Ante-natal or post-partum - severe sepsis / septic shock
Severe sepsis or septic shock is a medical emergency requiring immediate treatment:
- Deliver Sepsis Six resuscitation bundle within 1 hour
- Discuss with ICU (intensive care unit) and Micro/ID if there are concerns or deterioration
- If known/suspected immunosuppression consult Micro/ID for advice
- Review antibiotics daily and consider early oral switch. Treat according to microbiology results
- Review empirical treatment within 48-72 hours
- It is important to differentiate between antenatal infection and antenatal sepsis where possible. See also Management of Sepsis in Maternity Guideline (appendices 1,2,3) for infection and sepsis tool
Preferred
amoxicillin 1g iv tds – review iv daily and consider early oral switch
AND
gentamicin* 5mg/kg iv single dose (Gentamicin is for a maximum of 3 days). Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring.
For patient at high risk of group A strep infection: ADD clindamycin 600mg iv qds
For patient where an abdominal or bowel focus of infection is suspected: ADD metronidazole 400mg po tds (500mg iv tds if NBM)
Alternative
For penicillin allergy (non-severe)
cefazolin 2g iv tds
AND
gentamicin* 5mg/kg iv (Gentamicin is for a maximum of 3 days). Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring.
For patient at high risk of group A strep infection: ADD clindamycin 600mg iv qds
For patient where an abdominal or bowel focus of infection is suspected: ADD metronidazole 400mg po tds (500mg iv tds if NBM)
For penicillin allergy (severe) and/or MRSA positive
vancomycin iv
AND
gentamicin* 5mg/kg iv (Gentamicin is for a maximum of 3 days). Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring.
For patient at high risk of group A strep infection: ADD clindamycin 600mg iv qds
For patient where an abdominal or bowel focus of infection is suspected: ADD metronidazole 400mg po tds (500mg iv tds if NBM)
Other information
- Intrapartum pyrexia is common, and is more often related to regional anaesthesia (e.g., epidural) than intrapartum infection.
- Lactate alone should not be used to inform decisions about the presence of infection or the need for antibiotics. It is commonly raised as part of normal labour, after operative birth, with dehydration, and in women and birthing people taking metformin.
- CRP and WCC is frequently elevated as part of normal labour or after operative birth, and can remain high for a few days (around a week for WCC). Therefore, CRP and WCC has very little diagnostic value in labour and should not be used to inform decisions about the presence of infection or the need for antibiotics until at least 72 hours (7 days for WCC) after birth.
- See Maternity - Management of Sepsis in Maternity Guideline (appendices 1,2,3) for infection and sepsis tool
*Gentamicin ototoxicity
Irreversible vestibular and auditory damage can occur with intravenous gentamicin use, even when serum levels are in range, and certain heritable mitochondrial mutations increase this risk. Upon initiation ask:
- Is there any existing hearing problem?
- Is there any family history of deafness or deafness, particularly after receiving antibiotics?
If the patient states yes for any of the above discuss with Micro/ID for alternative antibiotic.
Where gentamicin is being used for more than 2 weeks see Audiometry and intravenous aminoglycosides for advice about frequency of audiometry assessments