Meropenem 2g TDS IV

AND

Vancomycin  25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

NB. Use meropenem with great caution and close clinical monitoring if history of immediate-onset or severe penicillin hypersensitivity – approximately 1% risk of immediate-onset hypersensitivity to meropenem in patients with history of immediate-onset penicillin hypersensitivity. 9-12

NB. Contact Consultant Microbiologist for advice and if alternative antimicrobial choice required.

Comments

Microbiological Investigations:

  • Blood cultures
  • EDTA blood sample for PCR
  • CSF
  • Throat swab to detect carriage of N. meningitidis

Duration

Duration depends on causative organism:

  • Neisseria meningitidis : Minimum 7 days
  • Haemophilus influenzae : Minimum 10 days
  • Streptococcus pneumoniae : Minimum 14 days
  • Listeria spp.: Minimum 21 days

Indication

Obstetrics - Meningococcal Prophylaxis 18,31

Please refer to:

  • " Meningococcal Prophylaxis for Contacts " section of antimicrobial guidelines
  • HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis 2012, revised 2016, available from www.hpsc.ie for indications for meningococcal prophylaxis.

Indication

Obstetrics - Peripheral Vascular Catheter (PVC) Infection

First Line Antimicrobials

Flucloxacillin 2g QDS IV

If history of MRSA colonisation, SUBSTITUTE Vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

N.B. Adjust dose if renal impairment, trough level monitoring required, click on link above for calculator and guideline.

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Cef-AZ-olin 2g TDS IV

If history of MRSA colonisation, SUBSTITUTE Vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

N.B. Adjust dose if renal impairment, trough level monitoring required, click on link above for calculator and guideline.

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Clindamycin 450mg QDS PO or 600mg QDS IV (excellent oral bioavailability)

If history of MRSA colonisation, SUBSTITUTE Vancomycin 25mg/kg loading dose (max 2g), followed by 15mg/kg BD IV

N.B. Adjust dose if renal impairment, trough level monitoring required, click on link above for calculator and guideline.

Comments

REMOVE THE INFECTED PVC IMMEDIATELY.

PVCs are a portal of entry for Staph. aureus .  PVC infections can manifest as local phlebitis or bloodstream infections.  The risk of PVC infection may be reduced by:

  • Insertion with care and strict attention to standard precautions
  • Daily review of ongoing need for PVC and removal as soon as no longer required.

Microbiological Investigations:

  • Blood cultures if systemically unwell
  • Swab pus or exudate from PVC exit site
  • N.B . Check for history of MRSA infection or colonisation – this may influence choice of empiric agent.

Duration of Treatment

If blood cultures positive for S. aureus :

  • 14 DAYS MINIMUM IV COURSE from the date of first negative set of blood cultures and absence of deep-seated infection (e.g. endocarditis) on further investigation. Always discuss with Clinical Microbiology team.

If phlebitis with sterile blood cultures:

  • Review at 5 days
  • Review empiric antimicrobial therapy in conjunction with C&S after 48 hours & consider IV to PO switch.

Indication

Obstetrics - Respiratory Tract Infections – Outpatient Treatment 18,21

First Line Antimicrobials

Amoxicillin 500mg TDS PO

Penicillin Allergy Alternatives

1st trimester : Erythromycin 500mg QDS PO

2nd and 3rd trimester : Clarithromycin 500mg BD PO

Duration

7 days

Indication

Obstetrics - Respiratory Tract Infections – Inpatient Treatment 18,21

First Line Antimicrobials

Co-amoxiclav 1.2g TDS IV

AND

1st trimester: Erythromycin 500mg QDS PO

2nd and 3rd trimester: Clarithromycin 500mg BD PO

Penicillin Allergy Alternatives

DELAYED-onset Penicillin Hypersensitivity

Cef-UR-oxime 1.5g QDS IV

AND

1st trimester: Erythromycin 500mg QDS PO

2nd and 3rd trimester: Clarithromycin 500mg BD PO

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Vancomycin 15mg/kg BD IV

AND

1st trimester: Erythromycin 500mg QDS PO

2nd and 3rd trimester: Clarithromycin 500mg BD PO

Comments

  • Consider adding oseltamivir during the influenza season if the patient has clinical signs or symptoms suggestive of influenza
  • Microbiological Investigations:
    • Blood cultures if pyrexial
    • Sputum for C&S
    • Pneumococcal and legionella urinary antigens
    • If viral aetiology suspected, send nose and throat viral swabs (in red-top tube containing viral transport medium) for influenza and SARS-CoV-2 PCR.
    • Rule out TB if suspected

Duration

7 – 10 days

Indication

Obstetrics - Varicella Zoster Virus (VZV) – Post Exposure Prophylaxis during Pregnancy

First Line Prophylaxis

See Irish Immunisation Guidelines, Varicella chapter, 2022

Indication

Obstetrics - Vulvovaginal Candidiasis – Uncomplicated 8,18,21, 32

First Line Antimicrobials

Clotrimazole 200mg vaginal pessary at night for 6 nights

Clotrimazole cream may also be used topically 2 to 3 times daily

Comments

Please discuss with Consultant Microbiologist if patient has PPROM.


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Useful References on Medicines in Pregnancy and Breast-Feeding

NB. The prescriber should always check the safety of each antimicrobial for use in pregnant or breast-feeding patients.

Information on the Safety of Antimicrobials in Pregnancy​

Information on the Safety of Antimicrobials in Breast-Feeding


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Pelvic Inflammatory Disease

Indication

Pelvic Inflammatory Disease - Mild to Moderate – Outpatient Treatment 16,19,35,37

First Line Antimicrobials

Not pregnant or breastfeeding:

Doxycycline 100mg BD PO for 14 days

AND

Metronidazole 400mg BD PO for 14 days

AND

If N. gonorrhoeae strongly suspected, ADD Cef-TRI-axone 1g IM stat

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Contact GU/ID Consultant for advice.

Comments

NB. Refer the patient and partner to the GUM clinic: 086 8241847.

Indication

Pelvic Inflammatory Disease - Severe – Inpatient Treatment 16,19,35,37

First Line Antimicrobials

Not pregnant or breastfeeding:

Cef-TRI-axone 2g daily IV

AND

Doxycycline 100mg BD PO (if cannot tolerate PO, Erythromycin 500mg QDS IV)

AND

Metronidazole 500mg BD IV

Oral switch: Doxycycline 100mg BD PO and Metronidazole 400mg BD PO to complete 14 days total

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Contact ID Consultant for advice.

Pregnant or Lactating Patient:

Cef-TRI-axone 2g daily IV

AND

Erythromycin 500mg QDS PO (if cannot tolerate PO, Erythromycin 500mg QDS IV)

AND

Metronidazole 500mg BD IV

Oral switch: Erythromycin 500mg QDS PO and Metronidazole 400mg BD PO to complete 14 days total

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Contact ID Consultant for advice.

Comments

NB. Refer the patient and partner to the GUM clinic: 086 8241847.


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References

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