A 42-year-old woman, gravida 6 para 6, is evaluated in the postpartum unit on postoperative day 2 after a cesarean delivery. The patient has had increasing vaginal bleeding, abdominal pain, and fever. She is breastfeeding exclusively with a good latch. The patient was initially admitted to the hospital for prelabor rupture of membranes at 40 weeks gestation. A primary cesarean delivery was performed for arrest of descent of a 5-kg (11-lb) infant after 3 hours of pushing. The pregnancy was complicated by recurrent vaginal candidiasis. Prior pregnancies were uncomplicated; the patient's last delivery was 12 years ago. Temperature is 38.7 C (101.7 F) , blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 18/min. On physical examination, the patient appears pale and tired. The lungs are clear to auscultation bilaterally; the breasts are full but without erythema. The uterine fundus is tender to palpation. Speculum examination shows heavy lochia but no active bleeding. The transverse incision across the lower abdomen is intact and without erythema or drainage. Item 1 of 2
Which of the following is the most appropriate pharmacotherapy for this patient?

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Explanation: This patient has fever >24 hours postpartum and uterine fundal tenderness, findings consistent with postpartum endometritis, the most common cause of postpartum fever. Other presenting features include purulent vaginal discharge, boggy uterus, and increased vaginal bleeding. Postpartum endometritis is a polymicrobial infection of the uterine decidua caused by ascending vaginal flora during labor, delivery, or the immediate postpartum period. Therefore, infection is common in patients with prelabor rupture of membranes (ie, membrane rupture prior to the onset of contractions at ≥37 weeks gestation) or with protracted labor because both increase exposure of the uterine cavity to ascending bacteria. Given the polymicrobial nature of postpartum endometritis, a broad-spectrum intravenous antibiotic regimen that includes penicillin-resistant anaerobic coverage is required. The most appropriate therapy is clindamycin plus gentamicin. Clindamycin covers aerobic gram-positive cocci and penicillin-resistant anaerobes (eg, Bacteroides fragilis). Gentamicin covers gram-negative (eg, Escherichia coli) and some gram-positive (eg, Staphylococcus) bacteria. Treatment is continued until the patient is afebrile for 24 hours. (Choice A) Ampicillin plus gentamicin is a broad-spectrum regimen commonly used to treat intrapartum intraamniotic infection. However, postpartum endometritis involves significantly greater anaerobic activity, and this regimen does not cover penicillin-resistant anaerobes. However, ampicillin-sulbactam is an acceptable alternate regimen. (Choice B) Cefoxitin plus doxycycline, which covers Neisseria gonorrhoeae and Chlamydia trachomatis, is used to empirically treat pelvic inflammatory disease, which is also a polymicrobial infection of the upper genital tract. However, it is not appropriate therapy in this patient because of lack of sufficient anaerobic coverage. In addition, doxycycline is avoided in pregnancy and while breastfeeding due to its potential teratogenic effects. (Choice C) In pregnant or breastfeeding patients, ceftriaxone plus azithromycin is the preferred regimen for the empiric treatment of acute cervicitis due to N gonorrhoeae and C trachomatis. However, neither antibiotic has anaerobic coverage; therefore, this regimen would be inadequate to treat postpartum endometritis. (Choice E) Vancomycin is a narrow-spectrum antibiotic effective only against gram-positive organisms (eg, methicillin-resistant Staphylococcus aureus). It is indicated for the treatment of breast abscesses and for group B Streptococcus prophylaxis in penicillin-allergic patients. Educational objective: Postpartum endometritis is a polymicrobial infection characterized by fever, uterine tenderness, and purulent vaginal discharge. The first-line treatment regimen is clindamycin plus gentamicin, which provides broad-spectrum antibiotic coverage for gram-positive, gram-negative, and anaerobic bacteria. References: Antibiotic regimens for postpartum endometritis. (http://www.ncbi.nlm.nih.gov/pubmed/25922861)

A 42-Year-Old Woman, Gravida 6 Para 6, Is Evaluated in the Postpartum