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Meta-Analysis
. 2015 Feb 2;2015(2):CD001067.
doi: 10.1002/14651858.CD001067.pub3.

Antibiotic regimens for postpartum endometritis

A Dhanya Mackeen  1 , Roger E Packard, Erika Ota, Linda Speer
Affiliations
Meta-Analysis

Antibiotic regimens for postpartum endometritis

A Dhanya Mackeen et al. Cochrane Database Syst Rev. .

Abstract

Background: Postpartum endometritis occurs when vaginal organisms invade the endometrial cavity during the labor process and cause infection. This is more common following cesarean birth. The condition warrants antibiotic treatment.

Objectives: Systematically, to review treatment failure and other complications of different antibiotic regimens for postpartum endometritis.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014) and reference lists of retrieved studies.

Selection criteria: We included randomized trials of different antibiotic regimens after cesarean birth or vaginal birth; no quasi-randomized trials were included.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

Main results: The review includes a total of 42 trials, and 40 of these trials contributed data on 4240 participants.Regarding the primary outcomes, seven studies compared clindamycin plus an aminoglycoside versus penicillins and showed fewer treatment failures (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.46 to 0.90). There were more treatment failures in those treated with an aminoglycoside plus penicillin when compared to those treated with gentamycin/clindamycin (RR 2.57, 95% CI 1.48 to 4.46). There were more treatment failures (RR 1.66, 95% CI 1.01 to 2.74) and wound infections (RR 1.88, 95% CI 1.08 to 3.28) in those treated with second or third generation cephalosporins (excluding cephamycins) versus those treated with clindamycin plus gentamycin. In four studies comparing once-daily with thrice-daily dosing of gentamicin, there were fewer failures with once-daily dosing. There were more treatment failures (RR 1.94, 95% CI 1.38 to 2.72) and wound infections (RR 1.88, 95% CI 1.17 to 3.02) in those treated with a regimen with poor activity against penicillin-resistant anaerobic bacteria as compared to those treated with a regimen with good activity against penicillin-resistant anaerobic bacteria. There were no differences between groups with respect to severe complications and no trials reported any maternal deaths.Regarding the secondary outcomes, three studies that compared continued oral antibiotic therapy after intravenous therapy with no oral therapy, found no differences in recurrent endometritis or other outcomes. Four trials that compared clindamycin plus aminoglycoside versus cephalosporins identified fewer wound infections in those treated with clindamycin plus an aminoglycoside (RR 0.53, 95% CI 0.30 to 0.93). There were no differences between groups for the outcomes of allergic reactions. The overall risk of bias was unclear in the most of the studies. The quality of the evidence using GRADE comparing clindamycin and an aminoglycoside with another regimen (compared with cephalosporins or penicillins) was low to very low for therapeutic failure, severe complications, wound infection and allergic reaction.

Authors' conclusions: The combination of clindamycin and gentamicin is appropriate for the treatment of endometritis. Regimens with good activity against penicillin-resistant anaerobic bacteria are better than those with poor activity against penicillin-resistant anaerobic bacteria. There is no evidence that any one regimen is associated with fewer side-effects. Following clinical improvement of uncomplicated endometritis which has been treated with intravenous therapy, the use of additional oral therapy has not been proven to be beneficial.

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Conflict of interest statement

A Dhanya Mackeen: none known. Roger E Packard: none known. Erika Ota: none known. Linda Speer: none known.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Funnel plot of comparison: 1 Clindamycin plus aminoglycoside versus any other regimen, outcome: 1.1 Treatment failure.
4
4
Funnel plot of comparison: 1 Clindamycin plus aminoglycoside versus any other regimen, outcome: 1.2 Severe complication.
5
5
Funnel plot of comparison: 1 Clindamycin plus aminoglycoside versus any other regimen, outcome: 1.4 Allergic reaction.
6
6
Funnel plot of comparison: 1 Clindamycin plus aminoglycoside versus any other regimen, outcome: 1.5 Diarrhea.
7
7
Funnel plot of comparison: 3 Beta‐lactamase inhibitor combination versus any other regimen, outcome: 3.1 Treatment failure.
1.1
1.1. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 1 Treatment failure.
1.2
1.2. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 2 Severe complication.
1.3
1.3. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 3 Wound infection.
1.4
1.4. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 4 Allergic reaction.
1.5
1.5. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 5 Diarrhea.
1.6
1.6. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 6 Length of stay.
1.7
1.7. Analysis
Comparison 1 Clindamycin plus aminoglycoside versus any other regimen, Outcome 7 Treatment failure despite administration of prophylactic antibiotics for cesarean.
2.1
2.1. Analysis
Comparison 2 Aminoglycoside plus penicillin or ampicillin versus any other regimen, Outcome 1 Treatment failure.
2.2
2.2. Analysis
Comparison 2 Aminoglycoside plus penicillin or ampicillin versus any other regimen, Outcome 2 Severe complication.
2.3
2.3. Analysis
Comparison 2 Aminoglycoside plus penicillin or ampicillin versus any other regimen, Outcome 3 Wound infection.
2.4
2.4. Analysis
Comparison 2 Aminoglycoside plus penicillin or ampicillin versus any other regimen, Outcome 4 Allergic reaction.
2.5
2.5. Analysis
Comparison 2 Aminoglycoside plus penicillin or ampicillin versus any other regimen, Outcome 5 Diarrhea.
3.1
3.1. Analysis
Comparison 3 Beta‐lactamase inhibitor combination versus any other regimen, Outcome 1 Treatment failure.
3.2
3.2. Analysis
Comparison 3 Beta‐lactamase inhibitor combination versus any other regimen, Outcome 2 Severe complication.
3.3
3.3. Analysis
Comparison 3 Beta‐lactamase inhibitor combination versus any other regimen, Outcome 3 Wound infection.
3.4
3.4. Analysis
Comparison 3 Beta‐lactamase inhibitor combination versus any other regimen, Outcome 4 Allergic reaction.
3.5
3.5. Analysis
Comparison 3 Beta‐lactamase inhibitor combination versus any other regimen, Outcome 5 Diarrhea.
3.6
3.6. Analysis
Comparison 3 Beta‐lactamase inhibitor combination versus any other regimen, Outcome 6 Length of stay.
4.1
4.1. Analysis
Comparison 4 Aztreonam plus clindamycin versus any other regimen, Outcome 1 Treatment failure.
4.2
4.2. Analysis
Comparison 4 Aztreonam plus clindamycin versus any other regimen, Outcome 2 Severe complication.
4.3
4.3. Analysis
Comparison 4 Aztreonam plus clindamycin versus any other regimen, Outcome 3 Wound infection.
4.4
4.4. Analysis
Comparison 4 Aztreonam plus clindamycin versus any other regimen, Outcome 4 Allergic reaction.
4.5
4.5. Analysis
Comparison 4 Aztreonam plus clindamycin versus any other regimen, Outcome 5 Diarrhea.
4.6
4.6. Analysis
Comparison 4 Aztreonam plus clindamycin versus any other regimen, Outcome 6 Length of stay.
5.1
5.1. Analysis
Comparison 5 Agent with longer half‐life versus similar agent with shorter half‐life, Outcome 1 Treatment failure.
5.2
5.2. Analysis
Comparison 5 Agent with longer half‐life versus similar agent with shorter half‐life, Outcome 2 Severe complication.
5.3
5.3. Analysis
Comparison 5 Agent with longer half‐life versus similar agent with shorter half‐life, Outcome 3 Wound infection.
5.4
5.4. Analysis
Comparison 5 Agent with longer half‐life versus similar agent with shorter half‐life, Outcome 4 Allergic reaction.
5.5
5.5. Analysis
Comparison 5 Agent with longer half‐life versus similar agent with shorter half‐life, Outcome 5 Diarrhea.
5.6
5.6. Analysis
Comparison 5 Agent with longer half‐life versus similar agent with shorter half‐life, Outcome 6 Length of stay.
6.1
6.1. Analysis
Comparison 6 Metronidazole plus gentamicin versus any other regimen, Outcome 1 Treatment failure.
7.1
7.1. Analysis
Comparison 7 Once daily versus thrice‐daily (8‐hourly) gentamicin dosing, Outcome 1 Treatment failure.
7.2
7.2. Analysis
Comparison 7 Once daily versus thrice‐daily (8‐hourly) gentamicin dosing, Outcome 2 Nephrotoxicity.
7.3
7.3. Analysis
Comparison 7 Once daily versus thrice‐daily (8‐hourly) gentamicin dosing, Outcome 3 Length of stay.
8.1
8.1. Analysis
Comparison 8 Continued oral versus no treatment (tx) after intravenous antibiotic course, Outcome 1 Treatment failure.
8.2
8.2. Analysis
Comparison 8 Continued oral versus no treatment (tx) after intravenous antibiotic course, Outcome 2 Severe complication.
8.3
8.3. Analysis
Comparison 8 Continued oral versus no treatment (tx) after intravenous antibiotic course, Outcome 3 Wound infection.
8.4
8.4. Analysis
Comparison 8 Continued oral versus no treatment (tx) after intravenous antibiotic course, Outcome 4 Urinary tract infection.
8.5
8.5. Analysis
Comparison 8 Continued oral versus no treatment (tx) after intravenous antibiotic course, Outcome 5 Recurrent endometritis.
8.6
8.6. Analysis
Comparison 8 Continued oral versus no treatment (tx) after intravenous antibiotic course, Outcome 6 Length of stay.
9.1
9.1. Analysis
Comparison 9 Poor activity against penicillin‐resistant anaerobic bacteria versus good activity, Outcome 1 Treatment failure.
9.2
9.2. Analysis
Comparison 9 Poor activity against penicillin‐resistant anaerobic bacteria versus good activity, Outcome 2 Severe complication.
9.3
9.3. Analysis
Comparison 9 Poor activity against penicillin‐resistant anaerobic bacteria versus good activity, Outcome 3 Wound infection.
9.4
9.4. Analysis
Comparison 9 Poor activity against penicillin‐resistant anaerobic bacteria versus good activity, Outcome 4 Allergic reaction.
9.5
9.5. Analysis
Comparison 9 Poor activity against penicillin‐resistant anaerobic bacteria versus good activity, Outcome 5 Diarrhea.
9.6
9.6. Analysis
Comparison 9 Poor activity against penicillin‐resistant anaerobic bacteria versus good activity, Outcome 6 Length of stay.
10.1
10.1. Analysis
Comparison 10 Oral ofloxacin/clindamycin versus intravenous clindamycin/gentamicin, Outcome 1 Treatment failure.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Knodel 1988 {published data only}
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Soper 1992 {published data only}
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References to studies excluded from this review

Alvarez 1988 {published data only}
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Dinsmoor 1991 {published data only}
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Faro 1987a {published data only}
    1. Faro S, Phillips LE, Baker JL, Goodrich KH, Turner RM, Riddle G. Comparative efficacy and safety of mezlocillin, cefoxitin, and clindamycin plus gentamicin in postpartum endometritis. Obstetrics & Gynecology 1987;69(5):760‐6. - PubMed
Faro 1987b {published data only}
    1. Faro S, Pastorek JG, Aldridge KE, Martens M, Phillips LE, Nicaud S, et al. Piperacillin versus clindamycin plus gentamicin in the treatment of postpartum endometritis. Current Therapeutic Research, Clinical and Experimental 1987;42:995‐1002.
Fernandez 1993 {published data only}
    1. Fernandez H, Gagnepain A, Bourget P, Peray P, Frydman R, Paiernik E, et al. Antibiotic prophylaxis against postpartum endometritis after vaginal delivery: a prospective randomized comparison between amox‐CA (Augmentin) and abstention. European Journal of Obstetrics & Gynecology and Reproductive Biology 1993;50:169‐75. - PubMed
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Hemsell 1988 {published data only}
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References to other published versions of this review

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