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• A leading cause of life-threatening perinatal infections in United States.

• 15–30% of women are asymptomatic carriers.


• Infection rate has decreased from 1.8/1000 in 1990 to 0.34/1000 live births in 2004.
• Early onset infection (80% within 6 hours of delivery)—4% neonatal mortality of term infants INFECTIOUS DISEASES Mastitis and Breast Abscess
and 23% mortality in preterm infants.

Table 7.1. Procedures


INFECTIOUS DISEASESfor collecting clinical specimens for culture of group B Streptococcus
Group B Streptococcus(GBS)
Drug Regimens
at 35–37 weeks’ gestation Table 7.5. Drug regimens for the treatment of mastitis
• Swab the lower vagina (vaginal introitus), followed by the rectum (i.e., insert swab through the anal sphincter) using Cephalexin (Keflex) 500 mg orally every 6 hr for 7 days
Table 7.2. Comparison of key points in the 2002 and 2010 centers for disease control and
the same swab or two different swabs. Cultures should be collected in the outpatient setting by the health care Amoxicillin/Clavulante potassium (Augmentin) 875 mg orally every 12 hr for 7 days
prevention
provider or,guidelines for theinstruction,
with appropriate prevention of patient
by the perinatal group
herself. B streptococcal
Cervical, diseaseor perineal specimens
perianal, perirectal, Azithromycin (Zithromax) 500 mg initially, then 250 mg orally daily for 5–7 days
are not acceptable, and a speculum should not be used for culture collection.
Topic in the Guidelines Key Points Unchanged from 2002 Key Points Changed from 2002 Dicloxacillin 250–500 mg orally every 8 hr for 7 days
• Place the swab(s) into a nonnutritive transport medium. Appropriate transport systems (e.g., Stuart’s or Amies with or
Clindamycin 300 mg orally every 8 hr for 7 days
Universal
withoutscreening
charcoal)forare commercially
Universal screening at 35–37
available. weeks of
GBS isolates Permissive
can remain viable statement for media
in transport limited role of
for several days at
GBS roomacidtemperature;
amplificationhowever,
gestation remains the
the recovery sole strategy
of isolates for IAP.
declines nucleic
over one to four days, especially at elevated tempera- Source: Reproduced with permission from Hager, W. David. Managing mastitis. Cont Ob/Gyn. 2004:Jan;33-47.
teststures,
for intrapartum
which can lead to false-negative results. When feasible, specimens should be refrigerated before processing. Cont Ob/Gyn is a copyrighted publication of Advanstar Communications Inc. All rights reserved.
GroupforBGBS
testing Streptococcus INFECTIOUS DISEASES
• Specimen requisitions should indicate clearly that specimens are for group B streptococcal testing. Patients who state
Preterm delivery New and separate algorithms for preterm
that they are allergic to penicillin should be evaluated for risk for anaphylaxis. If a woman is determined to be at high Prevention
labor and for PPROM (see Fig. 7.1 and
risk for anaphylaxis,* susceptibility testing for clindamycin and erythromycin
Fig. 7.2)
should be ordered. • Avoid cracked or fissured nipples.
Patient allergic to penicillin?
GBS*Patients
specimen collection
with a history ofRectovaginal swab specimens
any of the following collected penicillin
after receiving Transport options clarifiedare considered to be at
or a cephalosporin • Use plain water to clean nipple area (No. soap or alcohol).
and
highprocessing at 35–37
No weeks
risk for anaphylaxis: anaphylaxis, of gestation
angioedema, remains the
respiratory distress, or urticaria.
Identification Yes expanded to include
options • Increase duration of nursing gradually to avoid soreness.
recommendation. use of chromogenic media and nucleic acid
Source: Reproduced from Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immu- • Use breast shield or topical cream to help healing of cracked nipples.
amplification
nization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). testsPrevention of perinatal group B • Place finger in corner of baby’s mouth during feeding to break sucking force.
streptococcal Penicillin
disease— G,revised guidelines
5 million fromdose,
units IV initial CDC, 2010. MMWR Recomm
a historyRep.
Laboratories
Patient with 2010
oftoany
report Nov
GBS
of the 19;59(RR-
in 10):1-36.
concentrations
following • Treat recurrent mastitis promptly but continue breastfeeding.
then 2.5–3.0 million units† every 4 hr until delivery of greater
after receiving thanororaequal
penicillin to 104 CFU
cephalosporin? § in urine INFECTIOUS DISEASES 2015 CDC STI Treatment Guidelines
or culture specimens (previously, it was GBS “in
Anaphylaxis Patient Information: What to Do If You Develop Mastitis?
any concentration”)
Ampicillin, 2 g IV initial dose, Angioedema Table 7.6. Patient information: what to do if you develop mastitis
Intrapartum antibiotic Penicillin
4 hrremains drug of choice with RespiratoryDefinition
distressof high risk for anaphylaxis is
prophylaxis
then 1 g IV every until delivery
ampicillin as an alternative. Cefazolin Urticariaclarified
Bacterial Vaginosis
If you have symptoms that suggest you have mastitis, you’ll need to heed the following advice:
remains the drug of choice for penicillin Minor change in penicillin dose permitted Table 7.36. 2015 CDC guidelines for treatment of bacterial vaginosis
allergy without anaphylaxis, angioedema, • Continue
Treatment is breastfeeding,
recommended starting on the affected
for all symptomatic side. women.
pregnant
No
respiratory distress, or urticaria. Erythromycin
Yes is no longer recommended
under any circumstances • If your baby doesn’t feed well or will not feed on the affected breast, empty the breast using a piston-type, hospital
387
GBS isolates from women at high risk of
D- test recommended to detect inducible 7 Recommended
breast pump.Regimens
anaphylaxis should be tested for uscep- • If possible, remain in bed
tibility to 2clindamycin and erythromycin. resistance in isolates tested for susceptibility

Metronidazole 500 mg orallyfortwice
the first
a day48 for
hr. 7 days
Cefazolin, g IV initial dose, Isolate susceptible
to to clindamycin
clindamycin and erythromycin • Drink more fluids.
then 1Vancomycin
g IV every 8use is recommended
hr until delivery if and erythromycin**? Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
isolate is resistant to either clindamycin or • Reduce your
Clindamycin salt intake.
cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
erythromycin. • Take acetaminophen or ibuprofen to reduce fever and discomfort so milk letdown will occur and the breast can be emptied.
Other obstetric No Data are not sufficient
Yes to make recommen- Alternative Regimens:
• Apply moist heat to speed up milk letdown and ease soreness; cool packs may be used initially to decrease swelling.
management issues dations regarding the timing of procedures Tinidazole 2 g orally oncetodaily
intended to facilitate progression of labor, • Apply gentle massage moveforthe
2 milk
daysforward and increase drainage from the infected area.

such as amniotomy, in GBS-colonized Tinidazole 1 g orally


• Avoid breast shells once dailyfitting
and tight- for 5bras.
days
Vancomycin, 1 g IV women.Clindamycin, 900 mg IV Clindamycin
• Avoid tight300 mg orally
clothing twice daily
and underwire for 7 days
bras.
every 12 hr until delivery everyantibiotic
8 hr until prophylaxis
delivery Clindamycin bedtime for 3 days*
Intrapartum is optimal • Wash yourovules
hands100 mghandling
before intravaginally once atbreast.
the infected
if administered at least 4 hours before
• Lanolin creamsovules
*Clindamycin may beuseused to treat nipples.
an oleaginous base Your physician
that might may latex
weaken prescribe medication
or rubber if you
products develop
(e.g., a fungal
condoms and vaginal
delivery; therefore, such procedures should
dd 387 Figure 7.4. Recommended regimens for intrapartum antibiotic prophylaxis forif possible.
prevention of infection
12/1/16 8:26ofAM
contraceptive the nipple. Use of such products within 72 hours following treatment with clindamycin ovules is not
diaphragms).
be timed accordingly,
recommended.
• Make sure your baby is in a comfortable nursing position that does not pull excessively on your nipple; if necessary,
early-onset group B streptococcal (GBS) disease* No medically necessary obstetric procedure
talk to a Reproduced
Source: lactation consultant to evaluate
from Workowski your
KA, nursing
Bolan GA.technique.
Sexually transmitted diseases treatment guidelines, 2015.
IV, intravenously. should be delayed in order to achieve
* Broader spectrum agents, including an agent active against GBS, 4might hoursbe of necessary for treatment
GBS prophylaxis before of delivery. INFECTIOUS
MMWR
• If you Recomm DISEASES
Rep.
have a fever, 2015
the Jun may
doctor 5;64(RR-03):1-137. 2015
prescribe antibiotics for 7–10 days. CDC aSTI
Schedule Treatment
follow- Guidelines
up appointment PID
in 7 days
chorioamnionitis. so that the doctor can check for an abscess. If your symptoms don’t respond within 48 hr of antibiotic treatment,
Newborn management Algorithm now applies to all newborns,
INFECTIOUS
† Doses ranging DISEASES
from 2.5 to 3.0 million units are acceptable for the doses whether administered every
Intra-
or not from GBS- 4 hoursmothers.
Amniotic
positive following
Infection Trichomoniasis
notify the physician.
the initial dose. The choice of dose within that range should be guided byClarificationwhich formulations of penicillin G are Table
Table 7.43.
7.37.
Source:
2015
Reproduced
CDC
2015with
CDC guidelines
guidelines
permission
for
for treatment
treatment
from Hager,
of pelvic
W. David.ofManaging
inflammatory
trichomoniasis disease (PID)
mastitis. Cont Ob/Gyn. 2004:Jan;33-47.
of “adequate” IAP. See full
readily available to reduce the need for pharmacies to specially prepare doses. CDC guidelines for details. Cont Ob/Gyn is a copyrighted publication of Advanstar Communications Inc. All rights reserved.
Parenteral Regimens
INTRA-
CDC, Centers
AMNIOTIC INFECTION
§ Penicillin-allergic patients with a history of anaphylaxis, angioedema, respiratory distress, or urticaria following Non-pregnant Patient Recommended Regimens
administration of for Disease
penicillin orControl and Prevention;
a cephalosporin CFU, colony-
are considered forming
to be units;
at high riskGBS, group B streptococci;
for anaphylaxis and shouldIAP, not Cefotetan 2 g IV
Metronidazole 2 every 12inhours
g orally PLUSdose
a single Doxycycline 100 mg orally or IV every 12 hours
Definition
intrapartum antibiotic
receive penicillin, prophylaxis;
ampicillin, PROM, premature
or cefazolin rupture of membranes.
for GBS intrapartum prophylaxis. For penicillin-allergic patients who do not
Cefoxitin 22g gIVorally
everyin6ahours
have a history
Source: of those with
Reproduced reactions, cefazolin
permission from is the preferred
American agent
College because pharmacologic
of Obstetricians data suggest
and Gynecologists Committeeit achieves
on Tinidazole singlePLUS
doseDoxycycline 100 mg orally or IV every 12 hours
•Obstetric
A bacterial infection of the chorion, amnion, and amniotic fluid often diagnosed during
Practice. ACOG
effective intraamniotic Committee Opinion
concentrations. VancomycinNo. and
485:clindamycin
Prevention of early-onset
should group Bforstreptococcal
be reserved disease
penicillin-allergic womenin
a Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance
Alternative Regimens:
prolonged
newborns.
at high riskObstet labor.
Gynecol. 2011 Apr;117(4):1019-27. Copyright © 2011 The American College of Ohstetricians
for anaphylaxis.
dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted.
398
and¶Gynecologists.
If laboratory facilities are adequate, clindamycin and erythromycin susceptibility testing should be performed Metronidazole 500 mgRegimen:
Alternative Parenteral orally twice a day for 7 days
Diagnosis
on prenatal GBS isolates from penicillin-allergic women at high risk for anaphylaxis. If no susceptibility testing is Pregnant Patient Recommended Regimens
Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours
•performed,
Maternal or the results are not
temperature available
100.4° at theC
F/38.0° time of labor,
with vancomycin
no other obvious is source
the preferred agentofforthe
and one GBS intrapar-
following
388
tumadditional
prophylaxis findings:
for penicillin-allergic women at high risk for anaphylaxis. Metronidazole 2
Recommended g orally in a singleRegimens
Intramuscular/Oral dose

◦ ** Resistance to erythromycin is often but not always associated with clindamycin resistance. If an isolate is
Fetal tachycardia Source: Reproduced
Ceftriaxone 250 mg IMfrom
in a Workowski
single dose KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015.

resistant to erythromycin, it might have inducible resistance to clindamycin, even if it appears susceptible to clinda-
Maternal tachycardia
mycin. If a GBS isolate is susceptible to clindamycin, resistant to erythromycin, and testing for inducible clindamycin
MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137.
PLUS
◦ Abdominal
resistance tenderness
has been performed and is negative (no inducible resistance), then clindamycin can be used for GBS Doxycycline 100 mg orally twice a day for 14 days
◦ Foul-prophylaxis
intrapartum smelling amniotic fluid
instead of vancomycin. WITH* or WITHOUT
◦ Leukocytosis
Source: Reproduced from Verani JR, McGee L, Schrag SJ; Division of Bacterial Diseases, National Center for Immu-
Metronidazole 500 mg orally twice a day for 14 days

nizationPositive
and Respiratory
amniotic Diseases,
fluid Centers
culturefor Disease Control and Prevention (CDC). Prevention of perinatal group B
streptococcal disease—revised guidelines from CDC, 2010. MMWR Recomm Rep. 2010 Nov 19;59(RR-10):1-36.
INFECTIOUS DISEASES Antibiotic Prophylaxis
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose
INFECTIOUS DISEASES
Risk Factors Febrile Morbidity and Endomyometritis
shp-gordon-batch3.indd 398 PLUS 12
• Prolonged rupture of membranes 393 ANTIBIOTIC PROPHYLAXIS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
•FEBRILE
Multiple MORBIDITY
vaginal exams in labor
AND and internal monitoring
ENDOMYOMETRITIS Table Antimicrobial
7.48. 500 prophylactic regimens by procedure
3.indd 388 Metronidazole
12/1/16 8:28 AM mg orally twice a day for 14 days
Definition
Antibiotics Other parenteral third-generation cephalosporin (e.g., ceftizoxime
Procedure or cefotaxime)Dose (Single Dose)
Antibiotic
• Mezlocillin
Two 4 g IVelevations
temperature q4–6hrs or topiperacillin 3–4 gF;IV
>38° C (100.4° q4hrs the first 24 hours after delivery)
outside PLUS
Hysterectomy Cefazolin† 1 g or 2 g‡ IV
• Ticarcillin/clavulanic
or acid 3.1 g IV q6hrs Doxycycline 100 mg orally twice a day for 14 days
§
• Ampicillin/sulbactam
A temperature of >38.7° 3 gCIV(101.5°
q4–6hrs F) at any time WITH* or WITHOUT
Urogynecology procedures, including those involving mesh Clindamycin plus 600 mg IV
• Ampicillin 2 g IV q6hrs and gentamicin 1.5 mg/kg load then 1.0 mg/kg q8hrs (if delivery by Metronidazole 500 mg orally twice a day for 14 days gentamicin or 1.5 mg/kg IV
Etiology
cesarean section, add clindamycin 900 mg IV q6hrs) 448 quinolone or || 400 mg IV
* The recommended third-generation cephalsporins are limited in the coverage of anaerobes. Therefore, until it is
• Seven Ws of febrile morbidity known that extended anaerobic coverage is not important aztreonam
for treatment of acute 1 g IV
PID, the addition of metronidazole to
Comments
◦Womb (endomyometritis) treatment regimens with third-generation cephalosporins should be considered.

§
Metronidazole plus 500 mg IV
ndd 393 • Some
Windclinicians continue
(atelectesis, antibiotics for 24–48 hours afebrile following delivery.
pneumonia) 12/1/16 8:29 IfAM
allergy precludes the use of cephalosporin therapy, if the community prevalence and individual risk for gonorrhea

• Chorioamnionitis is notinfection
Water (urinary tract an indication for cesarean delivery.
or pyelonephritis) gentamicin
are low, and if follow-up is likely, use of fluoroquinolones for 14 days or 1.5500
(levofloxacin mg/kg IV
mg orally once daily, ofloxacin

• Fetal
Walkoutcome is improved
(deep vein by maternal
thrombosis antibiotic
or pulmonary therapy and ↓ temperature. Give IV fluids
embolism)
daily) can be considered
daily) with||metronidazole
400 mg twice daily, or moxifloxacin 400 mg orally once quinolone 400formg
14IVdays (500 mg orally, twice


andWound
acetaminophen for maternal
(wound infection, and fetal
episiotomy resuscitation.
infection) Laparoscopy None


• Always consider
Weaning other
(breast sources of maternal
engorgement, fever (pyelonephritis,
mastitis, breast abscess) pneumonia, appendicitis).
Source: Reproduced from Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015.
Diagnostic
MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1-137.

• Watch for postpartum
Wonder (drug fever— hemorrhage and dystocia secondary to inadequate uterine action.
wonder drugs) Operative Patient with mastitis or breast engorgement
• Chorioamnionitis may represent a risk factor for cerebral palsy. Tubal
Evaluation MRSA Infections
Sterilization
INFECTIOUS DISEASES
• Physical examination including pelvic exam to rule out hematoma or retained membranes shp-gordon-batch3.indd 448 Laparotomy
Laparotomy Breast segment swollen,
None firm, tender
None 12
• Complete blood count with differential, urinalysis, urine, and blood cultures as indicated MRSA INFECTIONS
Hysteroscopy None
• Chest X-ray, ultrasound as indicated Diagnostic
Chills
Table 7.49. Rates of resistance and dosing of oral agents for treatment of community acquired
Operative No evidence of infection
Treatment MRSAFever to 102°–104° F
infections
Flu-like symptoms
Endometrial ablation
• Cefotetan 1–2 g IV q12hrs
Resistance Typical Adult Oral
Essure
• Mezlocillin 4 g IV q4–6hr or piperacillin 3–4 g IV q4hrs Antimicrobial Agent or Chromotubation
Rates Dosing Doxycycline¶ Comments
Hysterosalpingogram 100 mg orally,
Probable twice daily for 5 days
simple
• Ticarcillin/clavulanate 3.1 g IV q6hrs Infectious mastitis
• Ampicillin/sulbactam 3 g IV q4–6hrs
Clindamycin
IUD insertion 3–24% 300 TIDNone breastbeengorgement
D-test should performed. Excellent
activity against strep. Increasing resistance
• Gentamicin 1.5 mg/kg load then 1.0 mg/kg q8hrs (or 5 mg/kg q24hrs) and clindamycin 900 Endometrial biopsy None
a concern.
mg IV q6hrs (plus ampicillin 2 g IV q6hrs as needed to cover enterococcus) 456
Induced abortion/dilation
Doxycycline Minocycline and evacuation
1
9–24% 100 mgDoxycycline
BID 100 mgand
Doxycycline orally 1 hour before
minocycline. procedure
probably
Perform breast-milk
100 mgMetronidazole
BID activeand 200 tetracycline
against mg orally after procedure
resistant strains.
Comments
394 cultures, leukocyte counts,
Trimethoprim-sulfamethoxazole 0–10%and bacterial
1–2 DScounts
(160/800
500 mg orally, twice daily for 5 days
Low resistance rates in community, reason-
• Continue IV antibiotics until 24–48 hours afebrile and improved physical exam. Urodynamics None
mg) BID able option for empiric therapy.
• Oral antibiotics following IV antibiotics have not been shown to be of proven value. Rifampin <1%device.
IV, intravenously; IUD, intrauterine 600 mg QD Should not be used alone; potential for 7
• If unresponsive following 48–72 hours of IV antibiotics, reexamine the patient. *A convenient time to administer antibiotic prophylaxis is
significant drug interactions.
just before induction of anesthesia.
◦ Consider broadening antibiotic coverage to cover enterococcus if using gentamicin and Fusidic acid <5%Continue nursing
500 mg or
express cefoxitin,
†Acceptable alternatives include cefotetan, milk
TIDmanually Should not be used alone; limited experi-
cefuroxime, or ampicillin-
ence sulbactam.
in children.
clindamycin. ‡A 2-g dose is recommended in women Avoidwith
milka stasis
◦ Consider pelvic abscess. Linezolid
220 lb.
<1% bodymg
600
• hot
mass
PO index
BID greaterExpensive.
compresses
than 35 or weight greater than 100 kg or

◦ Consider septic pelvic thrombophlebitis. §1Antimicrobial


Rates shown are for tetracycline and are • hot
likely to soaks
be <5% or less for doxycycline
agents of choice in women with a history of immediate hypersensitivityand to
minocycline.
penicillin.
◦ Consider drug fever. ||Source: Reproduced
Ciprofloxacin with permission
or levofloxacin from DeLeo FR, Otto M, Kreiswirth BN, Chambers HF. Community-associated
or moxifloxacin.
shp-gordon-batch3.indd 456 methicillin-resistant Staphylococcus aureus. Lancet. 2010 May 1;375(9725):1557-68. Copyright © 2010 Elsevier.
¶If patient has a history of pelvic inflammatory disease or procedure demonstrates dilated fallopian tubes. No
12
Treat iswith
prophylaxis antibiotics
indicated for a study without dilated tubes. Symptoms still present after 48 hours
3.indd 394 12/1/16 11:08 AM Reproduced with permission from ACOG Committee on Practice Bulletins—Gynecology. ACOG Practice
Source:
Bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol. 2009 May;113(5):1180-9.
Copyright © 2009 The American College of Obstetricians and Gynecologists.