› First-line postpartum regimen
› Clindamycin plus gentamicin
› Clindamycin IV 900 mg q8h
› Anaerobe coverage
› Toxin suppression benefit in streptococcal infection concern
› Gentamicin IV 5 mg/kg q24h
› Adjusted body weight if obesity
› Trough monitoring per local protocol if prolonged course
› Continue until afebrile 24 to 48 hours
› No routine oral step-down required after clinical response
› Enterococcus coverage triggers
› If no improvement by 48 hours, add ampicillin
› Ampicillin IV 2 g q6h
› Enterococcus coverage
› If known GBS colonization with clindamycin resistance concern, add ampicillin
› Alternative single-agent IV regimens
› Ampicillin-sulbactam IV 3 g q6h
› Broad aerobic and anaerobic coverage
› Useful if aminoglycoside avoidance
› Piperacillin-tazobactam IV 4.5 g q8h
› If severe sepsis or polymicrobial concern
› If persistent fever after first-line regimen
› Ertapenem IV 1 g q24h
› If beta-lactamase risk and stable hemodynamics
› Avoid if Pseudomonas concern
Sepsis resuscitation and supportive care
› Fluids and pressors
› Crystalloid bolus strategy
› 500 to 1000 mL reassessment cycles if not meeting 30 mL/kg pathway
› Lung ultrasound for fluid tolerance adjunct
› Norepinephrine infusion
› Initiate if MAP < 65 mmHg after fluids
› Titrate q2 to 5 minutes to MAP target
› Antipyresis and analgesia
› Acetaminophen
› Max daily dose per local protocol
› NSAIDs if no renal injury or bleeding concern
› Thromboprophylaxis
› Pharmacologic VTE prophylaxis during admission if no contraindications
› Mechanical prophylaxis if bleeding risk
› Retained products pathway
› If ultrasound supports retained products with ongoing bleeding, obstetrics evacuation planning
› If hemodynamic instability with hemorrhage, emergent uterine evacuation pathway
› Abscess pathway
› If imaging confirms abscess, drainage planning
› Interventional radiology percutaneous drainage
› Operative drainage if percutaneous not feasible
› Necrotizing infection pathway
› If perineal crepitus or rapid progression, emergent debridement
› Broad necrotizing coverage regimen per sepsis protocol
Treatment failure and escalation
› Persistent fever > 48 to 72 hours on appropriate antibiotics
› CT abdomen and pelvis for abscess or thrombophlebitis
› Antibiotic broadening pathway
› Switch to piperacillin-tazobactam
› Consider carbapenem if resistant organism concern
› Septic pelvic thrombophlebitis suspicion
› Persistent fevers with negative imaging for abscess
› Anticoagulation consideration with obstetrics and hematology
› Continue antibiotics during anticoagulation course
Evidence levels and outcomes
› Evidence summary
› Clindamycin plus gentamicin as effective first-line regimen for postpartum endometritis (ACEP Level C)
› Once-daily gentamicin dosing similar clinical success to q8h dosing in postpartum endometritis (ACEP Level C)
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