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Limited Course of Antibiotic Treatment for

Chorioamnionitis
Lauren Page Black, BA, Lindsay Hinson, MD, and Patrick Duff, MD

OBJECTIVE: We sought to estimate the effectiveness of a patients who delivered by cesarean may have benefited
limited course of antibiotics in treating patients with from a more extended course of antibiotic therapy.
chorioamnionitis. (Obstet Gynecol 2012;119:11025)
METHODS: We conducted a retrospective review of DOI: 10.1097/AOG.0b013e31824b2e29
patients treated for chorioamnionitis at our medical cen- LEVEL OF EVIDENCE: III
ter from 2005 to 2009. Patients received ampicillin plus
gentamicin as soon as the diagnosis was made. Postpar-
tum they received only the next scheduled dose of each
antibiotic. Patients who underwent a cesarean delivery
received either metronidazole or clindamycin immedi-
C horioamnionitis is a common obstetric complica-
tion, occurring in 15% of term pregnancies and in
up to 25% of patients who undergo preterm delivery.1,2
ately after cord clamping. The primary outcome was If chorioamnionitis is treated promptly, serious sequelae
treatment failure, defined as persistent fever requiring are rare. Intrapartum treatment of chorioamnionitis
continuation of antibiotics, surgical intervention, or ad- reduces neonatal morbidity; thus, prompt and effective
ministration of heparin.
treatment is critically important for both the mother and
RESULTS: Of the 423 patients, 282 delivered vaginally, the fetus.3 6 The most tested antibiotic regimen for
and 141 delivered by cesarean. Overall, 399 (94%; 95% chorioamnionitis is a combination of ampicillin, 2 g
confidence interval [CI], 9296%) were treated success-
intravenously every 6 hours, plus gentamicin, 1.5 mg/kg
fully and 24 (6%; 95% CI 3.7 8.3%) failed short-course
treatment. Of the 282 patients who delivered vaginally, every 8 hours.7,8 Metronidazole or clindamycin should
279 (99%; 95% CI 98 100%) were cured with short-term be added to this regimen to enhance coverage of
therapy. Of the 141 who delivered by cesarean, 120 (85%; anaerobic organisms if the patient requires cesarean
95% CI 79 91%) were cured (P<.001). Seventeen of the delivery. Failure to add anaerobic coverage in patients
patients with total treatment failure had endometritis and who undergo a cesarean delivery will result in treatment
responded to continuation of antibiotics. Seven patients failure in up to 25% of patients.2,7
had more serious complications: wound infection (n4) In most published reports of patients with chorio-
and septic thrombophlebitis (n3). All of the serious
amnionitis, antibiotic treatment was continued until
complications occurred after cesarean delivery, and all of
the patient was asymptomatic and afebrile for 24 48
the affected patients either were obese or had prolonged
labor or prolonged rupture of membranes. hours, but this treatment approach was based largely
on expert opinion.9 In 2003, Edwards and Duff10
CONCLUSION: A limited course of antibiotics was suf-
ficient for virtually all patients (99%) with chorioamnio- published a study that compared single-dose postpar-
nitis who had a vaginal delivery. However, a subset of tum antibiotic therapy with extended treatment in
patients with chorioamnionitis. This randomized con-
From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal trolled trial demonstrated that there was no statisti-
Medicine, University of Florida College of Medicine, Gainesville, Florida. cally significant difference in adverse outcomes (2.9%
Presented as a poster at the American College of Obstetricians and Gynecologists compared with 4.3%; P.749) between patients who
Annual Clinical Meeting, May 59, 2012, San Diego, California. had only a single dose of postpartum antibiotics
Corresponding author: Patrick Duff, MD, University of Florida College of compared with those who received an extended
Medicine, Gainesville, FL 32610-0294; e-mail: duffp@ufl.edu.
course of medications (ie, treatment until they had
Financial Disclosure
The authors did not report any potential conflicts of interest.
been afebrile and asymptomatic for a minimum of 24
hours). As a result of this study, an extended course of
2012 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins. antibiotics for chorioamnionitis has no longer been
ISSN: 0029-7844/12 used at our institution.

1102 VOL. 119, NO. 6, JUNE 2012 OBSTETRICS & GYNECOLOGY


The purpose of the present study was to estimate pelvic abscess or incisional abscess), or administration
the adequacy and safety of this limited course of treat- of heparin (for septic pelvic vein thrombophlebitis).
ment for chorioamnionitis in a larger series of patients Persistent fever was defined as a single temperature of
treated over a multiyear period. We wanted to assess 39C or higher after the first postpartum dose of
whether limited-course therapy had waned in effective- antibiotics or two or more temperatures of 38.4C or
ness as a result of changes in patient demographics or higher at least 4 hours apart. Patients identified as
microbial susceptibility to our chosen antibiotics. having therapeutic failures were divided into those
with endometritis and those with the more serious
MATERIALS AND METHODS complications of wound infection, pelvic abscess, and
With approval from the University of Florida Health septic pelvic thrombophlebitis. The treatment failure
Center Institutional Review Board, under a protocol group was analyzed for commonalities that may have
exempted from informed consent, we reviewed all contributed to the development of postpartum compli-
records in our departments electronic database cations. Differences in the primary outcome in patients
coded for a diagnosis of chorioamnionitis from Janu- who had a vaginal delivery compared with a cesarean
ary 1, 2005, through December 31, 2009. The diag- delivery were assessed using the uncorrected 2 test.
nosis of clinical chorioamnionitis was defined by an P.05 was considered significant; 95% confidence inter-
intrapartum temperature of 38C or more and one or vals (CIs) were determined, as appropriate.
more of the following findings: maternal heart rate
greater than 100 beats per minute (bpm), baseline RESULTS
fetal heart rate greater than 160 bpm, uterine tender- Our medical center serves a predominantly indigent,
ness, or foul-smelling amniotic fluid. In addition, rural population. Most patients are insured under the
patients had no other obvious localizing sign of Florida Medicaid Insurance Program or are self-pay.
infection.2 This stringent definition excluded patients The entire group of patients from whom we derived
who may have had transient mild temperature eleva- our study population is presented in Figure 1. As
tions secondary to epidural anesthesia or misoprostol noted in the figure, our final sample included 423
administration. patients, which represented 3.9% of the laboring
At the time the diagnosis of chorioamnionitis was patients during this time period.
made, patients were treated with our standard regi- Of the 423 patients reviewed, 282 delivered
men of ampicillin 2 g intravenously every 6 hours vaginally and 141 delivered by cesarean. Seventy-six
plus gentamicin 1.5 mg/kg every 8 hours, until deliv- percent of patients received epidural anesthesia.
ery, followed by a single postpartum dose at the Overall, 399 (94%; 95% CI 9296%) were treated
appropriate drug-specific time interval.10 This treat- successfully and 24 (6%; 95% CI 3.7 8.3) failed
ment regimen was specified in a set of standing orders treatment. Of the 282 patients who delivered vagi-
to ensure consistent compliance with recommended nally, 279 (99%; 95% CI 98 100%) were cured with
treatment. In patients who had a cesarean delivery, a short-course therapy. Of the 141 who delivered by
single intravenous dose of metronidazole (500 mg) cesarean, 120 (85%; 95% CI 79 91%) were cured
was administered after the neonates umbilical cord (P.001). Of those patients who failed therapy, 17
was clamped to provide specific coverage against had endometritis. The remaining treatment failures
anaerobic organisms. Patients who were allergic to included four patients with wound infections and
penicillin were treated intrapartum with clindamycin
(900 mg intravenously every 8 hours) plus gentamicin
(1.5 mg/kg intravenously every 8 hours) once the Patients within study period (January
diagnosis of chorioamnionitis was established. If these 1, 2005, to December 31, 2009)
N=13,399
patients had a cesarean delivery, metronidazole was
not administered because clindamycin also has excel- Laboring patients Scheduled cesarean; no labor
lent antianaerobic coverage. Fewer than 10% of pa- n=10,843 n=2,556
tients received clindamycin in lieu of metronidazole.
Patients were followed after delivery by a team con- Patients with chorioamnionitis
n=424; 3.9%
sisting of four residents and an attending physician. Excluded for sepsis at time of diagnosis
n=1
We used descriptive statistics to assess the key Study patients
outcome measure, which was therapeutic failure, de- n=423

fined as persistent postpartum fever requiring contin- Fig. 1. Overview of patient population during the study period.
uation of antibiotics, surgical intervention (to drain a Black. Treatment of Chorioamnionitis. Obstet Gynecol 2012.

VOL. 119, NO. 6, JUNE 2012 Black et al Treatment of Chorioamnionitis 1103


three patients with septic vein thrombophlebitis. seven women were obese, defined as a BMI between
These seven patients were categorized as having 30 and 39, or extremely obese, defined as a BMI
serious complications (Fig. 2). higher than 40. One was overweight, defined as a
Of the 17 patients with endometritis, 14 underwent a BMI of 25 to 29. One was of normal weight.
cesarean delivery. The average hospital stay for these Overall, of the 21 treatment failures in the cesar-
patients was 4 days (range 36 days). All except one had ean delivery group, 16 women had either prolonged
received antianaerobic therapy during cesarean delivery rupture of membranes (n6) or a BMI greater than 30
as per our protocol. All subsequently received gentamicin (n10). Six women had both prolonged rupture of
7 mg/kg intravenously every 24 hours and clindamycin membranes and were obese. In the 120 women who
900 mg intravenously every 8 hours until they were had a cesarean delivery and were successfully treated,
afebrile for 24 hours. None of these individuals required 42 had either prolonged rupture of membranes (n3)
surgical intervention. or a BMI higher than 30 (n39). None had both
Four patients had wound infections, all after prolonged rupture of membranes and a BMI higher
cesarean delivery. Their average hospital stay was 4 than 30. The difference in frequency of either pro-
days (range 320 days). Three of these patients had longed rupture of membranes or a BMI higher than
had misoprostol inductions of labor, with lengths of 30 in treatment failures compared with treatment
labor of 27 hours, 28 hours, and 34 hours, and they successes was highly significant (P.01).
subsequently required cesarean delivery for an arrest All patients with treatment failure were identified
of dilation. Their body mass indexes (BMIs, calcu- while they were still hospitalized. A search of our
lated as weight (kg)/[height (m)]2) were 44.8, 31.1, and electronic database demonstrated that none of the
48.5, respectively. The remaining patient had a cesar- patients with an initially uncomplicated hospital
ean delivery at 29 weeks for preterm premature course required readmission to our medical center
rupture of membranes, chorioamnionitis, and malpre- with a delayed complication of chorioamnionitis.
sentation. All patients were discharged home on oral We did not do routine microbiologic studies in
antibiotics; none developed fascial dehiscences. patients with endometritis, wound infection, or septic
Three patients, all of whom delivered by cesar- pelvic vein thrombophlebitis. No patient had drain-
ean, had septic pelvic vein thrombophlebitis (ovarian age of an intra-abdominal abscess for isolation of
vein thrombosis) confirmed by computed tomo- microorganisms.
graphic scan. All received additional antianaerobic
therapy immediately after the umbilical cord was DISCUSSION
clamped. The average hospital stay for these patients Several authors have recommended shorter courses
was 13 days. All patients eventually responded to of antibiotic treatment for chorioamnionitis. In 1997
antibiotics plus intravenous heparin. Two had had Chapman and Owen11 studied 109 women who had
misoprostol inductions of labor, with lengths of labor been treated for chorioamnionitis in the intrapartum
of 27 hours and 20 hours. Their BMIs were 29.2 and period and delivered vaginally. Of these, 55 women
31.1, respectively. The remaining patient was deliv- were given a single dose of antibiotics postpartum and
ered secondary to preterm premature rupture of 54 women were given multiple doses; women in both
membranes, chorioamnionitis, and malpresentation. treatment groups had a similar incidence of failure.
Her BMI was 40.3. For women who delivered vaginally, a single postpar-
The average BMI of the seven patients who tum dose of antibiotics reduced the cost and average
developed serious complications was 37. Five of the length of hospital stay compared with women who

Total
n=423

Infection resolved Endometritis Serious complications


n=399; 94.3% n=17; 4.0% n=7; 1.7%

Cesarean deliveries Vaginal deliveries Endometritis after Endometritis after Septic vein phlebitis Wound infections after
n=120; 85.1% of 141 n=279; 98.9% of 282 cesarean delivery vaginal delivery after cesarean cesarean delivery
n=14 n=3 delivery n=4
n=3

Fig. 2. Clinical outcome of patients treated with a limited course of antibiotics for chorioamnionitis.
Black. Treatment of Chorioamnionitis. Obstet Gynecol 2012.

1104 Black et al Treatment of Chorioamnionitis OBSTETRICS & GYNECOLOGY


were treated with multiple doses of antibiotics. The complications, five were obese and one was severely
socioeconomic characteristics of the patients in this overweight.
study were similar to those of our patients. All our cases of serious complications occurred
In a prospective, randomized, placebo-controlled, after cesarean delivery. Six of these deliveries were in
double-blinded trial of 36 women who delivered vagi- patients who not only were obese, but also had a
nally, LaBella et al12 found that postpartum antibiotics prolonged period of rupture of membranes. The
added little therapeutic benefit. In both the long and remaining patient had prolonged preterm premature
short arms of the trial, the incidence of persistent infec- rupture of membranes. These findings indicate that,
tion was less than 5% (Pnot significant). whereas single-dose postpartum antibiotic therapy is
Our study supports the conclusions of these re- sufficient for essentially all patients having a vaginal
ports and the previous report from our institution10 delivery and for the majority of patients having a
that a limited course of antibiotics is sufficient post- cesarean delivery, a distinct subset of patients, namely
partum therapy for most patients with chorioamnio- obese patients and those who are delivered by cesar-
nitis, particularly those who deliver vaginally. In the ean after a long period of labor and ruptured mem-
original report by Edwards and Duff,10 the overall branes, may benefit from a more extended course of
treatment failure rate was 4.6% in the short-term antibiotic therapy.
treatment group and 3.5% in the extended treatment
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