Ante-natal infection (chorioamnionitis, PROM with signs of infection, suspected infection in labour)
Severe sepsis or Septic shock
Stable patient: fever and suspected chorioamnionitis
Stable patient with fever and suspected chorioamnionitis (NOT severe sepsis):
- Fever in labour
- Odorous liquor
- Tachycardia
Preferred - Includes penicillin allergy (non-severe):
cefazolin 2g iv tds AND metronidazole 400mg po tds
Alternative - For penicillin allergy (severe) OR MRSA positive patients:
teicoplanin 12mg/kg iv 12 hourly for 3 doses, then 24 hourly* AND clindamycin 600mg iv tds
*See teicoplanin monograph for dose banding, dosing in renal impairment and monitoring.
Deteriorating patient
Deteriorating patient already on cefazolin, teicoplanin or benzylpenicillin:
ADD gentamicin* 5mg/kg iv single dose (Gentamicin is for a maximum of 3 days). Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring.
Consider clindamycin 600mg iv/po tds (stop metronidazole, if clindamycin commenced)
Oral treatment options
Oral options / IV to oral switch
Preferred - Includes penicillin allergy (non-severe):
cefalexin 1g po tds
Alternative - For penicillin allergy (severe):
clindamycin 450mg po tds
MRSA positive: Discuss with Micro/ID
*Gentamicin ototoxicity
Irreversible vestibular and auditory damage can occur with intravenous gentamicin use, even when serum levels are in range, and certain heritable mitochondrial mutations increase this risk. Upon initiation ask:
- Is there any existing hearing problem?
- Is there any family history of deafness or deafness, particularly after receiving antibiotics?
If the patient states yes for any of the above discuss with Micro/ID for alternative antibiotic.
Where gentamicin is being used for more than 2 weeks see Audiometry and intravenous aminoglycosides for advice about frequency of audiometry assessments