Cochrane evidence supports clindamycin plus gentamicin as effective regimen
WHO recommendation supports clindamycin plus gentamicin for postpartum endometritis
Enterococcus coverage when indicated
Ampicillin IV
2 g every 6 hours
Persistent fever at 48 to 72 hours
High enterococcal risk
Duration and endpoint
Continue IV until afebrile for 24 to 48 hours
Merck Manual describes IV therapy until afebrile for 48 hours
Severe sepsis or toxic shock concern
Broader empiric options per local antibiogram
Piperacillin-tazobactam IV
4.5 g every 6 to 8 hours
Meropenem IV
1 g every 8 hours
Add clindamycin for toxin suppression when group A streptococcus suspected
Early obstetric involvement
Retained products evaluation
Operative source control planning
Surgical site and soft tissue infection
Superficial cellulitis post-cesarean
Oral therapy when mild and no systemic signs
Cephalexin PO
500 mg every 6 hours
If MRSA risk, add MRSA-active agent per local guidance
IV therapy when systemic signs or rapid progression
Cefazolin IV
2 g every 8 hours
If MRSA risk, vancomycin IV per weight-based dosing and trough targets
Abscess or deep incisional infection
Source control
Incision and drainage
Debridement for devitalized tissue
Empiric coverage
Broad gram-positive and anaerobic coverage based on depth and contamination
Necrotizing soft tissue infection
Immediate actions
Emergent surgical debridement
Broad-spectrum antibiotics immediately
Empiric regimen example
Piperacillin-tazobactam IV
4.5 g every 6 hours
Vancomycin IV
Per weight-based dosing and renal function
Clindamycin IV
900 mg every 8 hours
Supportive care
ICU-level monitoring
Aggressive resuscitation
Mastitis and breast abscess
Lactational mastitis
Continue breastfeeding or milk expression
Prevent milk stasis
Improve symptoms and reduce abscess risk
Antibiotics when systemic symptoms or no improvement within 12 to 24 hours supportive measures
Dicloxacillin PO
500 mg every 6 hours
Cephalexin PO
500 mg every 6 hours
If MRSA risk, MRSA-active agent per local guidance
Breast abscess
Drainage
Ultrasound-guided aspiration
Surgical drainage if large or recurrent
Antibiotics
Coverage for Staphylococcus aureus
Adjust based on culture
Urinary tract infection
Cystitis
Oral therapy options
Nitrofurantoin PO
100 mg twice daily for 5 days
Fosfomycin PO
3 g single dose
Culture-directed adjustment
Tailor to susceptibilities
Pyelonephritis
IV therapy
Ceftriaxone IV
1 to 2 g daily
Broader coverage if severe sepsis or resistant risk
Transition criteria
Afebrile
Improved symptoms
Oral tolerance
Pregnancy
Recently pregnant physiology and risk
Maternal sepsis priority
Sepsis as leading contributor to maternal morbidity and mortality
Consider sepsis in all recently pregnant people with suspected infection
Medication considerations in lactation
Compatibility checks for antibiotics
Infant monitoring for GI upset or thrush with maternal antibiotics
Imaging considerations
Contrast decisions guided by clinical urgency and renal function
Ultrasound first-line for pelvic and breast sources
Geriatric
Older postpartum patients
Atypical infection presentation
Less prominent fever
Higher delirium risk
Medication risk
Renal dosing adjustments
Higher adverse drug event risk
Comorbidity burden
Diabetes
Cardiovascular disease
Pediatrics
Neonate and infant exposure considerations
Breastfeeding exposure
Monitor infant for diarrhea
Monitor infant for rash
Household infection control
Hand hygiene
Wound care hygiene
Maternal-infant dyad planning
Admission planning to support feeding and bonding when safe
Epidemiology
Postpartum infection burden
Puerperal sepsis significance
Important cause of postpartum mortality worldwide
StatPearls notes puerperal sepsis accounts for a substantial proportion of postpartum deaths
Endometritis risk gradient
Higher after cesarean than vaginal delivery
Reduced by prophylactic antibiotics at cesarean
Common postpartum infection sources
Genital tract
Surgical wounds
Breast
Urinary tract
Pathophysiology
Endometritis mechanisms
Polymicrobial ascending infection
Anaerobes
Gram-negative rods
Streptococci
Tissue injury and devitalization
Placental bed
Cesarean uterine incision
Retained products as nidus
Ongoing bleeding
Persistent inflammation
Sepsis physiology
Dysregulated host response
Vasodilation
Capillary leak
Microvascular dysfunction
Organ dysfunction pathways
Acute kidney injury
Acute lung injury
Therapeutic Considerations
Antibiotic rationale
Broad polymicrobial coverage for endometritis
Anaerobe coverage importance
Evidence favoring clindamycin plus gentamicin
Toxin suppression strategy
Clindamycin for suspected group A streptococcus or toxic shock physiology
Source control principle
Drain infected collections
Abscess drainage improves outcomes
Remove infected tissue
Necrotizing infection requires debridement
Address retained products
Uterine evacuation when infected retained tissue suspected
Guideline alignment
NICE NG255 provides recognition and early management guidance for suspected sepsis in pregnant or recently pregnant people
RCOG Green-top Guideline 64 addresses identification and management of maternal sepsis during and following pregnancy
WHO recommends clindamycin plus gentamicin for postpartum endometritis
copy discharge instructions
Home care
Hydration
Maintain oral fluids
Avoid dehydration during breastfeeding
Medication adherence
Complete antibiotic course as prescribed
Take doses on schedule
Wound care if applicable
Keep incision clean and dry
Daily inspection for redness and drainage
Return to ED now
Fever
Temperature ≥ 38.0 C after discharge
Recurrent fever after improvement
Sepsis symptoms
Fainting
Confusion
Severe weakness
Fast breathing
New blue or gray lips
Pelvic symptoms
Worsening pelvic pain
Foul-smelling lochia
Heavy bleeding
Passing large clots
Wound symptoms
Spreading redness
Pus
Wound opening
Severe pain at incision
Breast symptoms
Worsening breast redness
New lump that is painful and not improving
Fever with breast pain
Urinary symptoms
Flank pain with fever
Unable to keep fluids down
Follow-up
Obstetrics or primary care follow-up
Within 24 to 48 hours if outpatient treatment
Earlier if symptoms worsen
Lactation support when breastfeeding issues present
Improve milk drainage
Reduce mastitis recurrence
Clinical guidelines and evidence sources
NICE
NG255 Suspected sepsis in pregnant or recently pregnant people recognition diagnosis early management last reviewed 19 November 2025
NG51 Suspected sepsis guideline replaced by NG253 to NG255 updates last updated 19 March 2024
RCOG
Green-top Guideline 64 Identification and management of maternal sepsis during and following pregnancy last reviewed 19 December 2024
Green-top Guideline 64b Bacterial sepsis following pregnancy archived and replaced by Guideline 64
WHO
WHO recommendations for prevention and treatment of maternal peripartum infections recommendation for clindamycin plus gentamicin for postpartum endometritis conditional recommendation very low-quality evidence
Cochrane
Antibiotic regimens for postpartum endometritis review supports clindamycin plus gentamicin as appropriate regimen
Surviving Sepsis Campaign
2021 guidelines recommend antimicrobials immediately ideally within 1 hour for possible septic shock or high likelihood sepsis strong recommendation low-quality evidence
2021 guidelines suggest antimicrobials within 3 hours for possible sepsis without shock if concern persists weak recommendation very low-quality evidence
Clinical references
Merck Manual Professional Postpartum endometritis treatment broad-spectrum IV antibiotics until afebrile for 48 hours
StatPearls Postpartum infection overview and epidemiology
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.