Obstetrics and Gynaecology

Differentials

• Chorioamnionitis
• Urinary tract infection
• Pneumonia, influenza, COVID-19

Tests to send

Bloods

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

Microbiology

• Blood cultures
• Urine for C&S
• HVS (if PROM)
• Sputum for C&S
• 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.

PAUSE before prescribing

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

Comments

• N.B. Antenatal infections where the source cannot be elucidated (after meticulous clinical evaluation) should be treated as chorioamnionitis until a definitive diagnosis can be made.
• In cases of severe sepsis+septic shock, refer directly to guideline on severe life-threatening antenatal sepsis .

Indication

Obstetrics - Severe Life-Threatening Antenatal Sepsis – Source Unclear

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

First Line Antimicrobials OR Penicillin Hypersensitivity

N.B. Check lab results for history of resistant organisms, e.g. MRSA, ESBL. ALWAYS contact clinical m icrobiologist for advice.

Meropenem 1g TDS IV

AND

Clindamycin 1.2g QDS IV

N.B. Use meropenem with 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.

Indication

Obstetrics - Chorioamnionitis / Sepsis - Source Unclear

First Line Antimicrobials

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

Benzylpenicillin 2.4g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

Cef-UR-oxime 1.5g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

N.B. Ask patient about the nature of their penicillin hypersensitivity .

N.B. Check lab results  for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

N.B. Check lab results for GBS history.

EMPIRIC 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

If known GBS susceptible to clindamycin, replace vancomycin and metronidazole in regimen above with clindamycin 900mg TDS IV.

Comments

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

Indication

Obstetrics - Listeriosis / Septic Miscarriage

First Line Antimicrobials

N.B. If concern for CNS infection, contact clinical microbiologist for advice.

Amoxicillin 2g four hourly IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

Penicillin Hypersensitivity

N.B. If concern for CNS infection, contact clinical microbiologist for advice.

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 - Malaria - Severe

> 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

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 team or clinical microbiologist.

Diagnostic tests:

• Send EDTA blood (FBC bottle) to haematology laboratory for malaria antigen test and malaria blood film (contact haematology scientist on call if out of hours)

• Send repeat 12 - 24 hours later if initial test is negative.

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 - Malaria - Uncomplicated

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 Artesunate 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 IV Artesunate 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 team for advice on how to complete required treatment to prevent relapse.

Comments

Malaria is a medical emergency.  Always discuss with ID team or clinical microbiologist.

Diagnostic tests:

• Send EDTA blood (FBC bottle) to haematology laboratory for malaria antigen test and malaria blood film (contact haematology scientist on call if out of hours)

• Send repeat 12 - 24 hours later if initial test is negative.

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 - Malaria - Non-falciparum

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 team 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 team 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 team 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 team regarding further required treatment to prevent relapse.

Comments

Malaria is a medical emergency.  Always discuss with ID team or clinical microbiologist.

Diagnostic tests:

• Send EDTA blood (FBC bottle) to haematology laboratory for malaria antigen test and malaria blood film (contact haematology scientist on call if out of hours)

• Send repeat 12 - 24 hours later if initial test is negative.

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 - Meningitis

First Line Antimicrobials

Cef-TRI-axone 2g BD IV (administer first)

AND

Amoxicillin 2g 4 hourly IV (administer second)

AND

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

AND

Consider dexamethasone phosphate 0.15mg/kg (max 10mg per dose) QDS IV for 4 days - discuss with senior obstetrician.

Penicillin Hypersensitivity

Meropenem 2g TDS IV

AND

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

AND

Consider dexamethasone phosphate 0.15mg/kg (max 10mg per dose) QDS IV for 4 days - discuss with senior obstetrician.

N.B. Use meropenem with 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.

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

Please refer to:

• Meningococcal Prophylaxis for Contacts section of these 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 no history of MRSA

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 no history of MRSA

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 no history of MRSA

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 S. 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:

• N.B . Check for history of MRSA infection or colonisation
• Blood cultures if systemically unwell
• Swab pus or exudate from PVC exit site.

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 microbiologist.

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 - Pre-term Pre-labour Rupture of Membranes (PPROM)

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 - Influenza (Flu)

First Line Antimicrobials OR Penicillin Hypersensitivity

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
• For close contacts of confirmed influenza, an individual risk assessment should be made on whether to give oseltamivir prophylaxis .

Duration

5 days

Indication

Obstetrics - Lower Respiratory Tract Infections – Outpatient Treatment

First Line Antimicrobials

Amoxicillin 500mg TDS PO

Penicillin Hypersensitivity

Azithromycin 500mg on day 1, followed by 250mg daily for 4 days.

Take azithromycin at least one hour before or two hours after food.

Duration

5 days

Indication

Obstetrics - Lower Respiratory Tract Infections – Inpatient Treatment

First Line Antimicrobials

Cef-UR-oxime 1.5g QDS IV

AND

Azithromycin 500mg on day 1, followed by 250mg daily for 4 days.

Take azithromycin at least one hour before or two hours after food.

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Cef-UR-oxime 1.5g QDS IV

AND

Azithromycin 500mg on day 1, followed by 250mg daily for 4 days.

Take azithromycin at least one hour before or two hours after food.

N.B. Ask patient about the nature of their penicillin hypersensitivity .

Contact clinical microbiologist for advice.

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 days (5 days for azithromycin)

Indication

Obstetrics - Tonsillitis (Bacterial)

First Line Antimicrobials

Phenoxymethylpenicillin 666mg QDS PO

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Azithromycin 500mg on day 1, followed by 250mg daily for 4 days.

Take azithromycin at least one hour before or two hours after food.

Comments

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

Duration

5 days. Depending on clinical response, duration can be extended to 10 days (except for azithromycin, for which 5 days is the total course).

If scarlet fever is suspected or confirmed, it is advisable to treat for 10 days duration (except for azithromycin, for which 5 days is the total course).

Indication

Obstetrics - Urinary Tract Infection -  Asymptomatic Bacteriuria or Cystitis

First Line Antimicrobials

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

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

OR

Cef-AL-exin 500mg TDS PO (if > 36 weeks gestation)

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

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

OR

Cef-AL-exin 500mg TDS PO (if > 36 weeks gestation)

N.B. Ask patient about the nature of their penicillin hypersensitivity .

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

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, cef-AL-exin 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 Infection – Pyelonephritis

First Line Antimicrobials

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

Cef-TRI-axone 2g daily IV (if no history of ESBL)

+/- if severe

Gentamicin 5mg/kg once daily IV

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

Cef-TRI-axone 2g daily IV (if no history of ESBL)

+/- if severe

Gentamicin 5mg/kg once daily IV

N.B. Ask patient about the nature of their penicillin hypersensitivity .

N.B. Check lab results for history of resistant organisms, e.g. ESBL.

N.B. Check lab results for GBS history.

Contact clinical microbiologist for advice.

Comments

• Always review empiric therapy after 48 hours in conjunction with C&S results.

Duration

10 – 14 days

Indication

Obstetrics - Varicella Zoster Virus (VZV) Post Exposure Prophylaxis

First Line Prophylaxis

See Irish Immunisation Guidelines, Varicella chapter, 2022

Indication

Obstetrics - Vulvovaginal Candidiasis

First Line Antimicrobials

Clotrimazole 500mg vaginal pessary at night for up to 7 nights

Clotrimazole 1% or 2% cream may also be used topically 2 to 3 times daily.

Comments

Please discuss with clinical microbiologist if patient has PPROM.

Please contact clinical microbiologist for advice if patient has recurrent candidiasis.

Indication

Obstetrics - Intrapartum Group B Streptococcus (GBS) Prophylaxis

In OLOL, risk factor based screening is the usual approach, see below algorithm from HSE National Clinical Practice Guideline Prevention of Early-Onset Group B Streptococcal Disease in Term Infants, 2023.

In addition, for patients with a known immediate-onset or severe penicillin hypersensitivity , universal screening for GBS with low vaginal/rectal swab is recommended at 35 to 37 weeks gestation.  If GBS is detected, C&S will be performed in the laboratory to determine the susceptiblity profile.

First Line Antimicrobials

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

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

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

N.B. Ask patient about the nature of their penicillin hypersensitivity .

N.B. Check lab results for GBS history.

EMPIRIC Vancomycin 20mg/kg by IV infusion TDS, max 2g per dose until delivery (max rate 10mg/min)

If known GBS susceptible to clindamycin, replace vancomycin with clindamycin 900mg TDS IV.

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

First Line Antimicrobials

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

Benzylpenicillin 3g STAT IV then 2.4g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

Post-delivery, change to Co-amoxiclav 1.2g TDS IV AND Gentamicin 5mg/kg once daily IV

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

N.B. Check lab results for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

Cef-UR-oxime 1.5g QDS IV

AND

Gentamicin 5mg/kg once daily IV

AND

Metronidazole 500mg TDS IV

N.B. Ask patient about the nature of their penicillin hypersensitivity .

N.B. Check lab results  for history of resistant organisms, e.g. ESBL. If present, contact clinical microbiologist for advice.

N.B. Check lab results for GBS history.

EMPIRIC 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

If known GBS susceptible to clindamycin, replace vancomycin and metronidazole in regimen above with clindamycin 900mg TDS IV.

Comments

Microbiological Investigations:

• Blood cultures
• Urine for C&S
• HVS (if PROM)
• Sputum for C&S
• 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.

If the patient does not respond to initial empiric treatment or is severely unwell, contact clinical microbiologist for advice.

Indication

Obstetrics - Severe Life-Threatening Postnatal Sepsis – Source Unclear

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

First Line Antimicrobials

N.B. Check lab results for history of resistant organisms, e.g. MRSA, ESBL. ALWAYS contact clinical microbiologist for advice.

Meropenem 1g TDS IV

AND

Clindamycin 1.2g QDS IV

N.B. 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.

Indication

Obstetrics - Mild Infection - C-section Wound / Endometritis / Perineal / post-ERPC

First Line Antimicrobials

Co-amoxiclav 625mg TDS PO

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Cef-AL-exin 500mg TDS PO

AND

Metronidazole 400mg TDS PO

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 - Moderate to Severe Infection - C-section Wound/ Endometritis/ Perineal/ post-ERPC/ Third or Fourth Degree Tear/ Source Unknown

First Line Antimicrobials

N.B. Check lab results for history of resistant organisms, e.g. MRSA, ESBL. If present, contact clinical microbiologist for advice.

Co-amoxiclav 1.2g TDS IV

AND

Gentamicin 5mg/kg once daily IV

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

N.B. Check lab results for history of resistant organisms, e.g. MRSA, ESBL. If present, contact clinical microbiologist for advice.

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

N.B. Ask patient about the nature of their penicillin hypersensitivity .

N.B. Check lab results  for history of resistant organisms, e.g. MRSA, ESBL. If present, contact clinical microbiologist for advice.

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

First Line Antimicrobials

Flucloxacillin 1g QDS PO

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Cef-AL-exin 1g QDS PO

Clindamycin 450mg QDS PO

Duration

7 days

Indication

Obstetrics - Mastitis/ Breast Abscess – Severe

First Line Antimicrobials

Flucloxacillin 2g QDS IV if no history of MRSA

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.

Cef-UR-oxime 1.5g QDS IV if no history of MRSA

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.

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:
  • MRSA screen
  • Blood cultures
  • Breast milk for C&S
  • Breast swab (if discharging abscess) for C&S.

Indication

Obstetrics - Nipple Thrush and Ductal Candidiasis

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. N.B . 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.

Second line treatment:

Fluconazole for ductal candidiasis should only be commenced after senior clinician review.

If symptoms persist for more than 5 - 7 days, consider oral treatment of mother with fluconazole in addition to topical treatment as above: Loading dose fluconazole 300mg PO, followed by 150mg daily PO for a total of 14 days of treatment.

Duration

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

Fluconazole PO: 14 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

Sepsis post-medical TOP: Mild to Moderate

First Line Antimicrobials

Doxycycline 100mg BD PO for 14 days

AND

Metronidazole 400mg BD PO for 14 days

AND

Cef-TRI-axone 1g IM stat

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

Doxycycline 100mg BD PO for 14 days

AND

Metronidazole 400mg BD PO for 14 days

AND

Cef-TRI-axone 1g IM stat

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Contact Gynaecology Consultant for advice.

Comments

Microbiological Investigations:

• Blood cultures if systemically unwell

• MSU

Duration of Treatment

Duration of each agent as listed in the dosing section.

Indication

Sepsis post-medical TOP: Severe

First Line Antimicrobials

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

AND

Metronidazole 400mg BD PO  (excellent oral bioavailability) or Metronidazole 500mg BD IV only where oral route is not feasible

AND

Cef-TRI-axone 2g daily IV

Empiric IV to oral switch: Doxycycline 100mg BD PO AND Metronidazole 400mg BD PO to complete 14 days total.

NON-immediate-onset and NON-severe Penicillin Hypersensitivity

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

AND

Metronidazole 400mg BD PO  (excellent oral bioavailability) or Metronidazole 500mg BD IV only where oral route is not feasible

AND

Cef-TRI-axone 2g daily IV

Empiric IV to oral switch: Doxycycline 100mg BD PO AND Metronidazole 400mg BD PO to complete 14 days total.

IMMEDIATE-onset or SEVERE Penicillin Hypersensitivity

Contact Gynaecology Consultant for advice.

Comments

Microbiological Investigations:

• Blood cultures if systemically unwell

• MSU

Duration of Treatment

Duration of each agent as listed in the dosing section.