Limited Course of Antibiotic Treatment for
Chorioamnionitis
Lauren Page Black, BA, Lindsay Hinson, MD, and Patrick Duff,
OBJECTIVE: We sought to estimate the effectiveness of a
limited course of antibiotics in treating patients with
chorioamnionitis.
METHODS: We conducted a retrospective review of
patients treated for chorioamnionitis at our medical cen-
ter from 2005 to 2009. Patients received ampicillin plus
gentamicin as soon as the diagnosis was made. Postpar-
tum they received only the next scheduled dose of each
antibiotic. Patients who underwent a cesarean delivery
received either metronidazole or clindamycin immedi-
ately after cord clamping. The primary outcome was
treatment failure, defined as persistent fever requiring
continuation of antibiotics, surgical intervention, or ad-
ministration of heparin.
RESULTS: Of the 423 patients, 282 delivered vaginally,
and 141 delivered by cesarean. Overall, 399 (94%; 95%
confidence interval [CI], 9296%) were treated success-
fully and 24 (6%; 95% CI 3.7 8.3%) failed short-course
treatment. Of the 282 patients who delivered vaginally,
279 (99%; 95% CI 98 100%) were cured with short-term
therapy. Of the 141 who delivered by cesarean, 120 (85%;
95% CI 79 91%) were cured (P<.001). Seventeen of the
patients with total treatment failure had endometritis and
responded to continuation of antibiotics. Seven patients
had more serious complications: wound infection (n4)
and septic thrombophlebitis (n3). All of the serious
complications occurred after cesarean delivery, and all of
the affected patients either were obese or had prolonged
labor or prolonged rupture of membranes.
CONCLUSION: A limited course of antibiotics was suf-
ficient for virtually all patients (99%) with chorioamnio-
nitis who had a vaginal delivery. However, a subset of
From the Department of Obstetrics and Gynecology, Division of Maternal-Fetal
Medicine, University of Florida College of Medicine, Gainesville, Florida.
Presented as a poster at the American College of Obstetricians and Gynecologists
Annual Clinical Meeting, May 59, 2012, San Diego, California.
Corresponding author: Patrick Duff, MD, University of Florida College of
Medicine, Gainesville, FL 32610-0294; e-mail: duffp@ufl.edu.
Financial Disclosure
The authors did not report any potential conflicts of interest.
2012 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/12
1102 VOL. 119, NO. 6, JUNE 2012
MD
patients who delivered by cesarean may have benefited
from a more extended course of antibiotic therapy.
(Obstet Gynecol 2012;119:11025)
DOI: 10.1097/AOG.0b013e31824b2e29
LEVEL OF EVIDENCE: III
C horioamnionitis is a common obstetric complica-
tion, occurring in 15% of term pregnancies and in
up to 25% of patients who undergo preterm delivery.1,2
If chorioamnionitis is treated promptly, serious sequelae
are rare. Intrapartum treatment of chorioamnionitis
reduces neonatal morbidity; thus, prompt and effective
treatment is critically important for both the mother and
the fetus.3 6 The most tested antibiotic regimen for
chorioamnionitis is a combination of ampicillin, 2 g
intravenously every 6 hours, plus gentamicin, 1.5 mg/kg
every 8 hours.7,8 Metronidazole or clindamycin should
be added to this regimen to enhance coverage of
anaerobic organisms if the patient requires cesarean
delivery. Failure to add anaerobic coverage in patients
who undergo a cesarean delivery will result in treatment
failure in up to 25% of patients.2,7
In most published reports of patients with chorio-
amnionitis, antibiotic treatment was continued until
the patient was asymptomatic and afebrile for 24 48
hours, but this treatment approach was based largely
on expert opinion.9 In 2003, Edwards and Duff10
published a study that compared single-dose postpar-
tum antibiotic therapy with extended treatment in
patients with chorioamnionitis. This randomized con-
trolled trial demonstrated that there was no statisti-
cally significant difference in adverse outcomes (2.9%
compared with 4.3%; P.749) between patients who
had only a single dose of postpartum antibiotics
compared with those who received an extended
course of medications (ie, treatment until they had
been afebrile and asymptomatic for a minimum of 24
hours). As a result of this study, an extended course of
antibiotics for chorioamnionitis has no longer been
used at our institution.
OBSTETRICS & GYNECOLOGY
 The purpose of the present study was to estimate
the adequacy and safety of this limited course of treat-
ment for chorioamnionitis in a larger series of patients
treated over a multiyear period. We wanted to assess
whether limited-course therapy had waned in effective-
ness as a result of changes in patient demographics or
microbial susceptibility to our chosen antibiotics.
MATERIALS AND METHODS
With approval from the University of Florida Health
Center Institutional Review Board, under a protocol
exempted from informed consent, we reviewed all
records in our departments electronic database
coded for a diagnosis of chorioamnionitis from Janu-
ary 1, 2005, through December 31, 2009. The diag-
nosis of clinical chorioamnionitis was defined by an
intrapartum temperature of 38C or more and one or
more of the following findings: maternal heart rate
greater than 100 beats per minute (bpm), baseline
fetal heart rate greater than 160 bpm, uterine tender-
ness, or foul-smelling amniotic fluid. In addition,
patients had no other obvious localizing sign of
infection.2 This stringent definition excluded patients
who may have had transient mild temperature eleva-
tions secondary to epidural anesthesia or misoprostol
administration.
At the time the diagnosis of chorioamnionitis was
made, patients were treated with our standard regi-
men of ampicillin 2 g intravenously every 6 hours
plus gentamicin 1.5 mg/kg every 8 hours, until deliv-
ery, followed by a single postpartum dose at the
appropriate drug-specific time interval.10 This treat-
ment regimen was specified in a set of standing orders
to ensure consistent compliance with recommended
treatment. In patients who had a cesarean delivery, a
single intravenous dose of metronidazole (500 mg)
was administered after the neonates umbilical cord
was clamped to provide specific coverage against
anaerobic organisms. Patients who were allergic to
penicillin were treated intrapartum with clindamycin
(900 mg intravenously every 8 hours) plus gentamicin
(1.5 mg/kg intravenously every 8 hours) once the
diagnosis of chorioamnionitis was established. If these
patients had a cesarean delivery, metronidazole was
not administered because clindamycin also has excel-
lent antianaerobic coverage. Fewer than 10% of pa-
tients received clindamycin in lieu of metronidazole.
Patients were followed after delivery by a team con-
sisting of four residents and an attending physician.
We used descriptive statistics to assess the key
outcome measure, which was therapeutic failure, de-
fined as persistent postpartum fever requiring contin-
uation of antibiotics, surgical intervention (to drain a
VOL. 119, NO. 6, JUNE 2012
pelvic abscess or incisional abscess), or administration
of heparin (for septic pelvic vein thrombophlebitis).
Persistent fever was defined as a single temperature of
39C or higher after the first postpartum dose of
antibiotics or two or more temperatures of 38.4C or
higher at least 4 hours apart. Patients identified as
having therapeutic failures were divided into those
with endometritis and those with the more serious
complications of wound infection, pelvic abscess, and
septic pelvic thrombophlebitis. The treatment failure
group was analyzed for commonalities that may have
contributed to the development of postpartum compli-
cations. Differences in the primary outcome in patients
who had a vaginal delivery compared with a cesarean
delivery were assessed using the uncorrected 2 test.
P.05 was considered significant; 95% confidence inter-
vals (CIs) were determined, as appropriate.
RESULTS
Our medical center serves a predominantly indigent,
rural population. Most patients are insured under the
Florida Medicaid Insurance Program or are self-pay.
The entire group of patients from whom we derived
our study population is presented in Figure 1. As
noted in the figure, our final sample included 423
patients, which represented 3.9% of the laboring
patients during this time period.
Of the 423 patients reviewed, 282 delivered
vaginally and 141 delivered by cesarean. Seventy-six
percent of patients received epidural anesthesia.
Overall, 399 (94%; 95% CI 9296%) were treated
successfully and 24 (6%; 95% CI 3.7 8.3) failed
treatment. Of the 282 patients who delivered vagi-
nally, 279 (99%; 95% CI 98 100%) were cured with
short-course therapy. Of the 141 who delivered by
cesarean, 120 (85%; 95% CI 79 91%) were cured
(P.001). Of those patients who failed therapy, 17
had endometritis. The remaining treatment failures
included four patients with wound infections and
Patients within study period (January
1, 2005, to December 31, 2009)
N=13,399
Laboring patients Scheduled cesarean; no labor
n=10,843 n=2,556
Patients with chorioamnionitis
n=424; 3.9%
Excluded for sepsis at time of diagnosis
n=1
Study patients
n=423
Fig. 1. Overview of patient population during the study period.
Black. Treatment of Chorioamnionitis. Obstet Gynecol 2012.
Black et al Treatment of Chorioamnionitis 1103
three patients with septic vein thrombophlebitis.
These seven patients were categorized as having
serious complications (Fig. 2).
Of the 17 patients with endometritis, 14 underwent a
cesarean delivery. The average hospital stay for these
patients was 4 days (range 36 days). All except one had
received antianaerobic therapy during cesarean delivery
as per our protocol. All subsequently received gentamicin
7 mg/kg intravenously every 24 hours and clindamycin
900 mg intravenously every 8 hours until they were
afebrile for 24 hours. None of these individuals required
surgical intervention.
Four patients had wound infections, all after
cesarean delivery. Their average hospital stay was 4
days (range 320 days). Three of these patients had
had misoprostol inductions of labor, with lengths of
labor of 27 hours, 28 hours, and 34 hours, and they
subsequently required cesarean delivery for an arrest
of dilation. Their body mass indexes (BMIs, calcu-
lated as weight (kg)/[height (m)]2) were 44.8, 31.1, and
48.5, respectively. The remaining patient had a cesar-
ean delivery at 29 weeks for preterm premature
rupture of membranes, chorioamnionitis, and malpre-
sentation. All patients were discharged home on oral
antibiotics; none developed fascial dehiscences.
Three patients, all of whom delivered by cesar-
ean, had septic pelvic vein thrombophlebitis (ovarian
vein thrombosis) confirmed by computed tomo-
graphic scan. All received additional antianaerobic
therapy immediately after the umbilical cord was
clamped. The average hospital stay for these patients
was 13 days. All patients eventually responded to
antibiotics plus intravenous heparin. Two had had
misoprostol inductions of labor, with lengths of labor
of 27 hours and 20 hours. Their BMIs were 29.2 and
31.1, respectively. The remaining patient was deliv-
ered secondary to preterm premature rupture of
membranes, chorioamnionitis, and malpresentation.
Her BMI was 40.3.
The average BMI of the seven patients who
developed serious complications was 37. Five of the
Infection resolved
n=399; 94.3%
Cesarean deliveries Vaginal deliveries Endometritis after
n=120; 85.1% of 141 n=279; 98.9% of 282 cesarean delivery
n=14
Fig. 2. Clinical outcome of patients treated with a limited course of antibiotics for chorioamnionitis.
Black. Treatment of Chorioamnionitis. Obstet Gynecol 2012.
1104 Black et al Treatment of Chorioamnionitis
seven women were obese, defined as a BMI between
30 and 39, or extremely obese, defined as a BMI
higher than 40. One was overweight, defined as a
BMI of 25 to 29. One was of normal weight.
Overall, of the 21 treatment failures in the cesar-
ean delivery group, 16 women had either prolonged
rupture of membranes (n6) or a BMI greater than 30
(n10). Six women had both prolonged rupture of
membranes and were obese. In the 120 women who
had a cesarean delivery and were successfully treated,
42 had either prolonged rupture of membranes (n3)
or a BMI higher than 30 (n39). None had both
prolonged rupture of membranes and a BMI higher
than 30. The difference in frequency of either pro-
longed rupture of membranes or a BMI higher than
30 in treatment failures compared with treatment
successes was highly significant (P.01).
All patients with treatment failure were identified
while they were still hospitalized. A search of our
electronic database demonstrated that none of the
patients with an initially uncomplicated hospital
course required readmission to our medical center
with a delayed complication of chorioamnionitis.
We did not do routine microbiologic studies in
patients with endometritis, wound infection, or septic
pelvic vein thrombophlebitis. No patient had drain-
age of an intra-abdominal abscess for isolation of
microorganisms.
DISCUSSION
Several authors have recommended shorter courses
of antibiotic treatment for chorioamnionitis. In 1997
Chapman and Owen11 studied 109 women who had
been treated for chorioamnionitis in the intrapartum
period and delivered vaginally. Of these, 55 women
were given a single dose of antibiotics postpartum and
54 women were given multiple doses; women in both
treatment groups had a similar incidence of failure.
For women who delivered vaginally, a single postpar-
tum dose of antibiotics reduced the cost and average
length of hospital stay compared with women who
Total
n=423
Endometritis Serious complications
n=17; 4.0% n=7; 1.7%
Endometritis after Septic vein phlebitis Wound infections after
vaginal delivery after cesarean cesarean delivery
n=3 delivery n=4
n=3
OBSTETRICS & GYNECOLOGY
were treated with multiple doses of antibiotics. The
socioeconomic characteristics of the patients in this
study were similar to those of our patients.
In a prospective, randomized, placebo-controlled,
double-blinded trial of 36 women who delivered vagi-
nally, LaBella et al12 found that postpartum antibiotics
added little therapeutic benefit. In both the long and
short arms of the trial, the incidence of persistent infec-
tion was less than 5% (Pnot significant).
Our study supports the conclusions of these re-
ports and the previous report from our institution10
that a limited course of antibiotics is sufficient post-
partum therapy for most patients with chorioamnio-
nitis, particularly those who deliver vaginally. In the
original report by Edwards and Duff,10 the overall
treatment failure rate was 4.6% in the short-term
treatment group and 3.5% in the extended treatment
group (P.639). In the vaginal delivery group, the
failure rate was 3.4% in the short-term group com-
pared with 4.5% in the long-term group (P.999). In
the cesarean delivery group, the failure rates were
6.3% and 1.9%, respectively (P.375).
The present study includes a larger sample size
than the original investigation (n423 compared with
n292) and confirms the effectiveness of the treat-
ment regimen over a longer period of time (5 com-
pared with 3 years). Our study shows that a limited
course of antibiotics, overall, is effective in treating
94% (95% CI 9296) of patients with chorioamnioni-
tis. Only 1% of patients who delivered vaginally failed
therapy compared with 15% of patients who delivered
by cesarean (P.001). Of the latter group, the women
who failed therapy were likely either to be obese or to
have had an extended duration of labor, ruptured
membranes or both. We believe that the higher
failure rate in the cesarean delivery group in the
present study compared with our previous study is
most likely due to the larger sample size, longer time
period of observation, and the steadily increasing
prevalence of obesity in our patient population.
With rising rates of obesity in the United States, it is
important to address complications that uniquely affect
this subset of the population. Obesity (BMI higher than
30) is clearly a major risk factor for wound infection.13 A
recent large series reported by Robinson et al14 confirmed
that obese women have an increased risk of preeclamp-
sia, antepartum venous thromboembolism, gestational
diabetes, premature induction of labor, cesarean delivery,
and wound infection, as well as a higher prevalence of
antibiotic use in labor and postpartum. The strong corre-
lation between increased postpartum morbidity and obe-
sity is also reflected in our treatment failure group. Of the
seven patients in our analysis who developed serious
VOL. 119, NO. 6, JUNE 2012
complications, five were obese and one was severely
overweight.
All our cases of serious complications occurred
after cesarean delivery. Six of these deliveries were in
patients who not only were obese, but also had a
prolonged period of rupture of membranes. The
remaining patient had prolonged preterm premature
rupture of membranes. These findings indicate that,
whereas single-dose postpartum antibiotic therapy is
sufficient for essentially all patients having a vaginal
delivery and for the majority of patients having a
cesarean delivery, a distinct subset of patients, namely
obese patients and those who are delivered by cesar-
ean after a long period of labor and ruptured mem-
branes, may benefit from a more extended course of
antibiotic therapy.
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