Antibiotic Prophylaxis for Premature Rupture of Membranes

Recommended Antibiotic Regimens

The American College of Obstetricians and Gynecologists recommends a 7-day course of antibiotics for preterm premature rupture of membranes (PPROM) ≥24 weeks, consisting of initial 48 hours of IV ampicillin 2g every 6 hours and erythromycin 250mg IV every 6 hours, followed by 5 days of oral amoxicillin 250mg every 8 hours and erythromycin 333mg every 8 hours, with a GRADE 2C recommendation for PPROM at 20-23 6/7 weeks 1
Azithromycin can be substituted for erythromycin when erythromycin is not available 2

The Centers for Disease Control and Prevention recommends that if receiving antibiotics for latency that include ampicillin 2g IV once, followed by 1g IV every 6 hours for at least 48 hours, this is adequate for Group B Streptococcus (GBS) prophylaxis 3
For women with PPROM who are GBS positive, continue antibiotics until delivery if in labor 2
For women with PPROM who are GBS negative, no GBS prophylaxis is needed at onset of true labor 2

The American Academy of Pediatrics recommends avoiding amoxicillin/clavulanic acid due to increased risk of necrotizing enterocolitis in neonates 2
Oral antibiotics alone are not adequate for GBS prophylaxis 3
GBS prophylaxis should be discontinued at 48 hours for women with PPROM who are not in labor 3
If GBS screen results become available during the 48-hour period and are negative, GBS prophylaxis should be discontinued at that time 3
A negative GBS screen is considered valid for 5 weeks 3

Appropriate antibiotic therapy prolongs pregnancy latency, reduces maternal infection and chorioamnionitis, decreases neonatal morbidity, and improves neonatal survival without severe morbidity 1

Antibiotic susceptibility testing should be performed to guide alternative therapy in penicillin-allergic patients 4

Antibiotics are indicated after 18 hours of membrane rupture regardless of other risk factors 1
Prompt administration of antibiotics is recommended when indicated based on gestational age 1

Women with rupture of membranes at <37 weeks gestation should receive antibiotics at hospital admission, as recommended by the Centers for Disease Control and Prevention (CDC) 5, 6, 7, 8
At 35 weeks with ruptured membranes, pregnant women have multiple indications for GBS prophylaxis even with unknown GBS status: delivery <37 weeks gestation and membrane rupture, according to the CDC 5, 6, 9

The antibiotics should have been started at hospital admission when PPROM was diagnosed, not delayed until the decision for cesarean section was made, as recommended by the CDC 5, 7, 8

If signs of chorioamnionitis develop, switch to broad-spectrum antibiotics (clindamycin plus gentamicin) that include GBS coverage, as recommended by the CDC 5
The importance of prompt delivery and infection prevention is reinforced in patients with IUGR diagnosis, according to the American College of Obstetricians and Gynecologists 10