OBSTETRICS & GYNAECOLOGY. Penicillin G 5 million units IV ; followed by 2.5 million units 4hourly upto delivery

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1 OBSTETRICS & GYNAECOLOGY A.OBSTETRICS Infection/Condition/likely organism Intrapartum Group B Streptococcal (GBS) infection; positive mothers Suggested treatment Preferred Penicillin G 5 million units IV ; followed by 2.5 million units 4hourly upto Alternative Ampicillin 2gm IV initial dose followed by 1gm IV 4hourly upto Comment RCOG Green top guideline 36 CDC Guidelines to prevent perinatal GBS If allergic to penicillin(nonanaphylactic) Cefazolin 2gm IV;followed by 1gm IV 8hrly till Preterm premature rupture of membranes (PPROM) Chorioamnionitis Gram (-) rods/ Gram (+) coccus/ Anaerobes Puerperal Sepsis Mixed:- Streptococcus Staphylococcus Gram Negative Bacilli Erythromycin 400mg orally 12 th hrly for10 days 2nd or 3rd gen. Cephalosporins, e.g. Cefuroxime 750mg IV q8h Cefoperazone 1g IV q12h 500mg IV q8h for If penicillin anaphylaxis 900mg IV,8hrly till Amoxycillin 500mg orally 8 th hourly Cefuroxime 250mg orally 12 th h for 10 days Ampicillin 1g IV q6h 500mg IV q8h Gentamicin1 5mg/kg IV q24h for RCOG guidelines RCOG

2 Anaerobes Valvular heart disease requiring prophylaxis β-lactam/β-lactamase inhibitors, e.g. Ampicillin/Sulbactam 1.5g IV q8h for Ampicillin 2g IV+Gentamicin 1.5mg/Kg IV stat. Follow up with Ampicillin 1g IV after 6 hours B.GYNAECOLOGY Infection/Condition/likel Suggested treatment y organism Preferred Pelvic Inflammatory Disease IV THERAPY (for C. Trachomatis moderate to Bacteroides sp. severe disease): Neisseria gonorrhoeae 2nd or 3rd gen. Gardnerella Vaginalis Cephalosporins, e.g. E. Coli Cefuroxime 750mg Streptococcus IV q8h Coagulase-negative Staphylococcus Ceftriaxone 2g IV q24h Doxycycline 100mg PO q12h 400mg PO q8h Duration of treatment is 14 days OUTPATIENT THERAPY (for mild disease): Cefuroxime 250- Alternative Ampicillin/Sulbacta m 3g IV q6h Doxycycline 100mg PO q12h Comment Antibiotic should be changed accordingly after C&S results available CDC/ACOG

3 Vaginitis Bacterial Vaginosis Gardnerella vaginalis 500mg PO q12h Doxycycline 100mg PO bd 400mg PO q8h 500mg PO bd x 300mg PO bd for - In pregnancy, treatment is indicated for symptomatic disease and asymptomati c women at high risk for preterm Candidiasis Candida albicans Fluconazole 150mg PO x 1 day Itraconazole 200mg po bd x 1day Sanford Guide Intravaginal azoles: In pregnancy: Clotrimazole pessary 100mg daily for Trichomoniasis Trichomonas Vaginalis Septic Miscarriage Streptococcus Staphylococcus Gram Negative Bacilli Anaerobes 500mg PO bd for 2g PO stat 2nd or 3rd gen. Cephalosporins, e.g. Cefuroxime 750mg IV q8h Cefoperazone 1g IV q12h Tinidazole 2gm PO single dose Ampicillin 500mg IV q6h 500mg IV q8h Gentamicin1 5mg/kg IV q24h for - Treat male sexual partner (2gm metronidazol e as single dose)

4 500mg IV q8h for Ampicillin/Sulbacta m 1.5g IV q8h for SURGICAL CHEMOPROPHYLAXIS Antimicrobial prophylaxis guidelines are intended to provide practitioners with a standardized approach to rational, safe and effective use of antimicrobial agents for the prevention of surgical site infections based on the currently available clinical information and emerging issues. The key issues that need to be addressed by these guidelines include: 1) Pre-operative dosing: It is recommended that antimicrobial prophylaxis should be started 60 minutes before skin incision. Agents like fluoroquinolones and vancomycin need to be administered 120 minutes before skin incision because they take 1-2hours to show their effect. 2) Selection of drug and dosage: Drug pharmacokinetics may vary in obese individuals. Therefore weight based dosing has its advantages. Choice of agents will depend on the specialities involved and alternative drug regimens need to be provided for beta lactam allergic and MRSA colonized patients.intra-operative redosing may be required for selected antimicrobial agents. 3) Duration of Prophylaxis: Newer guidelines recommend shorter prophylaxis periods. There is very little evidence to support continuing antimicrobial prophylaxis till all catheter and drains are removed. Secondly, duration of prophylaxis may again be debated in cardiac procedures. Guidelines have to be formulated after reviewing the existing data of individual hospitals.

5 Infection/Condition/likely organism 1.OBSTETRICS Caesarean Section Repair of Vaginal/Birth tract trauma/ Manual removal of placenta e.g. third and fourth degree perineal tears Suggested treatment Preferred Alternative Cefazolin 1g IV (single dose before incision) Ampicillin 1g orally stat 500mg IV In patients with beta lactam allergy: 900mg IV+ Gentamicin 5mg/Kg In complicated LSCS (with bowel &/or bladder involvement or possibility of chorioamnionitis): ADD 500mg IV Comment ACOG,AAP and ASHP guidelines GYNAECOLOGY Hysterectomy (Abdominal/Vaginal) Coliforms, Enterococcus, Streptococcus, Clostridia and Bacteroides sp Cefazolin 2gm IV In patients with beta lactam allergy: 900mg IV+ Gentamicin 5mg/Kg Second dose if procedure > 3 hours ASHP guidelines Emergency Laparotomy Cefazolin 1g IV (single dose before incision) In patients with beta lactam allergy: 900mg IV+ Gentamicin 5mg/Kg In bowel &/or bladder involvement ADD

6 500mg IV References 1. Clinical Practice Guidelines for antimicrobial prophylaxis in surgery, Feb Am J Health-Syst Pharm. 2013; 70: Obstetric and medical complications.in: American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village,IL: American Academy of Pediatrics;2008: