Obstetrics

Pyrexia in Labour

A single temperature ≥ 38.0 C.

See also Sepsis section and Sepsis in Pregnancy.

First Line

Co-amoxiclav 1.2g TDS IV+ Gentamicin 5mg /kg once daily (booking weight, max 480mg)

In patients with a booking weight BMI ≥30kg/m ² use Obese Dosing Weight/Adjusted Body Weight and not Actual Body Weight to calculate gentamicin dose (Please see Formulae for weight calculation) . (Please see Gentamicin dosing schedule).

Penicillin Allergy

NOT IgE-mediated /anaphylaxis/severe penicillin reaction

CefUROXime 1.5g IV QDS

+ Metronidazole 500mg IV TDS

+ Gentamicin 5mg /kg once daily (booking weight, max 480mg) (Please see Gentamicin dosing schedule) .

IgE-mediated /anaphylaxis/severe penicillin reaction:

Vancomycin 15mg/kg IV 12 hourly (booking weight, max 2g/dose (Please see Vancomycin dosing schedule).

+ Gentamicin 5mg /kg once daily (booking weight, max 480mg)

+ Metronidazole 500mg IV TDS

In patients with a booking weight BMI ≥30kg/m ² use Obese Dosing Weight/Adjusted Body Weight and not Actual Body Weight to calculate gentamicin dose (Please see Formulae for weight calculation).

Note: Both vancomycin and gentamicin can cause nephrotoxicity as an adverse effect. This risk is increased when both agents are used with other nephrotoxic medications. Review use of these medications daily, monitor renal function and drug levels.

If a woman is receiving Intrapartum Antibiotic Prophylaxis (IAP) and develops pyrexia in labour review antibiotics as follows:

If IAP with Benzylpenicillin : Stop benzylpenicillin and Start Co-Amoxiclav and Gentamicin.

If IAP with CefUROXime: Continue CefUROXime and add Gentamicin and Metronidazole.

If IAP with Vancomycin: Continue Vancomycin and add Gentamicin and Metronidazole.

Sepsis in Pregnancy

General points

See Sepsis and National Clinical Guideline No26 Sepsis management for adults including maternity 2021

• See below for antimicrobial recommendations for

1. Sepsis in pregnancy (no identifiable source)

2. Severe sepsis (eg.septic shock) in pregnancy.

• NB. Check previous microbiology test results for antimicrobial resistance.
• Note Group B Streptococci (GBS) are universally susceptible to penicillins and most cephalosporins including cefuroxime and ceftriaxone. Between 20-30% of GBS isolates both locally and nationally are resistant to clindamycin therefore for empiric use (where susceptibility is unknown) clindamycin cannot be recommended.
• These regimes are not suitable for patients with known or suspected MDROs such as ESBL, CPE. Discuss these cases with Clinical Microbiologist.
• Take prior antimicrobial use into account when prescribing as recent exposure to a particular agent is a risk factor for resistance to same.
• Ensure appropriate microbiological specimens (blood, urine, swabs) sent before starting treatment where possible.
• Identify source of sepsis as soon as possible to ensure timely source control.
• The empirical antimicrobial regime should be rationalised as soon as microbiology test results available.
• Review need for Gentamicin/Amikacin daily.

Sepsis in Pregnancy (no identifiable source)

First Line (Empiric Therapy)

Co-amoxiclav 1.25g TDS IV + Gentamicin 5mg/kg OD IV (booking weight, max 480mg) (Please see Gentamicin dosing schedule).

Note: Early escalation to Piperacillin-tazobactam 4.5g IV QDS + Gentamicin 5mg/kg OD IV (booking weight, max 480mg) may be warranted depending on clinical severity, recent microbiology test results or recent co-amoxiclav use.

If history of MRSA colonisation or infection consider adding Vancomycin 15mg/kg IV 12 hourly (booking weight, max 2g/dose, see Vancomycin dosing algorithm) Consider 25mg/kg (max 2g) loading dose if severe infection or septic shock (Please see Vancomycin dosing schedule).

In patients with a booking weight BMI ≥30kg/m ² use Obese Dosing Weight/Adjusted Body Weight and not Actual Body Weight to calculate gentamicin dose (Please see Formulae for weight calculation).

Penicillin Allergy (Empiric Therapy)

NOT IgE-mediated /anaphylaxis/severe penicillin reaction:

CefUROXime 1.5g IV QDS.

+ Metronidazole 500mg IV TDS.

+ Gentamicin 5mg/kg OD IV (booking weight, max 480mg) (Please see Gentamicin dosing schedule).

If history of MRSA colonisation or infection consider adding Vancomycin 15mg/kg IV 12 hourly (booking weight, max 2g/dose, see Vancomycin dosing algorithm) Consider 25mg/kg (max 2g) loading dose if severe infection or septic shock (Please see Vancomycin dosing schedule).

IgE-mediated /anaphylaxis/severe penicillin reaction:

Vancomycin 15mg/kg IV 12 hourly (booking weight, max 2g/dose, see Vancomycin dosing algorithm). Consider 25mg/kg (max 2g) loading dose if severe infection or septic shock (Please see Vancomycin dosing schedule).

+ Gentamicin 5mg /kg once daily (use booking weight) ( Please see Gentamicin dosing schedule).

+ Metronidazole 500mg IV TDS

Add clindamycin if invasive Group A Strep Infection suspected.

In patients with a booking weight BMI ≥30kg/m ² use Obese Dosing Weight/Adjusted Body Weight and not Actual Body Weight to calculate gentamicin dose (Please see Formulae for weight calculation).

Note: Both vancomycin and gentamicin can cause nephrotoxicity as an adverse effect. This risk is increased when both agents are used together and is increased further with the use of concomitant piperacillin-tazobactam and other nephrotoxic medications. Review use of these medications daily, monitor renal function and drug levels.

Sepsis (severe) in Pregnancy eg. septic shock

First Line & Penicillin Allergy (Not IgE-mediated/anaphylaxis or non-severe penicillin allergy) Empiric Therapy

Meropenem 1-2g TDS

+ Gentamicin 5mg/kg IV (booking weight, max 480mg) once daily (Please see Gentamicin dosing schedule).

+ Clindamycin 1.2g QDS IV.

If history of or risk factors for MRSA colonisation or infection add Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg IV 12 hourly (booking weight, max 2g/dose (Please see Vancomycin dosing schedule).

In patients with a booking weight BMI ≥30kg/m ² use Obese Dosing Weight/Adjusted Body Weight and not Actual Body Weight to calculate gentamicin dose (Please see Formulae for weight calculation).

If there is a strong suspicion clinically that the septic shock may be relating to Group A Streptococcus, then IV immunoglobulin could be considered.

IgE-mediated/anaphylaxis or Severe Penicillin Allergy Empiric Therapy

Vancomycin 25mg/kg (max 2g) loading dose then 15mg/kg IV 12 hourly (Please see Vancomycin dosing schedule)

+ Clindamycin 1.2g QDS IV

+ Gentamicin 5mg/kg IV once daily (booking weight, max 480mg) (Please see Gentamicin dosing schedule)

In patients with a history of Gentamicin resistant Gram negative infections (eg. UTI) use Amikacin 15mg/kg OD IV (booking weight, max 1.5g). (Please see Amikacin dosing schedule).

Ciprofloxacin 400mg BD IV may be added for additional Gram-negative cover.

Meropenem can be considered for use in select cases. Discuss with Microbiology/Obstetric teams.

In patients with a booking weight BMI ≥30kg/m ² use Obese Dosing Weight/Adjusted Body Weight and not Actual Body Weight to calculate gentamicin dose (Please see Formulae for weight calculation).

Review Gentamicin/Amikacin daily with culture results and clinical response. If patient is clinically improving, consider stopping after 48 hours.

Note: Both vancomycin and gentamicin/amikacin can cause nephrotoxicity as an adverse effect. This risk is increased when both agents are used together and is increased further with the use of other nephrotoxic medications. Review use of these medications daily, monitor renal function and drug levels.

If there is a strong suspicion clinically that the septic shock may be relating to Group A Streptococcus, then IV immunoglobulin could be considered.

Intrapartum Antimicrobial Prophylaxis (IAP) for the Reduction of Early onset Invasive Group B Streptococcal Disease in the Neonate

These antibiotic recommendations are indicated for the reduction of GBS infection in the neonate and NOT treatment of infection in the mother .

In sepsis/clinically unwell/pyrexia in labour, the antibiotics listed below are NOT suitable. Please see section on Sepsis in Pregnancy or Pyrexia in Labour.

Group B Streptococci (GBS) are universally susceptible to penicillin and most cephalosporins including cefuroxime. Between 20-30% of GBS isolates both locally and nationally are resistant to clindamycin therefore for empiric use (where susceptibility is unknown) clindamycin cannot be recommended.

For further information on penicillin allergy see Table below.

Indications for IAP

• Woman with a previous baby with invasive GBS disease regardless of GBS status in current pregnancy.
• GBS colonization, bacteriuria or infection in current or previous pregnancy.
• Preterm labour or induction of labour prior to 37 weeks with or without rupture of membranes irrespective of GBS carrier status.
• Prolonged rupture of membranes >18hrs.
• Pyrexia in labour (a single temperature >38ºC).

First line Antibiotics

Benzylpenicillin 3g IV loading dose, then 1.8g IV every 4 hours until delivery.

NB: Benzylpenicillin should be administered as an infusion over 30-60 minutes.

Rapid administration has been associated with CNS toxicity including seizures and coma.

Penicillin Allergy

NOT IgE-mediated/anaphylaxis or severe penicillin allergy:

CefUROXime 1.5g IV QDS until delivery.

IgE-mediated/anaphylaxis or severe penicillin allergy:

Vancomycin 15mg/kg IV 12 hourly (use booking weight, max 2g/dose) (Please see Vancomycin dosing schedule)

NB: Vancomycin should be administered at a maximum rate of 10mg/min to avoid infusion reactions such as “red man syndrome”.

OR

Clindamycin 900mg TDS IV IF GBS isolate is known to be clindamycin susceptible

(20-30% of GBS isolates both locally and nationally are resistant to clindamycin)

References

Volume 1. Medication Guidelines for Obstetrics and Gynaecology. First Edition. Antimicrobial Prescribing Guidelines. HSE Clinical Programme for Obstetrics and Gynaecology 2017. https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/antimicrobial-prescribing-guidelines .

Volume 2 Antimicrobial Safety in Pregnancy and Lactation, Medication Guidelines For Obstetrics and Gynaecology First Edition. HSE Clinical Programme for Obstetrics and Gynaecology 2017 https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/antimicrobial-safety-in-pregnancy-and-lactation.pdf

RCOG Green-top Guideline No. 36, September 2017. “Prevention of Early-onset Neonatal Group B Streptococcal Disease” https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg36/

ACOG Prevention of Group B Streptococcal Early-Onset Disease in Newborns Committee Opinion Number 797 February 2020. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns?utm_source=vanity&utm_medium=web&utm_campaign=clinical#s6

S J Knowles et al. Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG 2015 Apr;122(5):663-71.

National Clinical Practice Guideline: Prevention of Early Onset Group B Streptococcal Disease in Term Infants. National Women and Infants Health Programme and The Institute of Obstetricians and Gynaecologists. January 2023. https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/prevention-of-early-onset-group-b-streptococcal-disease-in-term-infants-2023-.pdf

National Clinical Guideline No26 Sepsis management for adults including maternity 2021 https://www.gov.ie/pdf/?file=https://assets.gov.ie/197784/2e897cca-3b57-4753-b420-c397474dd171.pdf#page=null