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Infectious Disease Clinics of North America

Volume 11, Issue 1, 1 March 1997, Pages 1-12

ANTIBIOTIC SELECTION IN OBSTETRIC PATIENTS

Author links open overlay panelPatrick Duff MD

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https://doi.org/10.1016/S0891-5520(05)70338-X

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PENICILLIN AND AMPIClLLIN

Penicillin and ampicillin interfere with the synthesis of the bacterial cell wall. These antibiotics are highly
effective against group A and group B streptococci, Neisseria gonorrhoeae, and anaerobic streptococci.
Ampicillin also provides excellent coverage against enterococci andmodest coverage against aerobic
gram-negative bacilli. Because of widespread use of ampicillin, however, an increasing number of
coliform organisms have developed resistance to this antibiotic. Up to 30% of strains of

THE CEPHALOSPORINS

Many cephalosporins are available for clinical use. All exert their effect by inhibiting bacterial cell wall
synthesis. Use of the terminology "first- versus second- versus third-generation" is somewhat confusing
because it suggests chronology of development of the drug rather than spectrum of activity. An
alternative is to classify the drugs into three categories: (1) limited spectrum, (2) intermediate spectrum,
and (3) extended spectrum. Table 1 lists the most commonly used drugs in each

EXTENDED-SPECTRUM PENICILLINS
The extended-spectrum penicillins can be divided into two groups. The first is composed of two
ureidopenicillins: mezlocillin (Mezlin) andpiperacillin (Pipracil). The second group includes the three
combination drugs of ticarcillin-clavulanic acid (Timentin), ampicillin-sulbactam (Unasyn), and
piperacillin-tazobactam (Zosyn). All of these antibiotics act by inhibiting bacterial cell wall synthesis.
Clavulanic acid, sulbactam, and tazobactam are β-lactamase inhibitors that are used in

IMIPENEM-CILASTATIN

Imipenem-cilastatin is one of two carbapenem antibiotics commercially available in the United States.
Imipenem is the active antibiotic; cilastatin is a compound that prevents the renal metabolism of
imipenem by dehydropeptidase I, thus reducing the risk of nephrotoxicity and slowing the rate of renal
excretion. Imipenem-cilastatin has very good to excellent activity against virtually every pelvic pathogen,
including the entero-coccus. Its spectrum of activity is sufficiently broad to justify

CLINDAMYCIN

Clindamycin exerts its effect by inhibiting bacterial protein synthesis. Clindamycin's spectrum of activity
includes group A and group B streptococci, staphylococci, anaerobic streptococci, and anaerobic gram-
negative bacilli. The drug is particularly effective against anaerobes, and it has modest activity against
chlamydia. Clindamycin lacks activity against aerobic gram-negative bacilli and enterococci; therefore, it
is usually administered in combination with other antibiotics such as an

METRONIDAZOLE

The mechanism of action of metronidazole is not completely understood. Once the drug enters the
bacterium, it undergoes a series of reduction reactions that result in production of several unstable, but
toxic, intermediates. These substances appear to interact with bacterial DNA to inhibit protein synthesis.
Metronidazole is primarily valuable for treatment of anaerobic infections, trichomoniasis, bacterial
vaginosis, giardiasis, and amebiasis. The antibiotic has essentially no activity against

AMINOGLYCOSIDES

The aminoglycoside antibiotics exert their effect by inhibiting bacterial protein synthesis. They function
most effectively in tissues where the pH and oxygen tension are normal, and they do not penetrate well
into abscess cavities.11 The three aminoglycosides that have been used most frequently in obstetrics
and gynecology are gentamicin, tobramycin, and amikacin. Although these drugs have modest activity
against staphylococci and gonococci, their principal spectrum of activity is the aerobic
AZTREONAM

Aztreonam is the only monobactam antibiotic that is presently available in the United States. The drug
acts by inhibiting synthesis of the bacterial cell wall. Its spectrum of activity is limited to aerobic gram-
negative bacilli, a spectrum virtually identical to that of the aminoglycosides. In patients with
polymicrobial pelvic infections, aztreonam is usually given in combination with an antibiotic such as
clindamycin that provides coverage against aerobic streptococci and anaerobes. The

ERYTHROMYCIN AND AZITHROMYCIN

Erythromycin and azithromycin are macrolide antibiotics that inhibit bacterial protein synthesis. In
obstetric patients, they are used primarily as an alternative to tetracycline for treatment of
endocervicitis caused by Chlamydia trachomatis.25 They also may be valuable in treating respiratory
infections caused by Mycoplasma pneumoniae and for providing intrapartum prophylaxis against group
B streptococci in patients who are allergic to β-lactam antibiotics.6

Clarithromycin and dirithromycin,

COST OF ANTIBIOTIC THERAPY

In the United States, approximately $6 billion is spent annually for antibiotics. Expenses are almost
evenly divided between inpatient and outpatient administration. In most hospitals, purchases of
antibiotics account for about 40% of pharmaceutical expenditures. Physicians must be aware that the
wholesale acquisition cost of an antibiotic represents only a fraction of the charge actually incurred by
the patient. Other costs, such as markup above wholesale, pharmaceutical dispensing fees, dose

SUMMARY

Penicillin and ampicillin are valuable antibiotics in obstetrics because of their excellent activity against
group A and group B streptococci. In addition, ampicillin is the treatment of choice for enterococcal
infections, particularly urinary tract infections. Limited spectrum cephalosporins are of primary value as
prophylactic agents. Ceftriaxone, an intermediate spectrum agent, is an excellent drug for treatment of
infections caused by N. gonorrhoeae. Extended spectrum cephalosporins,

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References (42)

M.B. Bansal et al.

In vitro activity and in vivo evaluation of ticarcillin plus clavulanic acid against aerobic and anaerobic
bacteria

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Serum tobramycin levels in puerperal women

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Gentamicin dosing in postpartum women with endometritis

Am J Obstet Gynecol

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P. Duff

The aminoglycosides

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Clinical uses of cephalosporins

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Carbapenems: Special properties contributing to their activity

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Metronidazole use in obstetrics and gynecology: A review

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(1983)

View more references

Cited by (32)

Perinatal Infections

2018, Diagnostic Pathology of Infectious Disease

Urinary Tract Infection and Bacteriuria in Pregnancy

2015, Urologic Clinics of North America

It is effective against many gram-negative organisms and has low cross-reactivity in penicillin-allergic
patients, but must be administered intravenously or intramuscularly. Limited data are available on the
use of aztreonam in pregnancy, yet the risk of adverse events or teratogenicity is considered low.27,50
Carabenems are a class of β-lactam antimicrobials that are resistant to the extended-spectrum β-
lactamase enzymes made by MDR gram-negative bacteria.40,51

Perinatal Infections

2010, Diagnostic Pathology of Infectious Disease: Expert Consult

Perinatal infections

2010, Diagnostic Pathology of Infectious Disease

Traveller's diarrhoea

2005, Lancet Infectious Diseases

Citation Excerpt :

Azithromycin has a low potential for notable drug interactions since it does not inactivate cytochrome
P450 and is unable to modify the pharmacokinetics of other compounds.84,85 Azithromycin is an
alternative to fluoroquinolones in areas of high incidence of campylobacter infection and for use in
children.86 Rifaximin is a semisynthetic antibiotic.

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Randomized comparison of quinine-clindamycin versus artesunate in the treatment of falciparum

2001, Transactions of the Royal Society of Tropical Medicine and Hygiene

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Address reprint requests to Patrick Duff, MD Division of Maternal-Fetal Medicine University of Florida
College of Medicine P.O. Box 100294 Gainesville, FL 32610–0294
View full text

Copyright © 1997 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.

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