Antibiotic Guideline For Obstetrics And Gynaecological Infections:GOI
In 2016 National Centre For Disease Control, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India came out with National Treatment Guidelines for Antimicrobial Use in Infectious Diseases.
Following are major recommendations for Obstetrics And Gynaecological Infections:
- Fluoroquinolones are contraindicated in 1st trimester.
- Cotrimoxazole is contraindicated in 1st trimester.
- Doxycycline is not recommended in nursing mothers. If need to administer doxycycline discontinuation of nursing may be contemplated.
| Infections | Likely organism | Primary treatment (presumptive antibiotics) | Alternate treatment | Remarks |
| Asymptomatic Bacteriuria > 1,00,000 cfu/ ml of bacteria of same species in 2 urine cultures obtained 2-7 days apart. Treat as per sensitivity result for 7 days. | Nitrofurantoin 100 mg Oral, BD for 7 days or Amoxicillin 500 mg Oral BD x 7-10 days . | Oral cephalosporins, TMP-SMX or TMP alone | Screen in 1st trimester. Can cause pylonephritis in upto 25% of all pregnant women. 30 % Chance of recurrence after empirical therapy 1. Few direct effects, uterine hypo perfusion due to maternal anemia dehydration, may cause fetal cerebral hypo perfusion. 2. LBW, prematurity,premature labour, hypertension, preeclampsia, maternal anemia, and amnionitis. Need to document pyuria (Pus cells > 10/HPF) | |
| Group B streptococcal Disease, Prophylaxis and Treatment | Group B Streptococci | IV Penicillin G 5 million units. (Loading dose) then 2.5 -3 million units IV QID until delivery. or Ampicillin 2 gm IV ( Loading dose) then 1 gm QID until delivery | Cefazolin 2 gm IV (Loading Dose) and then 1 gm TID Clindamycin 900 mg IV TID or vancomycin IV or teicoplanin for penicillin allergy | Prevalance very low so the prophylaxis may be required only on culture documented report Associated with high risk of pre-term labour,still birth,neonatal sepsis |
| Chorioamnionitis | Group B streptococcus, Gram negative bacilli, chlamydiae, ureaplasma and anaerobes, usually Polymicrobial | Clindamycin/ vancomycin/ teicoplanin and cefoperazone-sulbactum If patient is not in sepsis then IV Ampicillin | Preterm Birth, 9-11% death rate in preterm infant’s unfavourable neurologic outcome, lesser risk to term infants. |
| Septic abortion | Bacteroides, Prevotella bivius, Group B, Group A Streptococcus, Enterobactereaceae, C. trachomatis, Clostridium perfringens. | Ampicillin 500 mg QID +Metronidazole 500mg IV TDS if patient has not taken any prior antibiotic (start antibiotic after sending cultures) If patient has been partially treated with antibiotics, send blood cultures and start PiperacillinTazobactam or Cefoperazonesulbactam till the sensitivity report is available. | Ceftriaxone 2g IV OD | |
| Endomyometritis and Septic Pelvic Vein Phlebitis | Bacteroides, Prevotella bivius, Group B, Group A Streptococcus, Enterobactereaceae, C. trachomatis, Clostridium perfringens | Same as above. | ||
| Obstetric Sepsis during pregnancy | Group A beta-haemolytic Streptococcus, E.coli, anaerobes. | If patient is in shock and blood culture reports are pending, then start Piperacillin-Tazobactam or Cefoperazone-sulbactam till the sensitivity report is available and modify as per the report. If patient has only fever, with no features of severe sepsis start amoxicillin clavulanate oral 625TDS/IV 1.2 gm TDS Or Ceftriaxone 2gm IV OD+ Metronidazole 500mg IV TDS +/-gentamicin 7mg/kg/day OD if admission needed. MRSA cover may be required if suspected or colonized (Vancomycin/ Teicoplanin) | ||
| Obstetric Sepsis following pregnancy | S. pyogenes, E. coli, S. aureus S. pneumoniae, Meticillin-resistant S. aureus (MRSA), C. septicum & Morganella morganii. | Same as above | Sources of sepsis outside Genital tract Mastitis UTI Pneumonia Skin and soft tissue (IV site, surgical site, drain site etc.) |
| Syphillis | Refer to STD program guidelines |
| Tuberculosis in pregnancy | Similar to NON PREGNANT population with some exceptions (see comment and chapter 8) | Please refer RNTCP guideline WHO has advocated that, all the first line drugs are safe in pregnancy and can be used except streptomycin. SM causes significant ototoxicity to the fetus (Pyrazinamide not recommended by US FDA) 1. Mother and baby should stay together and the baby should continue to breastfeed. 2. Pyridoxine supplementation is recommended for all pregnant or breastfeeding women taking isoniazid as well as to neonate who are being breast fed by mothers taking INH. | Very small chance of transmission of infection to fetus. Late diagnosis can predispose to LBW, prematurity. |
| VIRAL INFECTIONS (NO ANTIBIOTICS TO BE GIVEN) |
| Influenza In pregnancy (seasonal And H1N1) The best preventive strategy is administration of single dose of killed vaccine. | Oseltamivir 75 mg Oral BD for 5 days | Nebulization with Zanamvir respules (2) 5 mg each, BD for 5 days | 1. Tendency for severe including premature labor &delivery. 2. Treatment should begin within 48 hrs of onset of symptoms. 3. Higher doses commonly used in non pregnant population (150 mg) are not recommended in pregnancy due to safety concerns. 4. Chemoprophylaxis can be used in significant exposures. 5. Live (nasal Vaccine) is contraindicated in pregnancy. | Direct fetal infection rare Preterm delivery and pregnancy loss. |
| Varicella | >20 wks of gestation, presenting within 24 hours of the onset of the rash, Aciclovir 800mg Oral 5 times a day IV acyclovir recommended for the treatment of severe complications, > 24 hrs from the onset of rash, antivirals are not found to be useful. | VZIG should be offered to susceptible women < 10 days of the exposure. VZIG has no role in treatment once the rash appears. The dose of VZIG is 125 units / 10kg not exceeding 625 units, IM. | Chickenpox during pregnancy does not justify termination without prior prenatal diagnosis as only. A minority of fetuses infected develop fetal varicella syndrome. |
| PARASITIC INFECTIONS |
| Acute Toxoplasmosis in pregnancy | <18 weeks gestation at diagnosis- Spiramycin 1 gm Oral qid until 16-18 weeks/Pyrimathamine + sulphadizine. Alternate every two weeks– If PCR Positive - >18 weeks gestation and documented fetal infection by positive amniotic fluid PCR. Pyremethamine 50 mg Oral BD x 2 days then 50 mg OD + Sulphadiazine 75 mg/kg Oral x 1 dose then 50mg/kg bd + Folinic Acid (10-20 mg Oral daily) for minimum of 4 weeks or for duration of pregnancy. |
| Malaria In pregnancy | As per national program |
| GENITAL TRACT INFECTIONS |
| Candidiasis | Candida species | Fluconazole oral 150 mg single dose For milder cases- Intravaginal agents as creams or suppositories clotrimazole, miconazole, nystatin. Intravaginal azoles, single dose to 7-14 days. | Non-pregnant- If recurrent candidiasis, (4 or more episodes/year) 6 months suppressive treatment with fluconazole 150 mg oral once a week or clotrimazole vaginal suppositories 500 mg once a week. |
| Bacterial vaginosis | Polymicrobial | Metronidazole500mg Oral BD x 7 days Or metronidazole vaginal gel 1 HS x 5 days Or Tinidazole 2 g orally ODx 3 days Or 2% Clindamycin Vaginal cream 5 gm HS x 5 days | Treat the partner. |
| Trichimoniasis | Trichomonas vaginalis | Metronidazole 2 gm single dose or 500 mg Oral BD X 7 days or Tinidazole 2 gm Oral single doseFor treatment failure – retreat with Metronidazole 500 mg Oral BD X 7 Days, if 2nd failure Metronidazole 2 gm Oral OD X 3- 5 days | Treat sexual partner with metronidazole 2 gm single dose |
| Cervicitis /Urethritis Mucopurulent gonoccocal | Polymicrobial | Ceftriaxone 250 mg IM Single dose + Azithromycin 1 gm single dose OR Doxycycline 100mg BD x 7 day | |
| Pelvic Inflammatory Disease (Salpingitis & tubo-ovarian abscess) | S. aureus, Enterobacteriacae, gonococci, gardenella | Outpatient treatment Ceftriaxone 250 mg IM/IV single dose plus +/- Metronidazole 500 mg BD x 14 days Plus Doxycycline 100 mg BD x 14 Days Inpatient Treatment Clindamycin +ceftriaxone till patient admitted then change to OPD treatment | Drainage of tuboovarian abscess wherever indicated Evaluate and treat sex partner |
| Mastitis without abscess | S. aureus | Amoxycillin clavulunate/Cephalexin 500 mg QID/ OR Ceftriaxone 2 gm OD OR MRSA- based on sensitivities Add Clindamycin 300 QID or Vancomycin I gm IV 12 hourly /teicoplanin 12mg/kg IV 12 hourly x 3 doses followed by 6 once daily IV | |
| Mastitis with abscess | Drainage with antibiotic cover for MRSA Clindamycin 300 QID or Vancomycin 15mg/kg IV 12 hourly (maximum 1gm 12 hourly)/teicoplanin 12mg/kg IV 12 hourly x 3 doses followed by 6 mg once daily IV |
You can read the full Guideline by clicking on the following link :
http://www.ncdc.gov.in/writereaddata/linkimages/AMR_guideline7001495889.pdf
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