Objective of the presentation

At the end of the presentation the students shall be

able to
Know the principles of antibiotic selection Describe the steps need to be considered in antibiotic

selection in obstetric and gynecology Indicate Common bacterial infections in obstetric and gynecology Know Indications for antibiotics treatment in obstetric and gynecology List Commonly used antibiotics in obstetric and gynecology

outline
Introduction
Principles of antibiotic selection in obstetric and

gynecology Steps need to be considered in antibiotic selection in obstetric and gynecology Common bacterial infections in obstetric and gynecology Indications for antibiotic treatment in obstetric and gynecology Commonly used antibiotics in obstetrics and gynecology

Introduction
Microbial infections were always been threat to

obstetric and gynecological patients, however the gratifying development of antibiotics have led to decrease in puerperal and postoperative morbidity, as well as prenatal mortality. Antibiotic is very essential in obstetric and gynecology due to high risk for diffrent infections. Effective monitoring of antibiotics is required in obstetric and gynecology, specially during pregnancy.

Principles of antibiotic selection in obstetric and gynecology

Several conditions are pertinent to most infections in

obstetric and gynecology. These are

Patients are generally healthy and free of debilitating

illnesses except some old patients and some patients with malignant diseases. Infections are mostly polymicrobial in origin such as postpartum infections, postoperative infections and PID.

continued
Mostly when clinical diagnosis of infection is made,

empirical therapy is indicated before culture results are available Because of limitations in laboratory techniques, culture results may not be available in a timely fashion or performed at all.

Steps need to be considered in antibiotic selection

A. Etiologic diagnosis

an attempt to decide on clinical grounds

Whether the patient has a microbial infection that may be influenced by antimicrobial drugs The most probable causative agent

B. Best Guess choose a drug or drug combination that is likely to be effective against the suspected infection

Cond
C. Laboratory control obtain meaningful specimen, if available, for laboratory examination to determine the causative infectious agent and, if appropriate , its susceptibility to antibiotics. D. Clinical response based on clinical response of the patients evaluate the laboratory reports and consider the desirability of changing drug regimen.

Cond
E. Drug susceptibility test to test the drug which has the minimum dose that can inhibit the maximum load of the causative infectious agent . f. Adequate dosage to determine whether the adequate dosage is being used, the serum assay level of the drug can be performed, but in obstetric and gynecology antibiotic test is usually unnecessary.

Cond
G. Route of administration route of administration may effect some drugs e.g. Oral penicillin is effected or impaired by food. H. Duration of antibiotic therapy mostly effective antibiotic therapy results in marked clinical improvement within a few days, but continued treatment for varying periods may be necessary to effective cure.

Con;d
I.

Adverse effects

Hypersensitivity Direct toxicity Suppression

J.

Oliguria, impaired renal function and uremia these have important influence on antimicrobial drug dosage , because most of these drugs are excreted through kidneys.

Common bacterial infections in obstetric and gynecology

Gram-negative cocci

gonococci

Klepsiella Protues mirabils and

gram-posetive cocci

pneumococci Streptococci Group B streptococcus Streptococcus viridins Streptococcus fecaelis Staphylococcus Acinetobacter Bacteriodes Entrobacter E.coli

vulgaris Pseudonomas aeruginosa Serratia, providencia Gram-posetive rods

Actinomyces Clostridium Listeria

Gram-negative rods

mycoplasmas

Cond
Sexually transmitted infections

syphilis Gonorrhea Chlamydia trachomatis PID

Vaginitis trichomonas vaginalis Bacterial vaginosis

Cond
Obstetric infection puerperal endometritis Clinical chorioamnionitis Sepsis Pyelonephritis Gynecologic infection postherectomy cuff infection Abdominal wound infection

Indications for antibiotic treatment in obstetric and gynecolgy

We can use antibiotics both for prophylactic and

therapeutics treatments.

prophylaxis
def:- is antibiotic used for prevention rather than treatment of infection.

prophylactic usage is restricted to clinical situations in which the benefit outweigh the potential risk.

cond
The Ideal prophylaxis should be Non toxic Effective against most organisms encountered with endogenous flora Long acting inexpensive

Cond
Antibiotic prophylaxis has become standard care for

obstetric and gynecologic operations like

Vaginal hysterectomy Radical abdominal hysterectomy Abdominal hysterectomy Some cases of cesarean section

Cond
Prophylactic recommendations based on various

categories suggested by center for disease control. Like:category1:-strongly recommended for adoption. category2:-moderately recommended for adoption. category3.weakly recommended for adoption

Cond
All patients with a prosthetic cardiac valve should

receive antibiotic prophylaxis for

1. 2.

3.
4. 5. 6. 7. 8.

Endometrial biopsy Insertion of IUD Urethral catheterization Dilatation and curettage Hysterectomy Normal vaginal delivery Cesarean section Sigmoidoscopy.

Cond
Premenopausal Patients undergoing vaginal hysterectomy with or without vaginal repair(category1) Patients with or without estrogen replacement therapy may receive prophylaxis(category2) For elective abortion Patients with valvular heart diseases History of acute salpingitis may be benefit from prophylaxis(category2)

Cond
Surgical conditions which likely may benefit from

prophylaxis
Abdominal hysterectomy Patients with valvular heart disease

Low socioeconomic status

cervical conization preceding hysterectomy from 2 to 21

days. Underlined conditions making a prolonged or difficult operation likely may benefit from prophylaxis(category2)

Cond
Prophylaxis for cesarean section Antibiotic of choice
o o

timing of administration Duration of administration

o Indigent or medically compromised patients with rupture of

membranes over 8 hours and labour only 12 hours should receive prophylaxis category1 . o Both ampicillin and first generation cephalosporin's have similar efficacy in reducing postoperative endometritis

there does not appear to be added benefit in utilizing the more broad spectrum agent or multiple dose regimen need for randomized trial to test the optimal timing of administration (immediately after the cord is clamped versus preoperative).

Cond
Duration of antibiotic administration
Single dose of antibiotic with a sufficiently long half-life can be as effective as prolonged courses of prophylaxis. A single dose given preoperatively(after clamping of umblical cord in c/s ) has Less dose Less potential for toxicity Less chance of promoting resistant bacteria

Cond
Six guidelines governing the prophylactic use of

antibiotics developed by ledger(monil1993)

1. 2.

3.
4. 5. 6.

Limit antibiotic use to high-risk situations Establish tissue levels of antibiotic before the incision Give a short course of therapy to minimize dose related adverse drug reactions Use second or third-line antibiotics Choose antibiotics that are effective against the anticipated pathogenic spectrum. Be sure that benefits outweigh the possibility of an adverse drug reaction.

Cond
Antibiotics most appropriate for prophylaxis of

postoperative infections depends on the nature of the operation. In aseptic(clean) operations gram-possetive postoperative infections are the primary concern.

Commonly used antibiotics

penicillins Are among the most widely effective antibiotics and also

least toxic drug, but increased resistance has limited their use They interfere the transpeptidation of bacterial cell wall synthesis Indications

Pencillin G(i/v or i/m)group A and B streptococcus, T.pallidum, aerobic gram-possetive rods and actinomyces. Benthazing pencillin G(i/m)..T.pallidum (syphilis). Amoxillin/ampicillin /carbenciliin etc(oral).gram-negative aerobesthese drugs are destroyed by Beta-lactimases, but can be solved by combination with clavunic acid, sulbactam etc

Cond
Adverse drug reactions
Allergy Toxicity Diarrhea

cephalosporins closely related to structurally and functionally to penicillin and they have also same mode of action

Indications

cocci(including pneumococci, S.viridins) Second generation(cefoxitine,cefotetan etc)anaerobes and for polymicrobial infections Third generations(ceftriaxone,cefixime etc)..uncompilicated gonnorrhea and urinary tract infections

First generations(cephalexin, cephadrine etc)..oral/im/iv..gram-posetive

Adverse reactions similar to penicillins

Cond
Macrolides(erythromycin, clarithromycin and azithromycin)
Protein synthesis inhibitor

Indications..

effective against chlamydia, ureaplasma urealyticum etc And as a alternative drug for patients allergic to penicillin and TTC during pregnance

Adverse reactions. Epigastric distress, acute cholestatic hepatitis

Tetracycline group(TTC, minocycline, doxycycline etc)

Protein synthesis inhibitors Cross-reactivity

indication

gram-negative, and gram-posetive and also strongly used by atypical bacteria (mycoplasmas, chlamydia and rekettsia).(oral/iv) Adverse reactions allergy, GI side effects, bone and teeth defects, liver damage, kidney damage and teratogenicity.

Cond
Aminoglycosides

Proein synthesis inhibitors Gentamycin, tobromycin etc Resistance from Anaerobic bacterias Water soluble and stable in solution Accumulate in amniotic fluid

indications
Gentamycin(i/v)..severe gram-negative infections (including pseudonomas) Tobromycin(i/v)..gentamycin resistance bacteria (specialy pseudonomas)

Adverse drug reaction Ototoxicity

Nephrotoxicity neurotoxicity

Cond
Sulfonamides-tremathoprim
Mostly we use sulfamethoxazole Two folic acid antagonists

indications
urinary tract infection Sexually transmitted diseases Parasitic infections

Adverse drug reactions

Hypersesetivity Direct toxicity Systemic side effects Urinary tract disturbances

Precaution in the use of sulfonamides

cross-allergicity of all sulfonamides Keep urine volume above 1500ml/d Check hemoglobin,WBC count and diffrential count every week

Cond
Metronidazole
Antiprotozoal drug, and also active against all anaerobes

indications
Trichomonas vaginitis Bacterial vaginosis Pseudomemberanous colitis Mixed or anaerobic infections

Adverse drug reactions

Stomatitis Naussea Diarrhea May cause peripheral neuropathy

Cond
Vancomycin
Bactericidal for gram-posetive bacteria Methicillin resistance staphylococci and enterococci Associated with chills, fever and thrombophelebitis

Quinolones
Block DNA gyrase, protein synthesis inhibition

indications
Gram-negative, gram-posetive, most aerobes and some clinically

important anaerobic bacteria Sexually transmitted diseases Urinary tract infections

Adverse drug reactions

nausea, vomiting, diarrhea, seizures and anaphylaxis headach, dizziness, insomnia, skin rashes, and liver function impairment

references
Current 2007
Danforth Infecious diseases in obstetric and gynecology