Trip Answers

Question answered:18/01/07 Warning! this question is over two years old.

Due to the potential harm associated with various drugs used during breastfeeding we recommend you contact the UK Drugs in Lactation Advisory Service (http://www.ukmicentral.nhs.uk/drugpreg/guide.htm).  They have an enquiry from at http://www.ukmicentral.nhs.uk/enquires/enq_preg.asp.

 

We searched the NLH Specialist Library for Women’s Health, and the TRIP and Medline databases but found very little evidence for using co-amoxiclav to treat mastitis or endometritis in breast feeding women.

 

However, GPNotebook gives the following information concerning treating mastitis:

 

“Blind therapy is with flucloxacillin, assuming infection with staphylococcus. Other antibiotics which may adversely effect the baby should of course be avoided. Use erythromycin if penicillin-allergic…
If the infection persists after an initial course of flucloxacillin (and results of culture and sensitivity are not available), then co-amoxiclav, which has a wider spectrum of action, may be tried.” [1]

 

Please note  for the latest safety information on prescribing co-amoxiclav to breast feeding patients, the NLH Q & A Service would recommend contacting the Drugs in Breast Milk Information Service on 0121 378 6017. 

 

Concerning the treatment for endometritis, GPNotebook suggests:

 

• “empirical treatment with antibiotics e.g. doxycycline 100mg/d PO and metronidazole 400mg tds PO
• a pyometra requires drainage and the treatment of cause
Puerperal pyrexia secondary to endometritis may require uterine curettage and treatment with intravenous antibiotics e.g. cephalexin and metronidazole. [2]

 

An e-Medicine article, an American source, by Witt on normal and abnormal puerperium states:

 

“No consensus exists regarding the antibiotic regimen for treatment of endometritis, although gentamicin in combination with clindamycin has become the standard by which all other regimens are judged... The addition of ampicillin (or vancomycin for patients with a penicillin allergy), is considered when the patient does not respond to the initial therapy of gentamicin and clindamycin to cover this organism.

 
Alternatively, broad-spectrum second- and third-generation cephalosporins, extended spectrum penicillins, and combination beta-lactamase inhibitors with penicillins have been used in an attempt to avoid polypharmacy and its associated toxicities. In general, these alternative therapies have a cure rate of 80-90%. The most accepted among this category of drugs are cefoxitin or moxalactam.” [3]

 

A second e-Medicine article on postpartum infections, focusing on patients presenting to emergency departments, notes:

 

• “Postpartum endometritis treatment
o Mild cases of endometritis after vaginal delivery may be treated with oral antimicrobial agents (such as doxycycline or clindamycin).
o Moderate-to-severe cases, including those involving cesarean deliveries, should be treated with parenteral broad-spectrum antimicrobials (cefoxitin with doxycycline or clindamycin).
o A rapid response to antibiotics is the typical response in the treatment of postpartum endometritis.
• Mastitis treatment
o Administer dicloxacillin, penicillinase-resistant penicillin, or clindamycin, and use local measures, such as ice packs, analgesics, and breast support…” [4]

 

A search in the Medline database identified one clinical trial examining the effectiveness of Amox-CA (Augmentin) in treating suspected postpartum endometritis; however, this trial dates from 1990. In this trial Amox-CA was compared to ampillicin-metronidazole and/or aminoglycoside.

 

“…The mild forms were defined by a temperature between 37.9 and 38.4 degrees C and the severe forms by a temperature of more than 38.5 degrees C (which alone required treatment with three antibiotics). The time until the return of apyrexia and the clinical cure rate, as well as duration of treatment, were identical in both groups. Tolerance was good: no side effect requiring discontinuation of treatment occurred. In the population value, the use of a single-agent therapy with amoxycillin/clavulanic acid is not significantly different from a double or triple-agent regimen, and the convenience is increase.” [5]

References
1. GPNotebook. Puerperal mastitis – management. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=1738145838&linkID=20488&cook=yes).
2. GPNotebook. Endometritis – management. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=604373010&linkID=14193&cook=yes).
3. Witt K. Normal and abnormal puerperium. e-Medicine. June 2006. (http://www.emedicine.com/med/topic3240.htm#section~infections).
4. Kennedy E. Pregnancy, postpartum infections. e-Medicine. March 2005. (http://www.emedicine.com/emerg/topic482.htm#section~treatment).
5. Fernandez H, Claquin C, Guibert M et al.  Suspected postpartum endometritis: a controlled clinical trial of single-agent antibiotic therapy with Amox-CA (Augmentin) vs. ampicillin-metronidazole +/- aminoglycoside. Eur J Obstet Gynecol Reprod Biol. 1990 Jul-Aug;36(1-2):69-74. (http://www.hubmed.org/display.cgi?uids=2194867).

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