Modernizing antibiotic regimens for obstetric infections through antimicrobial stewardship

Maternal sepsis remains a major and largely preventable contributor to maternal morbidity and mortality, with intra-amniotic infection and postpartum endometritis remaining common obstetric sources of sepsis. Intra-amniotic infection complicates approximately 2%-5% of term deliveries, and postpartum endometritis occurs in up to 7% of births. Both conditions are typically polymicrobial, arising from ascending infection involving gram-positive, gram-negative, and anaerobic organisms. Despite rising antimicrobial resistance, the recommended antibiotic regimens for obstetric infections have remained unchanged since the 1980's. Current guidelines endorse ampicillin and gentamicin, with the addition of clindamycin at the time of cesarean delivery, for the treatment of intra-amniotic infection based on heterogeneous and largely dated studies. Gentamicin and clindamycin remain the mainstay of treatment for postpartum endometritis. Evidence guiding optimal dosing strategies, antibiotic selection, and postpartum duration of therapy remains limited for both clinical entities. Concerns regarding the continued effectiveness of these regimens include increasing antimicrobial resistance among Enterobacterales, anaerobes, and group B streptococcus, and recent aminoglycoside breakpoint changes necessitating higher gentamicin dosing. Antimicrobial stewardship offers an opportunity to modernize obstetric infection management through institution-specific antibiograms and multidisciplinary collaboration among obstetric, infectious diseases, pharmacy, and microbiology teams. Leveraging local resistance data to tailor antibiotic selection aligns with contemporary sepsis management principles and may improve safety, efficiency, and antimicrobial sustainability. In the absence of new randomized controlled trials, stewardship-driven, evidence-informed approaches represent a practical strategy to optimize treatment of intra-amniotic infection and postpartum endometritis in modern obstetric practice.