Antibiotic regimens for endometritis after delivery
Endometritis leading to sepsis is a major cause of maternal death, particularly in developing countries. Compared with other antibiotic regimens, the combination of clindamycin and gentamycin is the most effective treatment for this condiction. However, owing to the high cost of clindamycin, this therapy may be inapplicable in most resource-poor settings.
RHL Commentary by Chongsomchai C
1. EVIDENCE SUMMARY
Thirty-nine randomized trials (involving 4221 participants) of different antibiotic regimens for the treatment of postpartum endometritis after caesarean section or vaginal delivery were included in this review. The main outcome measures in these trials were treatment failure, complications and side-effects. A combination of clindamycin and gentamycin was associated with statistically significantly fewer treatment failures than other antibiotics [relative risk (RR) 1.44; 95% confidence interval (CI) 1.15–1.80]. There were fewer failures with once daily dosage of gentamycin compared with a thrice daily dosage (four trials, 463 women, RR 0.70; CI 0.49–1.00). Regimens of antibiotics not active against penicillin-resistant anaerobic bacteria had significantly more treatment failures. Overall, there were no differences between the antibiotics in terms of side-effects, except for significantly less diarrhoea with second and third generation cephalosporins. Continuation of intravenous treatment with oral treatment did not yield any additional benefits.
All randomized trials which met eligibility criteria specified in the protocol were included and appropriately analysed. A subgroup analysis of the antibiotics by route of delivery could not be conducted owing to lack of adequate data.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Endometritis leading to sepsis is a major cause of maternal death, particularly in developing countries. The incidence of endometritis is higher after caesarean section compared to vaginal delivery. One study from Thailand reported endometritis in 1.1% of 461 postpartum patients during a 2 months survey period (1). In another study in the USA 17% of women developed endometritis following caesarean section (2).
2.2 Applicability of the results
Thirty-four of the 38 trials were conducted in developed countries (32 in the USA and one each in France and Italy). Only four trials were conducted in developing countries. Nevertheless, the results of this review are probably applicable to most developing countries because the etiology of endometritis following delivery is polymicrobial and the pathogens are likely to be the same in all parts of the world.
2.3. Implementation of the intervention
The main barrier to the implementation of clindamycin and gentamycin is the cost of clindamycin. While gentamycin is available in most hospitals in Thailand and is not expensive (costing about US$ 1.5/daily dose, clindamycin is still expensive and not widely available (US$ 60/daily dose). Thus, the recommended combined regimen of gentamycin and clindamycin may not be feasible in Thailand and possibly other developing countries.
A multicentre randomized controlled trial with sufficient power is needed to compare the efficacy of regimens that are currently used in developing countries (and also currently recommended by the World Health Organization (3), e.g. a combination of ampicillin, gentamycin and metronidazole) with the regimen clindamycin plus gentamycin (the gold standard).
Source of support : Faculty of Medicine, Khon Kaen University, Thailand.
Acknowledgement : Dr.Pisake Lumbiganon, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Thailand.
- Patrachai S, Taneepanichskul S, Intaraprasert S, O-Prasertsawat P, Pongthai. A survey of postpartum morbidity in Ramathibodi Hospital. Thai journal of obstetrics and gynecology 1997;9:183-187.
- Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial. Obstetrics and gynecology 2001;98:745-750.
- Mathai M, Sanghvi H, Guidotti RJ. Managing complications in pregnancy and childbirth : a guide for midwives and doctors. Geneva, World Health Organization 2000;S-110 .
This document should be cited as: Chongsomchai C. Antibiotic regimens for endometritis after delivery: RHL commentary (last revised: 27 October 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.