Antibiotic regimens for endometritis after delivery

 

Abstract

Background

Postpartum endometritis, which is more common after cesarean section, occurs when vaginal organisms invade the endometrial cavity during labor and birth. Antibiotic treatment is warranted.

Objectives

The effect of different antibiotic regimens for the treatment of postpartum endometritis on failure of therapy and complications was systematically reviewed.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007).

Selection criteria

Randomized trials of different antibiotic regimens for postpartum endometritis, after cesarean section or vaginal birth, where outcomes of treatment failure or complications were reported were selected.

Data collection and analysis

We abstracted data independently and made comparisons between different types of antibiotic regimen based on type of antibiotic and duration and route of administration. Summary relative risks were calculated.

Main results

Thirty-nine trials with 4221 participants were included. Fifteen studies comparing clindamycin and an aminoglycoside with another regimen showed more treatment failures with the other regimen (relative risk (RR) 1.44; 95% confidence interval (CI) 1.15 to 1.80). Failures of those regimens with poor activity against penicillin resistant anaerobic bacteria were more likely (RR 1.94; 95% CI 1.38 to 2.72). In three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, no differences were found in recurrent endometritis or other outcomes. In four studies comparing once daily with thrice daily dosing of gentamicin there were fewer failures with once daily dosing. There was no evidence of difference in incidence of allergic reactions. Cephalosporins were associated with less diarrhea.

Authors' conclusions

The combination of gentamicin and clindamycin is appropriate for the treatment of endometritis. Regimens with activity against penicillin-resistant anaerobic bacteria are better than those without. There is no evidence that any one regimen is associated with fewer side-effects. Once uncomplicated endometritis has clinically improved with intravenous therapy, oral therapy is not needed.

 

Plain language summary

Antibiotic regimens for endometritis after delivery

Intravenous gentamicin plus clindamycin more effective than other antibiotics for endometritis after childbirth.

Inflammation of the lining of the womb (postpartum endometritis), also known as puereral fever, is caused by infection entering the womb (uterus) during childbirth. It occurs in about 1% to 3% of births, and is up to ten times more common after caesarean section. Prolonged rupture of membranes and multiple vaginal examinations also appear to increase the risk. Endometritis causes fever, uterine tenderness and unpleasant-smelling lochia, and it can have serious complications such as abscess formation, sepsis and blood clots. It is also an important cause of maternal mortality worldwide, although this is very rare in high-income countries with the use of antibiotics. There can be early-onset form, occurring within 48 hours, or late-onset, up to six weeks after the birth. There are many antibiotic treatments currently in use. The review compared different antibiotics, routes of administration and dosages. The review identified 39 studies involving 4221 women, although overall they were not methodologically strong and often funded by the drug companies. The combination of intravenous gentamicin and clindamycin, and drugs with a broad range of activity against bacteria including certain penicillin-resistant strains, were found to be most effective for treating endometritis after childbirth. There was no evidence that any treatment had fewer adverse effects than others, but no studies looked at outcomes on the baby and there are no data on the possible development drug resistance. If the endometritis was uncomplicated and improved with intravenous antibiotics, there was no need to follow with an oral course of drugs.

 

摘要

背景

產後子宮內膜炎的抗生素處方

產後子宮內膜炎在剖腹產之後較常見，是因為陰道的細菌在產程中侵襲子宮內膜腔，需要使用抗生素治療。

目標

系統性回顧各種抗生素處方用於治療產後子宮內膜炎治療失敗及併發症的效果。

搜尋策略

我們搜尋Cochrane Pregnancy和Childbirth Group's Trials Register (2007年1月)。

選擇標準

在剖腹產或自然產後，用於產後子宮內膜炎的各種抗生素處方的隨機試驗，探討其治療失敗或併發症之報告。

資料收集與分析

我們獨立摘錄資料，並且根據抗生素類型與給藥期間和路徑，比較各種不同抗生素處方，計算總結的相關風險。

主要結論

納入39篇試驗、4221名研究對象。15篇研究比較clindamycin加aminoglycoside和其他處方，顯示使用其他處方較易失敗(RR為1.44; 95% CI為1.1 1.80)。這些失敗處方主要是因為對於penicillin阻抗厭氧菌較無作用活性(RR為 1.94; 95% CI為1.38 – 2.72)。3篇研究比較靜脈注射治療後持續口服抗生素治療和無口服治療，發現在子宮內膜炎復發或其他結果方面沒有差異。4篇研究比較每天1次和每天3次的gentamicin，每天1次的失敗較少。過敏反應之發生率並無證據顯示差異。Cephalosporins治療較少發生腹瀉。

作者結論

併用gentamicin和clindamycin適合用於治療子宮內膜炎。併用對於penicillin阻抗厭氧菌有活性的處方優於無併用者。沒有證據證明哪種處方的副作用較少。一旦單純無併發症之子宮內膜炎使用靜脈治療有改善之後，不需要口服治療。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

靜脈注射gentamicin加clindamycin 比其他抗生素更可以有效治療產後的子宮內膜炎。子宮內膜發炎(產後子宮內膜炎)也稱為產褥熱，是因為產程中細菌侵入子宮所引起的。發生率約1% – 3% ，剖腹產後發生之比率更是高達10倍之多。破水時間較長與多次陰道檢查都會增加此風險。子宮內膜炎會引起發燒、子宮壓痛、味道不佳之惡露，也會有嚴重併發症如膿瘍、敗血症和血塊。雖然在有使用抗生素的高收入國家罕見，在全球依舊是造成母親死亡率的重要原因之一。可能是在48小時內發生的早發型、或者是在產後6週發生的遲發型。目前使用的抗生素處方很多種。此回顧比較各種抗生素、給藥途徑與劑量，共納入39篇研究、4221名婦女，不過大多數的研究方法不?周詳有力的且多數由藥廠贊助。併用靜脈注射gentamicin加clindamycin，與可對抗某些penicillin阻抗菌株的廣效藥物，治療產後子宮內膜炎最有效。沒有證據證明哪種治療的副作用較少，也沒有研究探討關於嬰兒的結果，及沒有發生藥物阻抗性之可能性的相關資料。如果是無併發症的子宮內膜炎且使用靜脈注射抗生素有所改善，就不需要再使用口服抗生素藥物。