Obstetrics antibiotics Flashcards
severe falciparum malaria treatment or any species
- Artesunate IV 2.4 mg/kg at 0, 12 and 24 hours, then daily thereafter. regardless of EGA
- Well enough: switch to oral artesunate 2 mg/kg (or IM artesunate 2.4 mg/kg) once daily,……………………plus clindamycin.
ALTERNATIVELY:
- Quinine IV 20 mg/kg loading dose (no loading dose if already quinine or mefloquine) in 5% dextrose over 4 hours and then
- 10 mg/kg IV over 4 hrs/ 8 hours + clindamycin IV 450 mg every 8 hours (max. dose quinine 1.4 g). (vomiting with noncomplicated falciparum)
- well enough: switch to oral quinine 600 mg 3 times a day to complete 5–7 days and oral clindamycin
450 mg 3 times a day 7 days
- If oral artesunate is not available, for severe complicated malaria
or
Uncomplicated malaria P. falciparum
Resistant P. vivax
7-day course of
- Oral quinine 600 mg 8 hourly and clindamycin at 450 mg 3 times a day 7 days.(after EGA <13 weeks)
3-day course of
- Riamet®(GSK) 20 mg/120 mg artemether & lumefantrine 4 tablets/dose for weight > 35 kg, twice daily for 3 days (with fat)
or
- atovaquone-proguanil (Malarone®, Novartis) 4 standard tablets daily for 3 days.or a
Drug treatment in malaria
severe falciparum malaria:
- Intravenous artesunate
- Intravenous quinine if artesunate not available.
uncomplicated P. falciparum (or mixed, ( P. falci& P. vivax). - quinine and clindamycin
P. vivax, P. ovale or P. malariae
- chloroquine
Primaquine should not be used in pregnancy.
Seek advice from infectious diseases specialists, especially for severe and recurrent cases.
quinine dosing if
- IV therapy extends more than 48 hours
- renal or
- hepatic dysfunction.
- reduced to 12-hourly
- severe and recurrent hypoglycaemia in late pregnancy.
- Preventing relapse DURING pregnancy
- Preventing relapse AFTER delivery
- Chloroquine oral 300 mg weekly until delivery
- Postpone until 3 months after delivery & G6PD testing
- P. ovale: Post delivery, post treatment prophylaxis
- P. vivax: Post delivery, post treatment prophylaxis
- Oral primaquine 15 mg single daily dose for 14 days
- Oral primaquine 30 mg single daily dose for 14 days
G6PD (mild) for P. vivax or P. ovale
Primaquine oral 45–60 mg once a week for 8 weeks
Non-falciparum malaria treatment
- Chloroquine (base) 600 mg orally
- followed by 300 mg 6–8 hours later.
- Then 300 mg day 2, and again day 3
Dosing regimen for chemoprophylaxis in pregnancy
Mefloquine:
- 1 tablet weekly 250mg,
- Chloroquine resistant (P. falciparum resistance)
Atovaquone-proguanila:
- 1 tablet daily
- 250mg, atovaquone + 100 proguanil
- Chloroquine resistant & mefloquine not tolerated or contraindicated OR Mefloquine resistant
- Folic acid supplements (5 mg daily) need to be taken if proguanil is used in those who are pregnant or seeking to become pregnant
Proguanila plus chloroquine:
- 2 tablets daily plus 2 tablets weekly
- 100 proguanil + 150 (chloroquine; base)
- No chloroquine resistance
which antibiotic should be used in women with known or suspected penicillin allergy? mild /severe
GBS carriage
- cefuroxime, 1.5 g loading dose followed by 750 mg every 8 hours).
- If allergy to beta-lactams is severe then intravenous vancomycin (1 g every 12 hours)
which antibiotic should be used for IAP?
GBS carriage
- 3 g intravenous benzylpenicillin ASAP after onset of labour & 1.5 g 4 hourly until delivery.
- atleast 4 hours prior. cord blood levels > MIC for GBS in 1 hour after. but ?? neonatal colonisation or d/s. evidence 2 hours before reduces neonatal colonisation but 4 hours effective than 2 hours EOGBS disease.
Amoxicillin is alternative but Cochrane review no difference between amoxicillin and benzylpenicillin and thus, the narrower spectrum antibiotic is preferred
antintimicrobial choices and limitation
Which empirical and specific antimicrobial therapy should be used to treat the woman in pregnancy
- Co-amoxiclav: not cover MRSA or Pseudomonas, and NEC in utero exposure.
- Metronidazole: Only covers anaerobes.
- Clindamycin: most strep and staph, including many MRSA, & switches off exotoxin production with significantly decreased mortality. Not renally excreted or nephrotoxic.
- Piperacillin–tazobactam(Tazocin) and carbapenems: Covers all except MRSA and are renal sparing (in contrast to aminoglycosides).
- Gentamicin (as a single dose Poses no problem in normal renal function but if doses are to be given regularly serum levels must be of 3–5mg/kg) monitored
Suggested empirical antimicrobials for use in bacterial sepsis after pregnancy.
- for mastitis
- Caesarean section wound infection or intravenous cannula site infection
Mastitis
- Organism: MSSA, streptococci
- Antimicrobial: Flucloxacillin + clindamycin
- If allergic: Vancomycin + clindamycin
- Trough level: vancomycin 5–20 mg/l necessary
Mastitis
Organism: MRSA, Streptococci
Antimicrobial: Vancomycin + clindamycin
If allergic: Clindamycin/teicoplanin are alternatives
Endometritis
Acute pyelonephritis
Organism: Gram-negative anaerobes, Streptococci
Antimicrobial: - Cefotaxime +gentamicin (gentamicin administered once only) + METRONIDAZOLE
If allergic: Gentamicin + ciprofloxacin + CLINDAMYCIN
Organism: Gram-negative bacteria, Occasionally staphylococci streptococci
Antimicrobial: - Cefotaxime +gentamicin (gentamicin administered once only)
If allergic: gentamicin: + ciprofloxacin
ESBLs: gentamicin and meropenem
Toxic shock syndrome
Organism: staphylococci streptococci
Antimicrobial:
- Flucloxacillin + clindamycin + gentamicin (gentamicin administered once only)
- For MRSA use vancomycin instead of flucloxacillin
If allergic:
- Vancomycin +clindamycin + immediately gentamicin (gentamicin administered once only)
or
- Linezolid + gentamicin (gentamicin administered once only)
Notes: - Regimen must contain an antitoxin agent such clindamycin or linezolid (lin EZ oh lid)
- Consider IVIG
