Perinattal Joint P Practice C Chorioam mnionitis O Original App proval: 11//06 Type: T Cliniical Guidelin ne R Revision/Re eview Approval: 04.2 23.12 Key K words : chorioamnionitis, ele evated temp perature, maternal m fev ver S Supersedes s: n/a P Posted date e: 09.27.12 2 Retire R date e: n/a able 1. Rec commended antibiotic regimens r forr treatment of chorio-a amnionitis Ta Ta able 2. Alte ernative trea atment options for penicillin allergy y Ta able 3. Pos stpartum tre eatment guid delines after diagnosis of chorio-am mnionitis Ta able 4. Rec commended antibiotics for post-partum treatm ment after cchorio-amnio onitis Ta able 5. Pos stpartum tre eatment guid delines after diagnosis of endomettritis Ta able 6. Rec commended treatment of post-parttum endom etritis A Applicability y All patients for whom a diagnosis of cho orioamnionittis may be m made P Purpose arify the und derstanding of a diagno osis of chorio oamnionitis To cla B Background d Epidural anesthes sia has been n shown to alter mater nal tempera ature regula ation. There efore, nts with mild d temperatu ure elevations may not have chorio oamnionitis.. When we currently patien diagnose chorioamnionitis ba ased solely on a matern nal tempera ature of ≥ 38 degrees C Celsius nd up treatin ng a larger then t necess sary group o of patients a and their ne ewborn infan nts. we en D Definition o-amnionitis s is a clinica al diagnosis based on in ndividual or multiple sig gns and sym mptoms, Chorio includ ding but not limited to:  Maternal fever f define ed as ≥ 38.4 4 degrees C Celsius or ≥ 100.4 degrrees Fahrenheit  Abdomina al tenderness usually in the setting of ruptured d membrane es and no otther obvious ex xplanation  New onsett maternal tachycardia t > 100 bea ats per minu ute  New onsett fetal tachy ycardia > 16 60 beats pe r minute  Foul smellling amniotic fluid Pagge 1 of 6 Chorioamnionitis, April 2012 Maternal and fetal baseline heart rates are defined as lasting at least 10 minutes. When the diagnosis of chorioamnionitis is made, the appropriate antibiotic coverage should be initiated. If the patient has an isolated elevated temperature of ≥ 38.0 but < 38.4 degrees Celsius, without any of the above listed signs or symptoms, then the diagnostic criteria are not met and antibiotics do not need to be initiated. In this scenario, the >24 hour neonatal observation is also not indicated. If the medical staff by clinical judgment initiates antibiotic therapy, then a >24 hour postdelivery stay for the newborn is part of the management. Table 1. Recommended antibiotic regimens for treatment of chorio-amnionitis Regimens Dosing 1st choice regimen combination Ampicillin 2 grams IV q6 hours and Gentamycin* 1.5 mg/kg IV q8 hours Alternate regimen combination (for penicillin allergy) Clindamycin+ 900mg IV q8 hours and Gentamycin* 1.5 mg/kg IV q8 hours + For patients with known GBS and PCN allergy, please check their GBS culture and make sure it is sensitive to Clindamycin. *Gentamycin may also be dosed as 5mg/kg IV q24 hours Page 2 of 6 Chorioamnionitis, April 2012 Table 2. Alternative treatment options for penicillin allergy Alternative Regimens Dosing Group B strep is a common pathogen in chorio-amnionitis. If the patient is PCN allergic and the allergic reaction is mild (rash, hives) cephalosporins may be appropriate. If the allergic reaction is severe, cephalosporins are not recommended and a combination of Vancomycin and Gentamycin should be used 1st choice regimen (mild penicillin allergy) Cefotetan 2 grams IV q 12 hours Alternate regimen combination (severe penicillin allergy) Vancomycin 15mg/kg IV q 12 hours and Gentamycin* 1.5 mg/kg IV q8 hours *Gentamycin may also be dosed as 5mg/kg IV q24 hours Table 3. Postpartum treatment guidelines after diagnosis of chorio-amnionitis Treatment completed Postpartum treatment needed Chorio-amnionitis, adequate antibiotic treatment and vaginal delivery No post-partum antibiotics indicated Chorio-amnionitis, adequate antibiotic treatment and Cesarean delivery Post-partum IV antibiotics x 24-48 hours afebrile. (See suggested regimen below in Table 4)) Chorio-amnionitis, no antibiotic treatment prior to vaginal delivery Post-partum antibiotics either 1 dose or 24 hours afebrile Chorio-amnionitis, no antibiotic treatment and Cesarean delivery Post-partum IV antibiotics x 48 hours afebrile Page 3 of 6 Chorioamnionitis, April 2012 Table 4. Recommended antibiotics for post-partum treatment after chorio-amnionitis Regimens Dosing 1st choice regimen combination Clindamycin 900mg IV q8 hours and Gentamycin 5mg/kg IV q12 hours Alternate regimen combination Clindamycin 900mg IV q8 hours and Flagyl 1 gram loading dose, followed by 500mg IV q6 hours Alternate regimen Zosyn 3.375grams IV q6 hours If patient remains febrile after 24-36 hours, add to cover Enterococcus (the most likely pathogen): Ampicillin 2 grams IV q6 hours If PCN allergy, consider Cephalosporin or Vancomycin (see Table 2 above for dosing) Table 5. Postpartum treatment guidelines after diagnosis of endometritis Delivery Type Postpartum Treatment Needed Vaginal delivery IV antibiotics x 24 hours afebrile Cesarean Delivery IV antibiotics x 48 hours afebrile Page 4 of 6 Chorioamnionitis, April 2012 Table 6. Recommended treatment of post-partum endometritis Regimens Dosing 1st choice regimen combination Clindamycin 900mg IV q8 hours and Gentamycin 5mg/kg IV q12 hours Alternate regimen combination Clindamycin 900mg IV q8 hours and Flagyl 1 gram loading dose, followed by 500mg IV q6 hours Alternate regimen Zosyn 3.375grams IV q6 hours If patient remains febrile after 24-36 hours, add to cover Enterococcus (the most likely pathogen): Ampicillin 2 grams IV q6 hours If PCN allergy, consider Cephalosporin or Vancomycin (see Table 2 above for dosing) Exhibits None References None Related Policies/Guidelines/Procedures/Standards None Author Author: C. van de Ven, MD Page 5 of 6 Chorioamnionitis, April 2012 Reviewed and Approved By Perinatal Joint Practice Committee: November 2006; April 23, 2012 Next Review April 2015 Disclaimer: These are general guidelines not based on specific medical diagnosis. Any medical case depends on specific medical diagnosis. The guidelines do not constitute medical advice and should not be used for specific cases. Our goal is to provide general information that may assist in the care of patients. General guidelines can never replace the expertise and clinical judgment of the treating physician. Each patient’s situation must be evaluated individually. ©2012 The Regents of the University of Michigan Author: UMHS Perinatal Joint Practice Committee Last Revised 04/2012 Page 6 of 6