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Abdel Halim AS, Ali MAM, Al Mamari R, Al Raisi F, Boufahja F, Chaudhary AA, Hegazy WAH. A Retrospective Exploration of Pre-operative Antibiotic Prophylaxis with Cefazolin in Cesarean Sections: Implications for Obstetrics and Gynecologic Surgery. Surg Infect (Larchmt) 2024; 25:513-520. [PMID: 38957977 DOI: 10.1089/sur.2024.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
Background: Post-partum infection is a major contributor to maternal mortality and is responsible for approximately 10% of maternal fatalities worldwide. The risk of infection is substantially higher in cesarean section procedures. Approximately 8% of women who undergo cesarean sections are susceptible to infection. Although the body of evidence supporting the regular pre-operative utilization of prophylactic antibiotic treatment is steadily expanding, its usefulness in cesarean sections has not yet been standardized, and post-partum infection is still a serious medical challenge. We aimed to retrospectively assess the prophylactic effectiveness of cefazolin in combination with other antibiotic agents in cesarean sections. Materials and Methods: Both uni-variable and multi-variable analyses were conducted to identify factors that may affect cefazolin pre-operative antibiotic prophylaxis in elective cesarean section operations. The uni-variable analysis included timing of administration, operation duration, body mass index (BMI), and wound type. A multi-variable logistic regression model was then created to determine which variables provide independent information in the context of other variables. Results: Time of administration did not affect prophylactic cefazolin efficacy. However, prophylactic cefazolin was 1.43 and 1.77 times more effective when the operation lasted for 45 minutes or more, compared with operations that were shorter than 45 minutes. Patients with a BMI ranging from 18 to 29 kg/m2 showed increased efficacy of prophylactic cefazolin compared with obese patients with a BMI exceeding 30 kg/m2. The effectiveness of prophylactic cefazolin decreased by 95% in patients with clean-contaminated surgical incisions compared with those with clean surgical incisions. Conclusions: Our findings demonstrate that administering pre-operative prophylactic antibiotic agents to women undergoing cesarean section resulted in a reduction in post-partum infections, thereby reducing maternal mortality. Furthermore, optimal timing of administration, re-dosing if necessary, length of prophylactic medication, and dosing adjustments for obese patients are crucial factors in preventing surgical site infections and promoting antimicrobial stewardship.
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Affiliation(s)
- Alyaa S Abdel Halim
- Department of Biochemistry, Faculty of Science, Ain Shams University, Abbassia, Egypt
| | - Mohamed A M Ali
- Department of Biology, College of Science, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
- Department of Biochemistry, Faculty of Science, Ain Shams University, Abbassia, Egypt
| | - Ruqiya Al Mamari
- Pharmacy Program, Department of Pharmacy Practice and Pharmaceutics, Oman College of Health Sciences, Muscat, Oman
| | - Fatma Al Raisi
- Pharmacy Program, Department of Pharmacology, Oman College of Health Sciences, Muscat, Oman
| | - Fehmi Boufahja
- Department of Biology, College of Science, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Anis Ahmad Chaudhary
- Department of Biology, College of Science, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Wael A H Hegazy
- Department of Microbiology and Immunology, Faculty of Pharmacy, Zagazig University, Zagazig, Egypt
- Department of Pharmaceutical Sciences, Pharmacy Program, Oman College of Health Sciences, Muscat, Oman
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Zhang T, Wang J, Hua Z, Yao X, Zhang F, Zhou Y. Effect of adjunctive prophylactic macrolides used at the caesarean section on endometritis and surgical site wound infection: A meta-analysis. Int Wound J 2023; 20:3307-3314. [PMID: 37161646 PMCID: PMC10502253 DOI: 10.1111/iwj.14211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023] Open
Abstract
A meta-analysis investigation was executed to measure the outcome of adjunctive prophylactic macrolides (APM) used at caesarean section (CS) on endometritis and surgical site wound infection (SSWI). A comprehensive literature inspection till February 2023 was applied and 1023 interrelated investigations were reviewed. The 10 chosen investigations enclosed 22 676 females with CS were in the chosen investigations' starting point, 14 034 of them were utilising APM, and 8642 were utilising control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of APM used at CS on endometritis and SSWI by the dichotomous approaches and a fixed or random model. Adjunctive prophylactic macrolides had significantly lower SSWI (OR, 0.43; 95% CI, 0.34-0.55, P < .001), and endometritis (OR, 0.34; 95% CI, 0.20-0.60, P = .005) compared with those with control in females with CS. Adjunctive prophylactic macrolides had significantly lower SSWI, and endometritis compared with those with control in females with CS. However, care must be exercised when dealing with its values because of the low number of nominated investigations for the meta-analysis.
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Affiliation(s)
- Taiwei Zhang
- Department of ObstetricsThe First Affiliated Hospital of Guizhou University of Chinese MedicineGuiyangGuizhouChina
| | - Jiuchong Wang
- Department of Infectious Diseases, Guang'anmen HospitalChina Academy of Chinese Medical SciencesBeijingChina
| | - Zhaozhao Hua
- Department of ObstetricsThe Second Affiliated Hospital of Guizhou University of Chinese MedicineGuiyangGuizhouChina
| | - Xiaoyun Yao
- Department of ObstetricsThe First Affiliated Hospital of Guizhou University of Chinese MedicineGuiyangGuizhouChina
| | - Fang Zhang
- Department of ObstetricsThe First Affiliated Hospital of Guizhou University of Chinese MedicineGuiyangGuizhouChina
| | - Yiyuan Zhou
- Eugenics Research CenterThe First Affiliated Hospital of Guizhou University of Chinese MedicineGuiyangGuizhouChina
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Hemingway-Foday J, Tita A, Chomba E, Mwenechanya M, Mweemba T, Nolen T, Lokangaka A, Tshefu Kitoto A, Lomendje G, Hibberd PL, Patel A, Das PK, Kurhe K, Goudar SS, Kavi A, Metgud M, Saleem S, Tikmani SS, Esamai F, Nyongesa P, Sagwe A, Figueroa L, Mazariegos M, Billah SM, Haque R, Shahjahan Siraj M, Goldenberg RL, Bauserman M, Bose C, Liechty EA, Ekhaguere OA, Krebs NF, Derman R, Petri WA, Koso-Thomas M, McClure E, Carlo WA. Prevention of maternal and neonatal death/infections with a single oral dose of azithromycin in women in labour in low-income and middle-income countries (A-PLUS): a study protocol for a multinational, randomised placebo-controlled clinical trial. BMJ Open 2023; 13:e068487. [PMID: 37648383 PMCID: PMC10471878 DOI: 10.1136/bmjopen-2022-068487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 05/15/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Maternal and neonatal infections are among the most frequent causes of maternal and neonatal mortality, and current antibiotic strategies have been ineffective in preventing many of these deaths. A randomised clinical trial conducted in a single site in The Gambia showed that treatment with an oral dose of 2 g azithromycin versus placebo for all women in labour reduced certain maternal and neonatal infections. However, it is unknown if this therapy reduces maternal and neonatal sepsis and mortality. In a large, multinational randomised trial, we will evaluate the impact of azithromycin given in labour to improve maternal and newborn outcomes. METHODS AND ANALYSIS This randomised, placebo-controlled, multicentre clinical trial includes two primary hypotheses, one maternal and one neonatal. The maternal hypothesis is to test whether a single, prophylactic intrapartum oral dose of 2 g azithromycin given to women in labour will reduce maternal death or sepsis. The neonatal hypothesis will test whether this intervention will reduce intrapartum/neonatal death or sepsis. The intervention is a single, prophylactic intrapartum oral dose of 2 g azithromycin, compared with a single intrapartum oral dose of an identical appearing placebo. A total of 34 000 labouring women from 8 research sites in sub-Saharan Africa, South Asia and Latin America will be randomised with a one-to-one ratio to intervention/placebo. In addition, we will assess antimicrobial resistance in a sample of women and their newborns. ETHICS AND DISSEMINATION The study protocol has been reviewed and ethics approval obtained from all the relevant ethical review boards at each research site. The results will be disseminated via peer-reviewed journals and national and international scientific forums. TRIAL REGISTRATION NUMBER NCT03871491 (https://clinicaltrials.gov/ct2/show/NCT03871491?term=NCT03871491&draw=2&rank=1).
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Affiliation(s)
| | - Alan Tita
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Elwyn Chomba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | | | - Trecious Mweemba
- University of Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Tracy Nolen
- RTI International, Research Triangle Park, North Carolina, USA
| | - Adrien Lokangaka
- University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Antoinette Tshefu Kitoto
- University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | - Gustave Lomendje
- Kinshasa School of Public Health, Kinshasa, Congo (the Democratic Republic of the)
| | | | - Archana Patel
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
- Datta Meghe Institute of Higher Education & Research (Deemed to be University), Wardha, Maharashtra, India
| | | | - Kunal Kurhe
- Lata Medical Research Foundation, Nagpur, Maharashtra, India
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Avinash Kavi
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Mrityunjay Metgud
- KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgavi, Karnataka, India
| | - Sarah Saleem
- Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | - Shiyam S Tikmani
- Community Health Sciences, The Aga Khan University, Karachi, Pakistan
| | | | | | - Amos Sagwe
- Moi University School of Medicine, Eldoret, Kenya
| | - Lester Figueroa
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Manolo Mazariegos
- Instituto de Nutricion de Centroamerica y Panama, Guatemala, Guatemala
| | - Sk Masum Billah
- The University of Sydney, Sydney, New South Wales, Australia
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Md Shahjahan Siraj
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | | | - Melissa Bauserman
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Carl Bose
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Edward A Liechty
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Nancy F Krebs
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Richard Derman
- Office of Global Affairs, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | | | - Waldemar A Carlo
- The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 48] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Schilling AL, Rody A, Bossung V. Antibiotic Use During Pregnancy and Childbirth: Prospective Observational Study on Prevalence, Indications, and Prescribing Patterns in a German Tertiary Center. Geburtshilfe Frauenheilkd 2023; 83:192-200. [PMID: 37151734 PMCID: PMC10155238 DOI: 10.1055/a-1934-1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/28/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Antibiotics are powerful drugs to prevent and treat perinatal infections. Overuse of antibiotics leads to antibiotic resistance, has potential side effects and influences the maternal and neonatal microbiome. Patients and Methods We performed a prospective observational study on the prevalence, indications, and prescribing patterns of antibiotics during pregnancy and childbirth. We included women who had given birth after 23+0 weeks of gestation at a single tertiary center in Germany from January 2020 to March 2021. Descriptive statistics and binomial regression were performed to analyze the factors influencing the prescription of antibiotics. Results We included 522 postpartum women into our study. 337 (64.6%) were exposed to antibiotics during pregnancy and/or childbirth. 115 women received antibiotics during pregnancy, 291 during birth. Most antibiotics during pregnancy were prescribed for urinary tract infections (UTIs) (56.0%). Most prescriptions were issued by obstetrics and gynecology physicians (65.8%), followed by hospitals (16.7%) and family medicine physicians (8.8%). Most antibiotics during childbirth were given for a cesarean section (64.3%), followed by preterm rupture of membranes (41.2%). 95.3% of women who had a preterm birth were exposed to antibiotics. In logistic regression models, lower gestational age at birth, higher maternal body-mass-index and smoking were independently associated with antibiotic use during pregnancy and childbirth. Conclusion We found a high rate of antibiotic exposure during pregnancy and childbirth. Our results imply an urgent need for antibiotic stewardship programs in perinatal medicine as well as further research on the effects of perinatal antibiotic exposure on microbiome development and childhood health.
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Affiliation(s)
- Anna-Lara Schilling
- Department of Obstetrics and Gynecology, University Hospital of
Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Achim Rody
- Department of Obstetrics and Gynecology, University Hospital of
Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Verena Bossung
- Department of Obstetrics and Gynecology, University Hospital of
Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
- Department of Obstetrics, University Hospital of Zürich, Zürich,
Switzerland
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6
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Šumilo D, Nirantharakumar K, Willis BH, Rudge GM, Martin J, Gokhale K, Thayakaran R, Adderley NJ, Chandan JS, Okoth K, Harris IM, Hewston R, Skrybant M, Deeks JJ, Brocklehurst P. Long-term impact of pre-incision antibiotics on children born by caesarean section: a longitudinal study based on UK electronic health records. Health Technol Assess 2022; 26:1-160. [PMID: 35781133 DOI: 10.3310/zyzc8514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Since changes in the national guidance in 2011, prophylactic antibiotics for women undergoing caesarean section are recommended prior to skin incision, rather than after the baby's umbilical cord has been clamped. Evidence from randomised controlled trials conducted outside the UK has shown that this reduces maternal infectious morbidity; however, the prophylactic antibiotics also cross the placenta, meaning that babies are exposed to them around the time of birth. Antibiotics are known to affect the gut microbiota of the babies, but the long-term effects of exposure to high-dose broad-spectrum antibiotics around the time of birth on allergy and immune-related diseases are unknown. OBJECTIVES We aimed to examine whether or not in-utero exposure to antibiotics immediately prior to birth compared with no pre-incisional antibiotic exposure increases the risk of (1) asthma and (2) eczema in children born by caesarean section. DESIGN This was a controlled interrupted time series study. SETTING The study took place in primary and secondary care. PARTICIPANTS Children born in the UK during 2006-18 delivered by caesarean section were compared with a control cohort delivered vaginally. INTERVENTIONS In-utero exposure to antibiotics immediately prior to birth. MAIN OUTCOME MEASURES Asthma and eczema in children in the first 5 years of life. Additional secondary outcomes, including other allergy-related conditions, autoimmune diseases, infections, other immune system-related diseases and neurodevelopmental conditions, were also assessed. DATA SOURCES The Health Improvement Network (THIN) and the Clinical Practice Research Datalink (CPRD) primary care databases and the Hospital Episode Statistics (HES) database. Previously published linkage strategies were adapted to link anonymised data on mothers and babies in these databases. Duplicate practices contributing to both THIN and the CPRD databases were removed to create a THIN-CPRD data set. RESULTS In the THIN-CPRD and HES data sets, records of 515,945 and 3,945,351 mother-baby pairs were analysed, respectively. The risk of asthma was not significantly higher in children born by caesarean section exposed to pre-incision antibiotics than in children whose mothers received post-cord clamping antibiotics, with an incidence rate ratio of 0.91 (95% confidence interval 0.78 to 1.05) for diagnosis of asthma in primary care and an incidence rate ratio of 1.05 (95% confidence interval 0.99 to 1.11) for asthma resulting in a hospital admission. We also did not find an increased risk of eczema, with an incidence rate ratio of 0.98 (95% confidence interval 0.94 to1.03) and an incidence rate ratio of 0.96 (95% confidence interval 0.71 to 1.29) for diagnosis in primary care and hospital admissions, respectively. LIMITATIONS It was not possible to ascertain the exposure to pre-incision antibiotics at an individual level. The maximum follow-up of children was 5 years. CONCLUSIONS There was no evidence that the policy change from post-cord clamping to pre-incision prophylactic antibiotics for caesarean sections during 2006-18 had an impact on the incidence of asthma and eczema in early childhood in the UK. FUTURE WORK There is a need for further research to investigate if pre-incision antibiotics have any impact on developing asthma and other allergy and immune-related conditions in older children. STUDY REGISTRATION This study is registered as researchregistry3736. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Brian H Willis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Isobel M Harris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Šumilo D, Nirantharakumar K, Willis BH, Rudge GM, Martin J, Gokhale K, Thayakaran R, Adderley NJ, Chandan JS, Okoth K, Harris IM, Hewston R, Skrybant M, Deeks JJ, Brocklehurst P. Long term impact of prophylactic antibiotic use before incision versus after cord clamping on children born by caesarean section: longitudinal study of UK electronic health records. BMJ 2022; 377:e069704. [PMID: 35580876 PMCID: PMC9112858 DOI: 10.1136/bmj-2021-069704] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the impact on child health up to age 5 years of a policy to use antibiotic prophylaxis for caesarean section before incision compared with after cord clamping. DESIGN Observational controlled interrupted time series study. SETTING UK primary and secondary care. PARTICIPANTS 515 945 children born in 2006-18 with linked maternal records and registered with general practices contributing to two UK primary care databases (The Health Improvement Network and Clinical Practice Research Datalink), and 7 147 884 children with linked maternal records in the Hospital Episode Statistics database covering England, of which 3 945 351 were linked to hospitals that reported the year of policy change to administer prophylactic antibiotics for caesarean section before incision rather than after cord clamping. INTERVENTION Fetal exposure to antibiotics shortly before birth (using pre-incision antibiotic policy as proxy) compared with no exposure. MAIN OUTCOME MEASURES The primary outcomes were incidence rate ratios of asthma and eczema in children born by caesarean section when pre-incision prophylactic antibiotics were recommended compared with those born when antibiotics were administered post-cord clamping, adjusted for temporal changes in the incidence rates in children born vaginally. RESULTS Prophylactic antibiotics administered before incision for caesarean section compared with after cord clamping were not associated with a significantly higher risk of asthma (incidence rate ratio 0.91, 95% confidence interval 0.78 to 1.05) or eczema (0.98, 0.94 to 1.03), including asthma and eczema resulting in hospital admission (1.05, 0.99 to 1.11 and 0.96, 0.71 to 1.29, respectively), up to age 5 years. CONCLUSIONS This study found no evidence of an association between pre-incision prophylactic antibiotic use and risk of asthma and eczema in early childhood in children born by caesarean section.
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Affiliation(s)
- Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Brian H Willis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Isobel M Harris
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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8
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Yan W, Machowska A, Sihavong A, Sychareun V, Chaleunvong K, Keohavong B, Eriksen J, Hanson C, Vongsouvath M, Brauner A, Mayxay M, Kounnavong S, Stålsby Lundborg C. Antibiotic Prescribing in Connection to Childbirth: An Observational Study in Two Districts in Lao PDR. Antibiotics (Basel) 2022; 11:antibiotics11040448. [PMID: 35453200 PMCID: PMC9029038 DOI: 10.3390/antibiotics11040448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/22/2022] [Accepted: 03/23/2022] [Indexed: 11/21/2022] Open
Abstract
Overuse and misuse of antibiotics has frequently been reported for obstetric conditions and procedures, which may impact both the mother and the unborn baby and increase antibiotic resistance. This study aimed to investigate the antibiotic prescribing pattern in connection to childbirth in two districts in Lao PDR. It is a cross-sectional observational study. Antibiotic prescription data related to childbirth was collected via reviews of medical records in two district hospitals and five health centers in Lao PDR from September 2019 to November 2020. In total, antibiotic prescription data for 1777 women were extracted from their medical records. It was found that all women received antibiotics during in-patient care irrespective of delivery mode. When in hospital, 85.5% of the women who underwent a caesarean section got antibiotic treatment for 5 days and women who had a vaginal delivery usually had antibiotic treatment for one day or less. All the women got oral antibiotics for an additional 4–5 days upon discharge. Antibiotic prescription rate in connection to childbirth was very high in comparison with the WHO guidelines, and antibiotics were used extensively in the participating health facilities. Interventions to guide appropriate prescribing behavior in relation to childbirth are urgently needed in Lao PDR.
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Affiliation(s)
- Weirong Yan
- Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (J.E.); (C.H.); (C.S.L.)
- Correspondence:
| | - Anna Machowska
- Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (J.E.); (C.H.); (C.S.L.)
| | - Amphoy Sihavong
- Vientiane Capital Health Department, Ministry of Health, Vientiane 01030, Laos;
| | - Vanphanom Sychareun
- Faculty of Public Health, University of Health Sciences (UHS), Vientiane 7444, Laos;
| | - Kongmany Chaleunvong
- Institute of Research and Education Development, UHS, Ministry of Health, Vientiane 01030, Laos; (K.C.); (M.M.)
| | - Bounxou Keohavong
- Food and Drug Department, Ministry of Health, Vientiane 01030, Laos;
| | - Jaran Eriksen
- Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (J.E.); (C.H.); (C.S.L.)
- Department of Infectious Diseases/Venhalsan, Stockholm South General Hospital,118 83 Stockholm, Sweden
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (J.E.); (C.H.); (C.S.L.)
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Welcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane 01000, Laos;
| | - Annelie Brauner
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 171 77 Stockholm, Sweden;
- Division of Clinical Microbiology, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Mayfong Mayxay
- Institute of Research and Education Development, UHS, Ministry of Health, Vientiane 01030, Laos; (K.C.); (M.M.)
- Lao-Oxford-Mahosot Hospital-Welcome Trust Research Unit (LOMWRU), Microbiology Laboratory, Mahosot Hospital, Vientiane 01000, Laos;
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford OX3 7LG, UK
| | - Sengchanh Kounnavong
- Lao Tropical and Public Health Institute, Ministry of Health, Vientiane 01030, Laos;
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (J.E.); (C.H.); (C.S.L.)
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Affiliation(s)
- Elizabeth M Stringer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Ashraf Nabhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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10
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Narulita L, Suharjono, Kuntaman, Akram M. Analysis of the use of antibiotics profile and factors of surgical site infections study on digestive and oncology surgeries. J Basic Clin Physiol Pharmacol 2021; 32:693-700. [PMID: 34214340 DOI: 10.1515/jbcpp-2020-0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/16/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The incision method operation with a high risk of infection in a clean and clean-contaminated operation requires the use of prophylactic antibiotics to minimize the risk of infection. This study was designed to analyze the effectiveness of prophylactic antibiotics in patients with digestive and oncology surgeries. METHODS The statistical method used was chi-square to determine the risk factors for infection at surgical site infections (SSI) in patients with digestive and oncology surgeries. This study had received ethical approval from the Ethics Committee of Dr. H. Slamet Martodirdjo Hospital, Pamekasan. RESULTS There were 67 patients consisted of 48 digestive surgeries (71.6%) and 19 oncology surgeries (28.4%). The criteria of observation on day 30 showed that as 1 (1.5%) SSI patient experienced purulence, inflammation, and erythema around the surgical wound so an analysis of p>0.05 was carried out so that there was no association with the incidence of SSI during hospitalization, but other factors originating from the patient, such as a lack of personal hygiene at home and lack of nutritious food intake was measured in temperature, pulse, respiration, and white blood cells examination before surgery and 24 h after surgery, all within normal ranges. The qualitative analysis of prophylactic antibiotics using the Gyssen method showed that 31 (46.3%) rationales needed an improvement process. CONCLUSIONS The widely used prophylactic antibiotics, namely cefazolin and cefuroxime are recommended antibiotics used in incision surgery and rationale used.
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Affiliation(s)
- Lisa Narulita
- Master of Clinical Pharmacy Program, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
| | - Suharjono
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
| | - Kuntaman
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Mohammad Akram
- Department of Surgery, Dr. H. Slamet Martodirdjo Hospital, Pamekasan, Indonesia
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Niederle B. [Hygiene measures in antenatal care]. DER GYNAKOLOGE 2021; 54:399-411. [PMID: 33976454 PMCID: PMC8103136 DOI: 10.1007/s00129-021-04794-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND The prevention of infections in the obstetric care of pregnant women is paramount, on the one hand with regard to pathogens of congenital infections and on the other hand due to the association of maternal infections with premature delivery. OBJECTIVES Which measures are recommended for effective prevention of bacterial and viral diseases relevant to obstetrics? MATERIALS AND METHODS Literature search on hygiene measures in terms of preventing transmission of infection. RESULTS The physiological vaginal flora of the pregnant woman is a fundamental factor in natural defence against infection. Its disruption-also through antimicrobial therapies-has a proven influence on the course of pregnancy (premature rupture of membranes, premature birth). It also leads to a disturbed intestinal microbiome in newborns, which has long-term consequences for their neurological, respiratory, metabolic and immunological development and increases mortality. The focus should therefore be on prevention-rather than therapy-of infectious diseases during pregnancy. This requires a detailed anamnesis, monitoring and updating of the vaccination status and, if necessary, clarification of the infection status by means of targeted serological tests. Then the gynecologist can give individual advice on preventive measures. This article provides specific recommendations on selected obstetrically relevant infections. CONCLUSIONS Focusing on hygiene measures to prevent infection in obstetrics can improve the health of both mother and child.
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Affiliation(s)
- Bernhard Niederle
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kempten und Immenstadt, Klinikverbund Allgäu, Robert-Weixler-Str. 50, 87439 Kempten, Deutschland
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12
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Williams MJ, Carvalho Ribeiro do Valle C, Gyte GM. Different classes of antibiotics given to women routinely for preventing infection at caesarean section. Cochrane Database Syst Rev 2021; 3:CD008726. [PMID: 33661539 PMCID: PMC8092483 DOI: 10.1002/14651858.cd008726.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. It is important to identify the most effective class of antibiotics to use and those with the least adverse effects. OBJECTIVES: To determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section, considering their effectiveness in reducing infectious complications for women and adverse effects on both mother and infant. SEARCH METHODS For this 2020 update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (2 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different classes of prophylactic antibiotics given to women undergoing caesarean section. RCTs published in abstract form were also included. We excluded trials that compared drugs with placebo or drugs within a specific class; these are assessed in other Cochrane Reviews. We excluded quasi-RCTs and cross-over trials. Cluster-RCTs were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 39 studies, with 33 providing data (8073 women). Thirty-two studies (7690 women) contributing data administered antibiotics systemically, while one study (383 women) used lavage and was analysed separately. We identified three main comparisons that addressed clinically important questions on antibiotics at caesarean section (all systemic administration), but we only found studies for one comparison, 'antistaphylococcal cephalosporins (1st and 2nd generation) versus broad spectrum penicillins plus betalactamase inhibitors'. We found no studies for the following comparisons: 'antistaphylococcal cephalosporins (1st and 2nd generation) versus lincosamides' and 'antistaphylococcal cephalosporins (1st and 2nd generation) versus lincosamides plus aminoglycosides'. Twenty-seven studies (22 provided data) included comparisons of cephalosporins (only) versus penicillins (only). However for this update, we only pooled data relating to different sub-classes of penicillins and cephalosporins where they are known to have similar spectra of action against agents likely to cause infection at caesarean section. Eight trials, providing data on 1540 women, reported on our main comparison, 'antistaphylococcal cephalosporins (1st and 2nd generation) versus broad spectrum penicillins plus betalactamase inhibitors'. We found data on four other comparisons of cephalosporins (only) versus penicillins (only) using systemic administration: antistaphylococcal cephalosporins (1st and 2nd generation) versus non-antistaphylococcal penicillins (natural and broad spectrum) (9 studies, 3093 women); minimally antistaphylococcal cephalosporins (3rd generation) versus non-antistaphylococcal penicillins (natural and broad spectrum) (4 studies, 854 women); minimally antistaphylococcal cephalosporins (3rd generation) versus broad spectrum penicillins plus betalactamase inhibitors (2 studies, 865 women); and minimally antistaphylococcal cephalosporins (3rd generation) versus broad spectrum and antistaphylococcal penicillins (1 study, 200 women). For other comparisons of different classes of antibiotics, only a small number of trials provided data for each comparison, and in all but one case data were not pooled. For all comparisons, there was a lack of good quality data and important outcomes often included few women. Three of the studies that contributed data were undertaken with drug company funding, one was funded by the hospital, and for all other studies the funding source was not reported. Most of the studies were at unclear risk of selection bias, reporting bias and other biases, partly due to the inclusion of many older trials where trial reports did not provide sufficient methodological information. We undertook GRADE assessment on the only main comparison reported by the included studies, antistaphylococcal cephalosporins (1st and 2nd generation) versus broad spectrum penicillins plus betalactamase inhibitors, and the certainty ranged from low to very low, mostly due to concerns about risk of bias, wide confidence intervals (CI), and few events. In terms of the primary outcomes for our main comparison of 'antistaphylococcal cephalosporins (1st and 2nd generation) versus broad spectrum penicillins plus betalactamase inhibitors': only one small study reported sepsis, and there were too few events to identify clear differences between the drugs (risk ratio (RR) 2.37, 95% CI 0.10 to 56.41, 1 study, 75 women, very low-certainty evidence). There may be little or no difference between these antibiotics in preventing endometritis (RR 1.10; 95% CI 0.76 to 1.60, 7 studies, 1161 women; low-certainty evidence). None of the included studies reported on infant sepsis or infant oral thrush. For our secondary outcomes, we found there may be little or no difference between interventions for maternal fever (RR 1.07, 95% CI 0.65 to 1.75, 3 studies, 678 women; low-certainty evidence). We are uncertain of the effects on maternal: wound infection (RR 0.78, 95% CI 0.32 to 1.90, 4 studies, 543 women), urinary tract infection (average RR 0.64, 95% CI 0.11 to 3.73, 4 studies, 496 women), composite adverse effects (RR 0.96, 95% CI 0.09 to 10.50, 2 studies, 468 women), and skin rash (RR 1.08, 95% CI 0.28 to 4.1, 3 studies, 591 women) (all very low certainty evidence). Although maternal allergic reactions were reported by two studies, there were no events. There were no infant outcomes reported in the included studies. For the other comparisons, the results for most outcomes had wide CIs, few studies and few women included. None of the included trials reported on longer-term maternal outcomes, or on any infant outcomes. AUTHORS' CONCLUSIONS Based on the best currently available evidence, 'antistaphylococcal cephalosporins' and 'broad spectrum penicillins plus betalactamase inhibitors' may have similar efficacy at caesarean section when considering immediate postoperative infection, although we did not have clear evidence for several important outcomes. Most trials administered antibiotics at or after cord clamping, or post-operatively, so results may have limited applicability to current practice which generally favours administration prior to skin incision. We have no data on any infant outcomes, nor on late infections (up to 30 days) in the mother; these are important gaps in the evidence that warrant further research. Antimicrobial resistance is very important but more appropriately investigated by other trial designs.
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Affiliation(s)
- Myfanwy J Williams
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Carolina Carvalho Ribeiro do Valle
- Infection Prevention and Control, Hospital da Mulher Prof. Dr. José Aristodemo Pinotti - CAISM, Department of Obstetrics and Gynaecology, University of Campinas, Campinas, Brazil
| | - Gillian Ml Gyte
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Carbone L, Saccone G, Conforti A, Maruotti GM, Berghella V. Cesarean delivery: an evidence-based review of the technique. Minerva Obstet Gynecol 2021; 73:57-66. [PMID: 33314903 DOI: 10.23736/s2724-606x.20.04681-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The cesarean section is utilized to deliver babies since the late 19th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.
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Affiliation(s)
- Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy -
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy
| | - Giuseppe M Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
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PrabhuDas M, Piper JM, Jean-Philippe P, Lachowicz-Scroggins M. Immune Regulation, Maternal Infection, Vaccination, and Pregnancy Outcome. J Womens Health (Larchmt) 2021; 30:199-206. [PMID: 33232632 PMCID: PMC8020511 DOI: 10.1089/jwh.2020.8854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
About 12.5% of all maternal deaths in the United States are due to infectious causes. This proportion, although stable during the past three decades, represents an increase in infectious causes of mortality, as the overall mortality rate in U.S. pregnant women had increased steadily during that same period. During healthy pregnancies, a delicate immunological balance-in which a mother's immune system tolerates the semi-allogeneic fetus yet maintains immune competency against infectious agents-is achieved and maintained. This immunological paradigm, however, results in increased susceptibility to infectious diseases during pregnancy, particularly in later stages and during the early postpartum period. The inflammatory process induced by these infectious insults, as well as some noninfectious insults, occurring during pregnancy can disrupt this carefully achieved balance and, in turn, lead to a state of rampant inflammation, immune activation, and dysregulation with deleterious health outcomes for the mother and fetus. Elucidating mechanisms contributing to the disruption of this immunologic homeostasis, and its disruption by infectious pathogens, might offer opportunities for interventions to reduce maternal and fetal morbidity and mortality.
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Affiliation(s)
- Mercy PrabhuDas
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Jeanna M. Piper
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Patrick Jean-Philippe
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
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15
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Antibiotic Prophylaxis for Cesarean Delivery: A Survey of Anesthesiologists. Anesthesiol Res Pract 2021; 2020:3741608. [PMID: 33488702 PMCID: PMC7787788 DOI: 10.1155/2020/3741608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/22/2020] [Accepted: 11/25/2020] [Indexed: 11/17/2022] Open
Abstract
Background The most common complication after cesarean delivery is surgical site infection. Antibiotic prophylaxis reduces infectious morbidity and current anesthetic quality metrics include preincision antibiotic prophylaxis. Recently, studies suggest reductions in infectious morbidity with the addition of azithromycin for unscheduled cesarean delivery. Larger doses of cefazolin are recommended for morbidly obese women, but evidence is conflicting. The aim of this study was to survey anesthesiologists to assess current practice for antibiotic prophylaxis for cesarean delivery. Methods We invited a random sample of 10,000 current members of the American Society of Anesthesiologists to complete an online survey about their current practice of antibiotic prophylaxis for cesarean delivery in November 2017. The survey included questions similar to a previous survey on this topic in 2012. Results The response rate was 12.2% (n = 1223). Most respondents had at least 15 years of experience (684, 55.9%), work at a nonteaching or community hospital (729, 59.6%), with >500 cesarean deliveries annually (619, 50.6%), and administer obstetric anesthesia several times a week (690, 56.4%). Routine preincision antibiotic prophylaxis was reported by 1162 (95.0%) of the 1223 respondents, a substantial improvement versus the 63.5% reported in the previous study in 2012. For intrapartum cesarean deliveries, 141 (11.5%) administer azithromycin for unscheduled cesarean deliveries. Those who use cefazolin, 509 (42.5%) administer 3 g for morbidly obese women. Conclusion Adherence to preincision antibiotic prophylaxis for cesarean delivery is very high, a significant improvement within 5 years. A minority of anesthesiologists utilize azithromycin for intrapartum cesarean deliveries. The dose of cefazolin for morbidly obese women varies widely.
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16
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Mekonnen AG, Mittiku YM. Surgical site infection and its association with rupture of membrane following cesarean section in Africa: a systematic review and meta-analysis of published studies. Matern Health Neonatol Perinatol 2021; 7:2. [PMID: 33388090 PMCID: PMC7777267 DOI: 10.1186/s40748-020-00122-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Surgical site infection occurs within 30 days after a surgical procedure and involves the skin, subcutaneous tissue, and soft tissue. Surgical site infection following cesarean section is a common postoperative complication and is associated with maternal morbidity and mortality in resource-limited settings. Even though the proportion of surgical site infection and some risk factors were reported by kinds of literature, varying results were stated across studies. There is also limited knowledge on the association between postpartum surgical site infection and the rupture of membrane. Hence, this systematic review and meta-analysis was designed to estimate the pooled proportion of surgical site infection and its association with rupture of membrane following cesarean section in Africa. Methods Studies published from January 01, 2000 to January 30, 2020 were searched from MEDLINE via PubMed, Scopus, Medscape, Web-science and CINAHL databases to search relevant published articles. We also performed a manual search of reference lists of key articles to retrieve additional relevant articles. Initially, 559 records were identified and 15 studies included in the analysis. The statistical analysis was performed using STATA 11. Heterogeneity between-study was explored by forest plot and inconsistency index (I2). The publication bias was checked by a funnel plot and Egger’s test. Pooled estimates of proportion and odds ratio were calculated by a random-effects model with a 95% confidence interval (CI). Results The overall pooled proportion of surgical site infection following cesarean section was 10.21% (I2 = 86.8, p < 0.000; 95% CI = 8.36, 12.06). The odds of developing surgical site infection among women who had the rupture of membrane before delivery were nearly 6 times higher than those who had not a rupture of the membrane (AOR = 5.65, 95% CI: 3.95–8.07). Conclusions The proportion of surgical site infections following the cesarean section is relatively high. Women who had rupture of the membrane before delivery were more likely to develop surgical site infections following the cesarean section. Due attention should be given to the provision of prophylactic antibiotics that can reduce surgical site infection after cesarean delivery. Supplementary Information The online version contains supplementary material available at 10.1186/s40748-020-00122-2.
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Affiliation(s)
- Alemayehu Gonie Mekonnen
- Department of Nursing, College of Health Science, Debre Berhan University, Po. Box. 445, Debre Berhan, Ethiopia.
| | - Yohannes Moges Mittiku
- Department of Midwifery, College of Health Sciences, Debre Berhan University, Po. Box. 445, Debre Berhan, Ethiopia
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ÖZKEÇECİ F, YAVAN T. Elektif sezaryen ameliyatlarında yapılan perioperatif uygulamaların ERAS protokolüne göre değerlendirilmesi. CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.745762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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18
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Sommerstein R, Marschall J, Atkinson A, Surbek D, Dominguez-Bello MG, Troillet N, Widmer AF. Antimicrobial prophylaxis administration after umbilical cord clamping in cesarean section and the risk of surgical site infection: a cohort study with 55,901 patients. Antimicrob Resist Infect Control 2020; 9:201. [PMID: 33349269 PMCID: PMC7754587 DOI: 10.1186/s13756-020-00860-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/20/2020] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization (WHO) recommends administration of surgical antimicrobial prophylaxis (SAP) in cesarean section prior to incision to prevent surgical site infections (SSI). This study aimed to determine whether SAP administration following cord clamping confers an increased SSI risk to the mother.
Methods Study design: Cohort. Setting: 75 participating Swiss hospitals, from 2009 to 2018. Participants: A total of 55,901 patients were analyzed. Main outcome measures: We assessed the association between SAP administration relative to incision and clamping and the SSI rate, using generalized linear multilevel models, adjusted for patient characteristics, procedural variables, and health-care system factors. Results SAP was administered before incision in 26′405 patients (47.2%) and after clamping in 29,496 patients (52.8%). Overall 846 SSIs were documented, of which 379 (1.6% [95% CI, 1.4–1.8%]) occurred before incision and 449 (1.7% [1.5–1.9%]) after clamping (p = 0.759). The adjusted odds ratio for SAP administration after clamping was not significantly associated with an increased SSI rate (1.14, 95% CI 0.96–1.36; p = 0.144) when compared to before incision. Supplementary and subgroup analyses supported these main results. Conclusions This study did not confirm an increased SSI risk for the mother in cesarean section if SAP is given after umbilical cord clamping compared to before incision.
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Affiliation(s)
- Rami Sommerstein
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland. .,Swissnoso, National Center for Infection Control, Bern, Switzerland.
| | - Jonas Marschall
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland.,Swissnoso, National Center for Infection Control, Bern, Switzerland
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, University of Bern, Bern, Switzerland.,Swiss Society of Obstetrics and Gynaecology, Bern, Switzerland
| | - Maria Gloria Dominguez-Bello
- Department of Biochemistry and Microbiology, Rutgers School of Environmental and Biological Science, New Brunswick, NJ, USA
| | - Nicolas Troillet
- Swissnoso, National Center for Infection Control, Bern, Switzerland.,Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Andreas F Widmer
- Swissnoso, National Center for Infection Control, Bern, Switzerland. .,Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland.
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Mohammed SO, A Shuaibu SD, Gaya SA, Rabiu A. The efficacy of two doses versus 7 days' course of prophylactic antibiotics following cesarean section: An experience from Aminu Kano Teaching Hospital. Ann Afr Med 2020; 19:103-112. [PMID: 32499466 PMCID: PMC7453943 DOI: 10.4103/aam.aam_39_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Postcesarean wound infection is a leading cause of prolonged hospital stay. Considerable debates still exist regarding choice of antibiotics, dose, and duration of use. Objectives: The objective is to compare the efficacy of 2 doses of amoxicillin-clavulanic acid versus a 7 days combination of amoxicillin-clavulanic acid and metronidazole as prophylactic antibiotics following cesarean section (CS). Methodology: It was a randomized controlled trial that was conducted among 160 women undergoing CS at Aminu Kano Teaching Hospital. Women were randomized into two groups. Group I (study group) received 2 doses of 1.2 g amoxicillin-clavulanic acid. Group II (control group) received a 7 days course of amoxicillin-clavulanic acid and metronidazole. The data obtained were analyzed using SPSS version 17. Categorical (qualitative) variables were analyzed using Ch-square test and Fisher’s exact test as appropriate while continuous (quantitative) variables were analyzed using independent sample t-test. P < 0.05 was considered statistically significant. Results: There was no statistically significant association in the occurrence of fever (12.8% vs. 15.8%, P = 0.6), wound infection (6.4% vs. 10.5%, P = 0.36), endometritis (7.7% vs. 11.8%, P = 0.38), UTI (6.4% vs. 5.3%, P = 1.00), mean duration of hospital stay (129.7 vs. 134.2 h, P = 0.48), and neonatal outcomes between the two groups. There was statistically significant difference in the mean cost of antibiotics (₦2883/US$9.5 vs. ₦7040/US$23.1, P < 0.001) and maternal side effects (10.3% vs. 26.3%, P < 0.001) between the study and the control groups, respectively. Conclusion: This study found no statistically significant difference in infectious morbidity, duration of hospital stay, and neonatal outcomes when two doses of amoxicillin-clavulanic acid was compared with a 7 days course of prophylactic antibiotic following CS. The use of two doses of amoxicillin-clavulanic acid has the advantages of reduced cost and some maternal side effects. The two doses were cheaper with minimal side effects.
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Affiliation(s)
| | - Samaila Danjuma A Shuaibu
- Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Sule Abdullahi Gaya
- Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ayyuba Rabiu
- Department of Obstetrics and Gynaecology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
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20
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Haas DM, Morgan S, Contreras K, Kimball S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev 2020; 4:CD007892. [PMID: 32335895 PMCID: PMC7195184 DOI: 10.1002/14651858.cd007892.pub7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane Review first published in 2010 and subsequently updated in 2012, twice in 2014, in 2017 and 2018. OBJECTIVES To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (7 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-RCTs were eligible for inclusion, but we did not identify any. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design. We included trials published in abstract form only if sufficient information was present in the abstract on methods and outcomes to analyze. DATA COLLECTION AND ANALYSIS At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies. MAIN RESULTS We included 21 trials, reporting results for 7038 women evaluating the effects of vaginal cleansing (17 using povidone-iodine, 3 chlorhexidine, 1 benzalkonium chloride) on post-cesarean infectious morbidity. Trials used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (17 trials) or the use of a saline vaginal preparation (4 trials). One trial did not report on any outcomes of interest. Trials were performed in 10 different countries (Saudi Arabia, Pakistan, Iran, Thailand, Turkey, USA, Egypt, UK, Kenya and India). The overall risk of bias was low for areas of attrition, reporting, and other bias. About half of the trials had low risk of selection bias, with most of the remainder rated as unclear. Due to lack of blinding, we rated performance bias as high risk in nearly one-third of the trials, low risk in one-third, and unclear in one-third. Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 7.1% in control groups to 3.1% in vaginal cleansing groups (average risk ratio (aRR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; 20 trials, 6918 women; moderate-certainty evidence). This reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions. Risks of postoperative fever and postoperative wound infection are also probably reduced by vaginal antiseptic preparation (fever: aRR 0.64, 0.50 to 0.82; 16 trials, 6163 women; and wound infection: RR 0.62, 95% CI 0.50 to 0.77; 18 trials, 6385 women; both moderate-certainty evidence). Two trials found that there may be a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82; 2 trials, 499 women; low-certainty evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Subgroup analysis suggested a greater effect with vaginal preparations for those women in labour versus those not in labour for four out of five outcomes examined (post-cesarean endometritis; postoperative fever; postoperative wound infection; composite wound complication or endometritis). This apparent difference needs to be investigated further in future trials. We did not observe any subgroup differences between women with ruptured membranes and women with intact membranes. AUTHORS' CONCLUSIONS Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis, postoperative fever, and postoperative wound infection. Subgroup analysis found that these benefits were typically present whether iodine-based or chlorhexidine-based solutions were used and when women were in labor before the cesarean. The suggested benefit in women in labor needs further investigation in future trials. There was moderate-certainty evidence using GRADE for all reported outcomes, with downgrading decisions based on limitations in study design or imprecision. As a simple intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries. Future research on this intervention being incorporated into bundles of care plans for women receiving cesarean delivery will be needed.
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Affiliation(s)
- David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarah Morgan
- OB/GYN Residency, St. Vincent Women's Hospital, Indianapolis, Indiana, USA
| | - Karenrose Contreras
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Savannah Kimball
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Yahya FB, Hathcock MA. A Retrospective Review of Neonatal Sepsis among GBS-Colonized Women Undergoing Planned Cesarean Section after Labor Onset or Rupture of Membranes. Infect Dis Obstet Gynecol 2020; 2020:4365259. [PMID: 32148387 PMCID: PMC7056999 DOI: 10.1155/2020/4365259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/22/2019] [Accepted: 12/30/2019] [Indexed: 11/17/2022] Open
Abstract
Background Sepsis is a leading cause of mortality and morbidity in neonates, with group B streptococcus (GBS) remaining the most frequent pathogen isolated from term infants. Surveillance data showed that the majority of cases of early-onset GBS disease were neonates born to women who either received no or suboptimal intrapartum antibiotic prophylaxis with a notable portion of those women having a missed opportunity to receive ≥4 hours of chemoprophylaxis. Women planning delivery by cesarean section who present in labor or rupture of membranes prior to their scheduled surgery are unlikely to receive optimal GBS chemoprophylaxis and thus their neonates are at risk of having sepsis. Materials and Methods. A retrospective cohort study of women-infant dyads was extracted from the Consortium on Safe Labor dataset. Women who had an unlabored cesarean section at ≥37 + 0 week gestation were selected and divided into four groups based on GBS status and timing of cesarean section with respect to onset of labor or rupture of membranes. The rate of neonatal sepsis and the patterns of intrapartum antibiotic chemoprophylaxis were determined. Results The sepsis rate (4.5%) among neonates of GBS-colonized women having their unlabored cesarean section after onset of labor or rupture of membranes was significantly higher than that in any other group in this study. In this group, 9.4% of women received chemoprophylaxis for ≥4 hours, while 31% had a missed opportunity to receive ≥4 hours of chemoprophylaxis. Conclusion This study suggests that neonates of GBS-colonized women having a planned cesarean section after onset of labor or rupture of membranes are at increased risk of having a sepsis diagnosis. This finding suggest the need for additional studies to assess the risk of sepsis among neonates of women in this group.
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Affiliation(s)
- Fadi B. Yahya
- Mayo Clinic Health System, 404 W. Fountain St. Albert Lea, MN 56007, USA
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Cai Y, Pan H, Zhang J, Cheng W, Shi Y, Zeng M, Shi L, Yu J, Shen Y, Chen S, Zhu Q, Mol BW, Huang D. Efficacy of adjunctive azithromycin versus single-dose cephalosporin prophylaxis for caesarean scar defect: study protocol for a randomised controlled trial. BMJ Open 2020; 10:e032379. [PMID: 31915163 PMCID: PMC6955559 DOI: 10.1136/bmjopen-2019-032379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Perioperative infections may be considered predictors of caesarean scar defect (CSD), and multidose antibiotics have a protective effect against CSD. However, the ability of adjunctive azithromycin combined with cephalosporin to reduce the prevalence of CSD remains unclear. The planned study aims to clarify the protective effect of antibiotics against CSD and to assess the effectiveness of adjunctive azithromycin prophylaxis for CSD. METHODS AND ANALYSIS This study is a double-blind, parallel-control randomised clinical trial that will be carried out at the International Peace Maternity and Child Health Hospital. A total of 220 eligible patients will be randomised (1:1) to receive either adjunctive azithromycin or single-dose cephalosporin 30 min before the incision. The evaluation criteria are the prevalence and characteristics of CSD as assessed by transvaginal ultrasound (TVU) and saline infusion sonohysterography (SIS) at 42 days, 6 months and 12 months after delivery. The primary outcome will be the prevalence of CSD, and the characteristics of CSD will be assessed by TVU and SIS 42 days after delivery; all other outcomes are secondary. ETHICS AND DISSEMINATION This protocol received authorisation from the Medical Research Ethics Committee of International Peace Maternity and Child Health Hospital on 25 April 2018 (approval no. GKLW2017-84). The findings will be reported in peer-reviewed publications and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER ChiCTR-INR-17013272.
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Affiliation(s)
- Yanqing Cai
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Hongjie Pan
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
- Obstetrics and Gynecology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, China
| | - Jian Zhang
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Weiwei Cheng
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Yiru Shi
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Min Zeng
- Ultrasound, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Liye Shi
- Ultrasound, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Jin Yu
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Ying Shen
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Shan Chen
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Qian Zhu
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
| | - Ben W Mol
- Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia
- Robinson Research Institute, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Ding Huang
- Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, Shanghai, China
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Suliman SM, Yousef BA, Hamadelnil AA. Impact of guidelines implementation for the rational use of prophylactic antibiotics in elective cesarean sections at Elqutainah Teaching Hospital. J Family Med Prim Care 2020; 9:162-167. [PMID: 32110584 PMCID: PMC7014875 DOI: 10.4103/jfmpc.jfmpc_903_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/03/2019] [Accepted: 12/12/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The clinical pharmacists have a sensible role in the implementation of guidelines by ensuring proper patient selection and medication use. This study aimed to implement a hospital guideline for the rational use of prophylactic antibiotics in elective cesarean sections (ECS) by establishing compliance with international guidelines regarding prophylactic antibiotic use in ECS at Elqutainah Teaching Hospital in White Nile State, Sudan, and define the area of medication cost-saving. METHODS A quasi-experimental design without control group was used from April to June 2018. 195 participants were included, 94 participants before and 101 participants after the intervention and data were collected using a designed checklist by the researchers. The intervention is based on withdrawal metronidazole dosage forms from prophylactic antibiotics for ECS according to international guidelines in antibiotics prophylaxis toward ECS. Finally, the data were compared between pre- and post-intervention. FINDINGS Before intervention; all participants had received intravenous cefuroxime and metronidazole infusions prior ECS and oral cefuroxime or amoxicillin-clavulanic acid, and metronidazole for 7 days upon discharge. While after the intervention, all participants didn't receive any metronidazole dosage forms before and after ECS also didn't receive amoxicillin-clavulanic acid. However, the dosage regimen of cefuroxime didn't change. This intervention was meaningful in minimizing overuse of antibiotics prophylaxis in the ECS, and reducing staff workload along with medication cost. CONCLUSIONS Clinical pharmacist intervention was concisely changing the physicians' practice toward using updated guidelines of the rational use of prophylactic antibiotics for ECS.
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Affiliation(s)
- Sara M. Suliman
- Clinical Pharmacy Unit, Elqutainah Teaching Hospital, Quttainah, Sudan
| | - Bashir A. Yousef
- Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Arkawait, Khartoum, Sudan
- Department of Pharmacology, Faculty of Pharmacy, Sudan International University, Arkawait, Khartoum, Sudan
| | - Afrah A. Hamadelnil
- Department of Pharmacology, Faculty of Pharmacy, Omdurman Islamic University, Omdurman, Sudan
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The relationship of prenatal and infant antibiotic exposure with childhood overweight and obesity: a systematic review. J Dev Orig Health Dis 2019; 11:335-349. [PMID: 31735183 DOI: 10.1017/s2040174419000722] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This study aimed to assess the evidence regarding the relationship between early-life antibiotic exposure and childhood overweight/obesity by reviewing observational studies on prenatal antibiotic exposure and systematic reviews on infant antibiotic exposure. A search in Pubmed, Embase and Google Scholar covering the period 1st January till 1st December 2018 led to the identification of five studies on prenatal antibiotic exposure and four systematic reviews on infant antibiotic exposure. Positive trends between prenatal antibiotic exposure and overweight/obesity were reported in all studies; two studies reported a significant overall relationship and the other three reported significant relationships under certain conditions. Effect sizes ranged from odds ratio (OR): 1.04 (0.62-1.74) to relative risk (RR): 1.77 (1.25-2.51). Regarding infant antibiotics, one review concluded there was substantial evidence that infant antibiotic exposure increased the risk of childhood overweight/obesity [pooled effect sizes: RR: 1.21 (1.09-1.33) for overweight and RR: 1.18 (1.12-1.25) for obesity]. Two reviews concluded there was some evidence for a relationship [pooled effect sizes: OR: 1.05 (1.00-1.11) and OR: 1.11 (1.02-1.20)]. The fourth review concluded the studies were too heterogeneous for meta-analyses and the evidence regarding the relationship between infant antibiotic exposure and childhood overweight/obesity was inconclusive. More well-designed studies are needed that include data on intra-partum antibiotics and address important potential confounders (including maternal and childhood infections). This review points to some evidence of a relationship between early-life antibiotic exposure and childhood overweight/obesity; this is especially evident in certain children (i.e. exposed to multiple and broad-spectrum antibiotics, earlier postnatal exposure and male gender) and merits further research.
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Knight M, Chiocchia V, Partlett C, Rivero-Arias O, Hua X, Bowler U, Gray J, Gray S, Hinshaw K, Khunda A, Moore P, Mottram L, Owino N, Pasupathy D, Sanders J, Sultan AH, Thakar R, Tuffnell D, Linsell L, Juszczak E. Intravenous co-amoxiclav to prevent infection after operative vaginal delivery: the ANODE RCT. Health Technol Assess 2019; 23:1-54. [PMID: 31590702 DOI: 10.3310/hta23540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of direct and indirect maternal death in both the UK and globally. All forms of operative delivery are associated with an increased risk of sepsis, and the National Institute for Health and Care Excellence's guidance recommends the use of prophylactic antibiotics at all caesarean deliveries, based on substantial randomised controlled trial evidence of clinical effectiveness. A Cochrane review, updated in 2017 (Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev 2017;8:CD004455), identified only one small previous trial of prophylactic antibiotics following operative vaginal birth (forceps or ventouse/vacuum extraction) and, given the small study size and extreme result, suggested that further robust evidence is needed. OBJECTIVES To investigate whether or not a single dose of prophylactic antibiotic following operative vaginal birth is clinically effective for preventing confirmed or presumed maternal infection, and to investigate the associated impact on health-care costs. DESIGN A multicentre, randomised, blinded, placebo-controlled trial. SETTING Twenty-seven maternity units in the UK. PARTICIPANTS Women who had an operative vaginal birth at ≥ 36 weeks' gestation, who were not known to be allergic to penicillin or constituents of co-amoxiclav and who had no indication for ongoing antibiotics. INTERVENTIONS A single dose of intravenous co-amoxiclav (1 g of amoxicillin/200 mg of clavulanic acid) or placebo (sterile saline) allocated through sealed, sequentially numbered, indistinguishable packs. MAIN OUTCOME MEASURES Primary outcome - confirmed or suspected infection within 6 weeks of giving birth. Secondary outcomes - severe sepsis, perineal wound infection, perineal pain, use of pain relief, hospital bed stay, hospital/general practitioner visits, need for additional perineal care, dyspareunia, ability to sit comfortably to feed the baby, maternal general health, breastfeeding, wound breakdown, occurrence of anaphylaxis and health-care costs. RESULTS Between March 2016 and June 2018, 3427 women were randomised: 1719 to the antibiotic arm and 1708 to the placebo arm. Seven women withdrew, leaving 1715 women in the antibiotic arm and 1705 in the placebo arm for analysis. Primary outcome data were available for 3225 out of 3420 women (94.3%). Women randomised to the antibiotic arm were significantly less likely to have confirmed or suspected infection within 6 weeks of giving birth (180/1619, 11%) than women randomised to the placebo arm (306/1606, 19%) (relative risk 0.58, 95% confidence interval 0.49 to 0.69). Three serious adverse events were reported: one in the placebo arm and two in the antibiotic arm (one was thought to be causally related to the intervention). LIMITATIONS The follow-up rate achieved for most secondary outcomes was 76%. CONCLUSIONS This trial has shown clear evidence of benefit of a single intravenous dose of prophylactic co-amoxiclav after operative vaginal birth. These results may lead to reconsideration of official policy/guidance. Further analysis of the mechanism of action of this single dose of antibiotic is needed to investigate whether earlier, pre-delivery or repeated administration could be more effective. Until these analyses are completed, there is no indication for administration of more than a single dose of prophylactic antibiotic, or for pre-delivery administration. TRIAL REGISTRATION Current Controlled Trials ISRCTN11166984. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 54. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christopher Partlett
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Xinyang Hua
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - James Gray
- Department of Microbiology, Birmingham Women's & Children's NHS Foundation Trust, Birmingham, UK
| | - Shan Gray
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kim Hinshaw
- Department of Obstetrics and Gynaecology, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK.,Faculty of Health Sciences, University of Sunderland, Sunderland, UK
| | - Aethele Khunda
- Department of Women's Health, James Cook University Hospital, Middlesbrough, UK
| | - Philip Moore
- Department of Microbiology, Birmingham Women's & Children's NHS Foundation Trust, Birmingham, UK
| | - Linda Mottram
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nelly Owino
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, King's Health Partners, London, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK.,Department of Women's Health, Cardiff and Vale University Health Board, Cardiff, UK
| | - Abdul H Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Derek Tuffnell
- Department of Women's Health, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Šumilo D, Nirantharakumar K, Willis BH, Rudge G, Martin J, Gokhale K, Thayakaran R, Adderley NJ, Chandan JS, Okoth K, Hewston R, Skrybant M, Deeks JJ, Brocklehurst P. Long-term impact of giving antibiotics before skin incision versus after cord clamping on children born by caesarean section: protocol for a longitudinal study based on UK electronic health records. BMJ Open 2019; 9:e033013. [PMID: 31558464 PMCID: PMC6773283 DOI: 10.1136/bmjopen-2019-033013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION In the UK, about a quarter of women give birth by caesarean section (CS) and are offered prophylactic broad-spectrum antibiotics to reduce the risk of maternal postpartum infection. In 2011, national guidance was changed from recommending antibiotics after the umbilical cord was cut to giving antibiotics prior to skin incision based on evidence that earlier administration reduces maternal infectious morbidity. Although antibiotics cross the placenta, there are no known short-term harms to the baby. This study aims to address the research gap on longer term impact of these antibiotics on child health. METHODS AND ANALYSIS A controlled interrupted time series study will use anonymised mother-baby linked routine electronic health records for children born during 2006-2018 recorded in UK primary care (The Health Improvement Network, THIN and Clinical Practice Research Datalink, CPRD) and secondary care (Hospital Episode Statistics, HES) databases. The primary outcomes of interest are asthma and eczema, two common allergy-related diseases in childhood. In-utero exposure to antibiotics immediately prior to CS will be compared with no exposure when given after cord clamping. The risk of outcomes in children delivered by CS will also be compared with a control cohort delivered vaginally to account for time effects. We will use all available data from THIN, CPRD and HES with estimated power of 80% and 90% to detect relative increase in risk of asthma of 16% and 18%, respectively at the 5% significance level. ETHICS AND DISSEMINATION Ethical approval has been obtained from the University of Birmingham Ethical Review Committee with scientific approvals obtained from the independent scientific advisory committees from the Medicines and Healthcare products Regulatory Agency for CPRD and the data provider, IQVIA for THIN. The results will be published in peer-reviewed journals, presented at national and international conferences and disseminated to stakeholders.
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Affiliation(s)
- Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, University of Birmingham, Birmingham, UK
| | - Brian H Willis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Dierikx TH, Berkhout DJC, Visser L, Benninga MA, Roeselers G, de Boer NKH, de Vries JIP, de Meij TGJ. The influence of timing of Maternal administration of Antibiotics during cesarean section on the intestinal Microbial colonization in Infants (MAMI-trial): study protocol for a randomised controlled trial. Trials 2019; 20:479. [PMID: 31382981 PMCID: PMC6683546 DOI: 10.1186/s13063-019-3552-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/02/2019] [Indexed: 02/08/2023] Open
Abstract
Background A disturbance in the early colonisation of the gut by microorganisms is associated with an aberrant innate immune system and a variety of clinical conditions later in life. Several factors are considered to influence this initial colonisation, including maternally administered antibiotics during pregnancy and delivery. Recent revisions to international obstetric guidelines have resulted in the exposure of all infants born by caesarean section (CS) to broad-spectrum antibiotics perinatally. To date, the consequences of these new guidelines on neonatal gut colonisation and the associated short- and long-term health implications have not yet been addressed. The aim of this study is to investigate the influence of the timing of antibiotic administration during CS to the mother on the course of neonatal intestinal colonisation up to 2 years of age. Methods/design This single-centre randomised controlled trial will recruit 40 women scheduled for an elective CS. The subjects will be randomised to receive 1500 mg of cefuroxime intravenously either prior to the skin incision (n = 20) or after clamping of the umbilical cord (n = 20). Levels of cefuroxime in cord blood will be determined for exposed neonates. Faecal samples from the children will be collected on days 1, 7 and 28 days and at 2 years old and analysed by 16S sequencing. Shannon-diversity indices, absolute and relative abundances, and unsupervised and supervised classification methods will be used to evaluate the effect of the timing of intrapartum cefuroxime administration on the composition of the microbiota. The outcomes for both study groups will be compared to the intestinal microbiota of vaginally born infants (n = 20). To detect possible effects on health state, a questionnaire on health-related issues will be taken at the age of 2 years. Discussion In the proposed study, changes in the intestinal microbiota of 40 children born by CS will be followed until the age of 2 years. Research on this topic is necessary since significant effects relating to the timing of antibiotic administration on microbial colonisation may conflict with the current guidelines, as this may have health consequences later in life. Trial registration Netherlands Clinical Trial Registry, NTR6000. Retrospectively registered on 25 July 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3552-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas H Dierikx
- Department of Paediatric Gastroenterology, Amsterdam UMC, location VUmc, 1081 HV, Amsterdam, The Netherlands.
| | - Daniel J C Berkhout
- Department of Paediatric Gastroenterology, Amsterdam UMC, location VUmc, 1081 HV, Amsterdam, The Netherlands
| | - Laura Visser
- Department of Gynaecology and Obstetrics, Amsterdam UMC, location VUmc, 1081 HV, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Paediatric Gastroenterology, Amsterdam UMC, location AMC, 1105 AZ, Amsterdam, The Netherlands
| | | | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location VUmc, AG&M Research Institute, 1081 HV, Amsterdam, The Netherlands
| | - Johanna I P de Vries
- Department of Gynaecology and Obstetrics, Amsterdam UMC, location VUmc, 1081 HV, Amsterdam, The Netherlands
| | - Tim G J de Meij
- Department of Paediatric Gastroenterology, Amsterdam UMC, location VUmc, 1081 HV, Amsterdam, The Netherlands
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López-Alcalde J, Stallings E, Cabir Nunes S, Fernández Chávez A, Daheron M, Bonfill Cosp X, Zamora J. Consideration of sex and gender in Cochrane reviews of interventions for preventing healthcare-associated infections: a methodology study. BMC Health Serv Res 2019; 19:169. [PMID: 30876452 PMCID: PMC6419810 DOI: 10.1186/s12913-019-4001-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 03/07/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Healthcare-associated infections (HAIs) are common and increase morbidity, mortality, and healthcare costs. Their control continues to be an unresolved issue worldwide. HAIs epidemiology shows sex/gender differences. Thus the lack of consideration of sex/gender in Cochrane reviews will limit their applicability and capacity to support informed decisions. This study aims to describe the extent to which Cochrane reviews of interventions for preventing HAIs consider sex and gender. METHODS Methodology study appraising Cochrane reviews of interventions to prevent HAIs. SEARCH METHODS Cochrane Database of Systematic Reviews from 1995 (launch of the journal) to 31 December 2016. Two authors independently extracted data with EPPI-Reviewer 4 software, and independently appraised the sex/gender content of the reviews with the Sex and Gender Appraisal Tool for Systematic Reviews (SGAT-SR). RESULTS This study included 113 reviews assessing the effects of interventions for preventing HAIs. 100 reviews (88%) used at least one sex or gender-related term. The terminology used was heterogeneous, being "sex" the term used in more reviews (51%). No review defined neither sex nor gender. Thus we could not assess the definitions provided. Consideration of sex and gender was practically absent in the included reviews; in fact, no review met all the applicable items of the SGAT-SR, and 51 reviews (50%) fulfilled no item. No review provided a complete description of the sex and the gender of the samples of the included studies. Only ten reviews (10%) planned to perform sex- and gender-based analysis and only three (3%) could complete the analysis. The method chosen was always the subgroup analysis based on sex (one review) or gender (two reviews). Three reviews (3%) considered sex or gender-related findings in the conclusions. CONCLUSION Consideration of sex and gender in Cochrane reviews of interventions for preventing HAIs was practically absent. This lack of attention to sex and gender reduces the quality of Cochrane reviews, and their applicability for all people: women and men, boys and girls, and people of diverse gender identities. Cochrane should attempt to address the shortfalls detected.
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Affiliation(s)
- Jesús López-Alcalde
- Department of Paediatrics, Obstetrics & Gynaecology and Preventative Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Faculty of Health Sciences, Universidad Francisco de Vitoria (UFV)-Madrid, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- Cochrane Associate Centre of Madrid, Madrid, Spain
| | - Elena Stallings
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | | | | | | | - Xavier Bonfill Cosp
- Iberoamerican Cochrane Centre, IIB Sant Pau, Universitat Autònoma de Barcelona, Madrid, Spain
- CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
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Hodgetts Morton V, Wilson A, Hewitt C, Weckesser A, Farmer N, Lissauer D, Hardy P, Morris RK. Chlorhexidine vaginal preparation versus standard treatment at caesarean section to reduce endometritis and prevent sepsis-a feasibility study protocol (the PREPS trial). Pilot Feasibility Stud 2018; 4:84. [PMID: 29881638 PMCID: PMC5985577 DOI: 10.1186/s40814-018-0273-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/18/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Worldwide caesarean section (CS) delivery is the most common major operation. Approximately 25% of pregnant women undergo a CS in the UK for delivery of their babies. Sepsis and post-natal infection constitute significant maternal mortality and morbidity. Infection following a CS has a number of primary sources including endometritis occurring in 7-17% of women. Sepsis reduction and reduction in antibiotic use have been identified as a national and international priority. The overarching aim of this research is to reduce infectious morbidity from caesarean sections. METHODS This is a parallel group feasibility randomised controlled trial comparing vaginal cleansing using chlorhexidine gluconate versus no cleansing (standard practice) at CS to reduce infection. Women will be recruited from four National Health Service maternity units. Two hundred fifty women (125 in each arm) undergoing elective or emergency CS, who are aged 16 years and above, and at least 34 weeks pregnant will be randomised. Allocation to treatment will be on a 1:1 ratio. The study includes a qualitative aspect to develop women centred outcomes of wellbeing after delivery. DISCUSSION The success of the feasibility study will be assessed by criteria related to the feasibility measurements to ascertain if a larger study is feasible in its current format, needs modification or is unfeasible, and includes recruitment, adherence, follow-up and withdrawal measures. TRIAL REGISTRATION The PREPS trial has been registered with ISRCTN (ISRCTN 33435996).
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Affiliation(s)
- V. Hodgetts Morton
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
| | - A. Wilson
- Birmingham Clinical Trials Unit, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - C. Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - A. Weckesser
- School of Health and Social Care, Birmingham City University, Birmingham, B15 3TN UK
| | - N. Farmer
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
| | - D. Lissauer
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - P. Hardy
- Birmingham Clinical Trials Unit, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - R. K. Morris
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
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von Wolff M, Stute P, Mosimann B. Neues und praktisch Relevantes aus der gynäkologischen Endokrinologie, Reproduktionsmedizin und Pränatalmedizin: Teil 1. GYNAKOLOGISCHE ENDOKRINOLOGIE 2018. [DOI: 10.1007/s10304-018-0177-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Huppertz H. Folgen perioperativer Antibiotikaprophylaxe bei Kaiserschnittentbindung für das Kind. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-017-0345-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O'Connor L, Cawthorne J, George RP, Crosbie EJ, Rithalia AD, Cheng H. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2018; 2:CD012653. [PMID: 29406579 PMCID: PMC6491077 DOI: 10.1002/14651858.cd012653.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. OBJECTIVES To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. METHODS Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
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Affiliation(s)
- Zhenmi Liu
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jane Blazeby
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Emma McFarlane
- National Institute for Health and Care ExcellenceCentre for GuidelinesLevel 1A, City TowerPiccadilly PlazaManchesterUKM1 4BD
| | - Nicky J Welton
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Louise O'Connor
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Julie Cawthorne
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Ryan P George
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Emma J Crosbie
- Faculty of Biology, Medicine and Health, University of ManchesterDivision of Cancer Sciences5th Floor ‐ ResearchSt Mary's HospitalManchesterUKM13 9WL
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Hung‐Yuan Cheng
- University of BristolBristol Centre for Surgical Research, Bristol Medical SchoolOffice 2.01Canynge Hall, 39 Whatley RoadBristolUKBS8 2PS
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Ierano C, Nankervis JAM, James R, Rajkhowa A, Peel T, Thursky K. Surgical antimicrobial prophylaxis. Aust Prescr 2017; 40:225-229. [PMID: 29377021 DOI: 10.18773/austprescr.2017.073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Courtney Ierano
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | | | - Rod James
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | - Arjun Rajkhowa
- National Centre for Antimicrobial Stewardship, Doherty Institute, Royal Melbourne Hospital/University of Melbourne
| | - Trisha Peel
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne
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Wickramasinghe ND, Horton J, Darshika I, Galgamuwa KD, Ranasinghe WP, Agampodi TC, Agampodi SB. Productivity cost due to postpartum ill health: A cross-sectional study in Sri Lanka. PLoS One 2017; 12:e0185883. [PMID: 29020101 PMCID: PMC5636104 DOI: 10.1371/journal.pone.0185883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/21/2017] [Indexed: 11/30/2022] Open
Abstract
Objective Even though postpartum morbidity continues to cause high disease burden in maternal morbidity and mortality across the globe, the literature pertaining to resultant productivity loss is scarce. Hence, the present study aimed at determining the productivity loss and associated cost of episodes of postpartum ill health. Methods A cross sectional study was conducted in two Medical Officer of Heath areas in the Anuradhapura district, Sri Lanka in 2011, among 407 women residing in Anuradhapura district with an infant aged between 8 to 24 weeks. Validated interviewer administered questionnaires, including the IMMPACT productivity cost tool, were used to collect data on self-reported episodes of postpartum ill health. The productivity loss was calculated as the sum of days lost due to partial and total incapacitation. The adjusted productivity loss for coping strategies was calculated. Productivity cost, both total and adjusted, were calculated based on the mean daily per capita income of the study sample. Results Of the 407 participants, 161(39.6%) reported at least one episode of postpartum illness. Hospitalisations were reported by 27 (16.8%) of all symptomatic postpartum women. Common symptoms of postpartum ill health were pain/infection at either episiotomy or surgical site (n = 44, 27.3%), lower abdominal pain (n = 40, 24.8%) and backache (n = 27, 16.8%). The mean productivity loss per episode of ill health was 15 days (SD = 7.8 days) and the mean productivity loss per episode after adjusting for coping strategies was 7.9 days (SD = 4.4 days). The mean productivity cost per an episode was US$ 34.2(95%CI US$ 26.7–41.6) and the mean productivity cost per an episode after adjusting for coping strategies was US$ 18.0 (95%CI US$ 14.1–22.0) Conclusions The prevalence of self-reported postpartum ill health, associated productivity loss and cost were high in the study sample and the main contributors were preventable conditions including pain and infection. Thus, effective pain management and proper infection prevention and control measures are important in reducing the burden of postpartum illness and resultant productivity cost.
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Affiliation(s)
- Nuwan Darshana Wickramasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
- * E-mail:
| | - Jennifer Horton
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Ishani Darshika
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Kaushila Dinithi Galgamuwa
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Wasantha Pradeep Ranasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Thilini Chanchala Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Suneth Buddhika Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
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Valent AM, DeArmond C, Houston JM, Reddy S, Masters HR, Gold A, Boldt M, DeFranco E, Evans AT, Warshak CR. Effect of Post-Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial. JAMA 2017; 318:1026-1034. [PMID: 28975304 PMCID: PMC5818802 DOI: 10.1001/jama.2017.10567] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The rate of obesity among US women has been increasing, and obesity is associated with increased risk of surgical site infection (SSI) following cesarean delivery. The optimal perioperative antibiotic prophylactic regimen in this high-risk population undergoing cesarean delivery is unknown. OBJECTIVE To determine rates of SSI among obese women who receive prophylactic oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind clinical trial comparing oral cephalexin and metronidazole vs placebo for 48 hours following cesarean delivery for the prevention of SSI in obese women (prepregnancy BMI ≥30) who had received standard intravenous preoperative cephalosporin prophylaxis. Randomization was stratified by intact vs rupture of membranes prior to delivery. The study was conducted at the University of Cincinnati Medical Center, Cincinnati, Ohio, an academic and urban setting, between October 2010 and December 2015, with final follow-up through February 2016. INTERVENTIONS Participants were randomly assigned to receive oral cephalexin, 500 mg, and metronidazole, 500 mg (n = 202 participants), vs identical-appearing placebo (n = 201 participants) every 8 hours for a total of 48 hours following cesarean delivery. MAIN OUTCOMES AND MEASURES The primary outcome was SSI, defined as any superficial incisional, deep incisional, or organ/space infections within 30 days after cesarean delivery. RESULTS Among 403 randomized participants who were included (mean age, 28 [SD, 6] years; mean BMI, 39.7 [SD, 7.8]), 382 (94.6%) completed the trial. The overall rate of SSI was 10.9% (95% CI, 7.9%-14.0%). Surgical site infection was diagnosed in 13 women (6.4%) in the cephalexin-metronidazole group vs 31 women (15.4%) in the placebo group (difference, 9.0% [95% CI, 2.9%-15.0%]; relative risk, 0.41 [95% CI, 0.22-0.77]; P = .01). There were no serious adverse events, including allergic reaction, reported in either the antibiotic group or the placebo group. CONCLUSIONS AND RELEVANCE Among obese women undergoing cesarean delivery who received the standard preoperative cephalosporin prophylaxis, a postoperative 48-hour course of oral cephalexin and metronidazole, compared with placebo, reduced the rate of SSI within 30 days after delivery. For prevention of SSI among obese women after cesarean delivery, prophylactic oral cephalexin and metronidazole may be warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01194115.
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Affiliation(s)
- Amy M. Valent
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Chris DeArmond
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Judy M. Houston
- Office of Clinical Research, Investigational Pharmacy, University of Cincinnati Health, Cincinnati, Ohio
| | - Srinidhi Reddy
- Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio
| | - Heather R. Masters
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | | | - Michael Boldt
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Emily DeFranco
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Arthur T. Evans
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
| | - Carri R. Warshak
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio
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Abstract
There are numerous measures of perinatal quality endorsed by national agencies such as the National Quality Forum (NQF). The sheer number of metrics may lead to confusion about what these measures truly assess, and how to interpret variation in these measures across hospitals, health care systems, and geographic regions. This review presents a conceptual model for the numerous validated measures, an overview of the types of measures endorsed for perinatal quality by NQF in 2016, and potential measures absent from endorsement by these national bodies.
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Affiliation(s)
- Scott A Lorch
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; PolicyLab, The Children's Hospital of Philadelphia, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; Center for Perinatal and Pediatric Health Disparities Research, The Children's Hospital of Philadelphia, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; Department of Pediatrics, The University of Pennsylvania School of Medicine, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVE To compare the costs associated with adjunctive azithromycin compared with standard cefazolin antibiotic prophylaxis alone for unscheduled and scheduled cesarean deliveries. METHODS A decision analytic model was created to compare cefazolin alone with azithromycin plus cefazolin. Published incidences of surgical site infection after cesarean delivery were used to estimate the baseline incidence of surgical site infection in scheduled and unscheduled cesarean delivery using standard antibiotic prophylaxis. The effectiveness of adjunctive azithromycin prophylaxis was obtained from published randomized controlled trials for unscheduled cesarean deliveries. No randomized study of its use in scheduled procedures has been completed. Cost estimates were obtained from published literature, hospital estimates, and the Healthcare Cost and Utilization Project and considered costs of azithromycin and surgical site infections. A series of sensitivity analyses were conducted by varying parameters in the model based on observed distributions for probabilities and costs. The outcome was cost per cesarean delivery from a health system perspective. RESULTS For unscheduled cesarean deliveries, cefazolin prophylaxis alone would cost $695 compared with $335 for adjunctive azithromycin prophylaxis, resulting in a savings of $360 (95% CI $155-451) per cesarean delivery. In scheduled cesarean deliveries, cefazolin prophylaxis alone would cost $254 compared with $111 for adjunctive azithromycin prophylaxis, resulting in a savings of $143 (95% CI 98-157) per cesarean delivery, if proven effective. These findings were robust to a multitude of inputs; as long as adjunctive azithromycin prevented as few as seven additional surgical site infections per 1,000 unscheduled cesarean deliveries and nine additional surgical site infections per 10,000 scheduled cesarean deliveries, adjunctive azithromycin prophylaxis was cost-saving. CONCLUSION Adjunctive azithromycin prophylaxis is a cost-saving strategy in both unscheduled and scheduled cesarean deliveries.
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Moulton LJ, Munoz JL, Lachiewicz M, Liu X, Goje O. Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution. J Matern Fetal Neonatal Med 2017; 31:1873-1880. [PMID: 28502188 DOI: 10.1080/14767058.2017.1330882] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution. METHODS This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors. RESULTS In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3-6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0-9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05-1.09; p = .02), asthma (OR 1.9; 95%CI 1.1-3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1-3.2; p = .02) were associated with increased SSI. CONCLUSIONS Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.
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Affiliation(s)
- Laura J Moulton
- a Obstetrics, Gynecology and Women's Health Institute , Cleveland Clinic , Cleveland , OH , USA
| | - Jessian L Munoz
- a Obstetrics, Gynecology and Women's Health Institute , Cleveland Clinic , Cleveland , OH , USA
| | - Mark Lachiewicz
- b Department of Gynecology and Obstetrics , Emory University School of Medicine , Atlanta , GA , USA
| | - Xiaobo Liu
- c Quantitative Health Sciences Department , Cleveland Clinic , Cleveland , OH , USA
| | - Oluwatosin Goje
- a Obstetrics, Gynecology and Women's Health Institute , Cleveland Clinic , Cleveland , OH , USA
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Zuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Womens Health 2017; 9:81-88. [PMID: 28255256 PMCID: PMC5322852 DOI: 10.2147/ijwh.s98876] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%-15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.
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Affiliation(s)
| | - Noah Zafran
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gali Garmi
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Raed Salim
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Nabhan AF, Allam NE, Hamed Abdel‐Aziz Salama M. Routes of administration of antibiotic prophylaxis for preventing infection after caesarean section. Cochrane Database Syst Rev 2016; 2016:CD011876. [PMID: 27314174 PMCID: PMC8572032 DOI: 10.1002/14651858.cd011876.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Post-caesarean section infection is a cause of maternal morbidity and mortality. Administration of antibiotic prophylaxis is recommended for preventing infection after caesarean delivery. The route of administration of antibiotic prophylaxis should be effective, safe and convenient. Currently, there is a lack of synthesised evidence regarding the benefits and harms of different routes of antibiotic prophylaxis for preventing infection after caesarean section. OBJECTIVES The aim of this review was to assess the benefits and harms of different routes of prophylactic antibiotics given for preventing infectious morbidity in women undergoing caesarean section. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 January 2016) and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing at least two alternative routes of antibiotic prophylaxis for caesarean section (both elective and emergency). Cross-over trials and quasi-RCTs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data from the included studies. These steps were checked by a third review author. MAIN RESULTS We included 10 studies (1354 women). The risk of bias was unclear or high in most of the included studies.All of the included trials involved women undergoing caesarean section whether elective or non-elective. Intravenous antibiotics versus antibiotic irrigation (nine studies, 1274 women) Nine studies (1274 women) compared the administration of intravenous antibiotics with antibiotic irrigation. There were no clear differences between groups in terms of this review's maternal primary outcomes: endometritis (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.70 to 1.29; eight studies (966 women) (low-quality evidence)); wound infection (RR 0.49, 95% CI 0.17 to 1.43; seven studies (859 women) (very low-quality evidence)). The outcome of infant sepsis was not reported in the included studies.In terms of this review's maternal secondary outcomes, there were no clear differences between intravenous antibiotic or irrigation antibiotic groups in terms of postpartum febrile morbidity (RR 0.87, 95% CI 0.48 to 1.60; three studies (264 women) (very low-quality evidence)); or urinary tract infection (RR 0.74, 95% CI 0.25 to 2.15; five studies (660 women) (very low-quality evidence)). In terms of adverse effects of the treatment on the women, no drug allergic reactions were reported in three studies (284 women) (very low-quality evidence), and there were no cases of serious infectious complications reported (very low-quality evidence). There was no clear difference between groups in terms of maternal length of hospital stay (mean difference (MD) 0.28 days, 95% CI -0.22 to 0.79 days, (random-effects analysis), four studies (512 women). No data were reported for the number of women readmitted to hospital. For the baby, there were no data reported in relation to oral thrush, infant length of hospital stay or immediate adverse effects of the antibiotics on the infant. Intravenous antibiotic prophylaxis versus oral antibiotic prophylaxis (one study, 80 women) One study (80 women) compared an intravenous versus an oral route of administration of prophylactic antibiotics, but did not report any of this review's primary or secondary outcomes. AUTHORS' CONCLUSIONS There was no clear difference between irrigation and intravenous antibiotic prophylaxis in reducing the risk of post-caesarean endometritis. For other outcomes, there is insufficient evidence regarding which route of administration of prophylactic antibiotics is most effective at preventing post-caesarean infections. The quality of evidence was very low to low, mainly due to limitations in study design and imprecision. Furthermore, most of the included studies were underpowered (small sample sizes with few events). Therefore, we advise caution in the interpretation and generalisability of the results.For future research, there is a need for well-designed, properly-conducted, and clearly-reported RCTs. Such studies should evaluate the more recently available antibiotics, elaborating on the various available routes of administration, and exploring potential neonatal side effects of such interventions.
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Affiliation(s)
- Ashraf F Nabhan
- Ain Shams UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine16 Ali Fahmi Kamel StreetHeliopolisCairoEgypt11351
| | - Nahed E Allam
- Alazhar UniversityDepartment of Obstetrics and GynaecologyAlmostashfa Elyounainy StCairoEgypt
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Belter CW. Citation analysis as a literature search method for systematic reviews. J Assoc Inf Sci Technol 2015. [DOI: 10.1002/asi.23605] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Nabhan AF, Allam NE, Hamed Abdel-Aziz Salama M. Routes of administration of antibiotic prophylaxis for preventing infection after caesarean section. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Zhang C, Zhang L, Liu X, Zhang L, Zeng Z, Li L, Liu G, Jiang H. Timing of Antibiotic Prophylaxis in Elective Caesarean Delivery: A Multi-Center Randomized Controlled Trial and Meta-Analysis. PLoS One 2015; 10:e0129434. [PMID: 26148063 PMCID: PMC4492889 DOI: 10.1371/journal.pone.0129434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 04/26/2015] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To compare the effectiveness of antibiotic prophylaxis before skin incision with that after umbilical cord clamping in elective caesarean delivery. METHODS We conducted a randomized open-label controlled trial with two parallel arms at three hospitals in western China. Participants meeting the inclusion criteria received antibiotics 30-60 minutes before skin incision while others received antibiotics after umbilical cords clamping. For the meta-analysis, studies were identified from the database of PUBMED, Cochrane Library and EMbase and assessed using the Cochrane risk of bias tool. RESULTS Four hundred and ten patients were randomized to receive antibiotics before skin incision (n = 205) or after umbilical cords clamping (n = 205). There was no difference in the incidence of postpartum endometritis (RR = 0.34, 95% CI 0.04 to 3.24), wound infection (RR = 3.06, 95% CI 0.13 to 74.69) and total puerperal morbidity (RR = 1.02, 95% CI 0.47 to 2.22). No increase in the incidence of neonatal sepsis (RR = 0.34, 95% CI 0.04 to 3.24), septic workup (RR = 0.41, 95% CI 0.08 to 2.07), or intermediate NICU admission (RR = 0.73, 95% CI 0.24 to 2.26) was observed. The meta-analysis involving nine RCTs showed that no statistically significant difference was found in terms of the risk of postpartum endometritis (RR = 0.73, 95% CI 0.39, 1.36), wound infection (RR = 0.80, 95%CI 0.55, 1.17), or puerperal morbidity (RR = 0.89, 95% CI 0.70, 1.13). No increase in the incidence of neonatal sepsis (RR = 0.65, 95% CI 0.35 to 1.20), septic workup (RR = 0.88, 95% CI 0.50 to 1.54), or intermediate NICU admission (RR = 0.91, 95% CI 0.70 to 1.18) was observed. CONCLUSION For elective caesarean delivery, the effects of antibiotic prophylaxis before skin incision and after umbilical cord clamping were equal. Both antibiotic prophylaxis before skin incision and that after umbilical cord clamping were recommended for elective caesarean delivery. The outcome of further studies should address both maternal and neonatal infectious morbidity as well as long-term neonatal follow up. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR-TRC-11001853.
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Affiliation(s)
- Chuan Zhang
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Lingli Zhang
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Xinghui Liu
- Department of Obstetric & Gynecologic, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Li Zhang
- Department of Obstetric & Gynecologic, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Zhiyou Zeng
- Department of Pharmacy, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Lin Li
- Department of Pharmacy, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Guanjian Liu
- The Chinese Cochrane Center, West China Hospital, Chengdu, Sichuan, China
| | - Hong Jiang
- Department of Obstetric & Gynecologic, Suining Central Hospital, Suining, Sichuan, China
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Gyte GML, Dou L, Vazquez JC. Different classes of antibiotics given to women routinely for preventing infection at caesarean section. Cochrane Database Syst Rev 2014; 2014:CD008726. [PMID: 25402227 PMCID: PMC7173707 DOI: 10.1002/14651858.cd008726.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. It is important to identify the most effective class of antibiotics to use and those with the least adverse effects. OBJECTIVES To determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing different classes of prophylactic antibiotics given to women undergoing caesarean section. We excluded trials that compared drugs with placebo or drugs within a specific class; these are assessed in other Cochrane reviews. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. MAIN RESULTS We included 35 studies of which 31 provided data on 7697 women. For the main comparison between cephalosporins versus penicillins, there were 30 studies of which 27 provided data on 7299 women. There was a lack of good quality data and important outcomes often included only small numbers of women.For the comparison of a single cephalosporin versus a single penicillin (Comparison 1 subgroup 1), we found no significant difference between these classes of antibiotics for our chosen most important seven outcomes namely: maternal sepsis - there were no women with sepsis in the two studies involving 346 women; maternal endometritis (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.81 to 1.52, nine studies, 3130 women, random effects, moderate quality of the evidence); maternal wound infection (RR 0.83, 95% CI 0.38 to 1.81, nine studies, 1497 women, random effects, low quality of the evidence), maternal urinary tract infection (RR 1.48, 95% CI 0.89 to 2.48, seven studies, 1120 women, low quality of the evidence) and maternal composite adverse effects (RR 2.02, 95% CI 0.18 to 21.96, three studies, 1902 women, very low quality of the evidence). None of the included studies looked for infant sepsis nor infant oral thrush.This meant we could only conclude that the current evidence shows no overall difference between the different classes of antibiotics in terms of reducing maternal infections after caesarean sections. However, none of the studies reported on infections diagnosed after the initial postoperative hospital stay. We were unable to assess what impact, if any, the use of different classes of antibiotics might have on bacterial resistance. AUTHORS' CONCLUSIONS Based on the best currently available evidence, cephalosporins and penicillins have similar efficacy at caesarean section when considering immediate postoperative infections. We have no data for outcomes on the baby, nor on late infections (up to 30 days) in the mother. Clinicians need to consider bacterial resistance and women's individual circumstances.
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Affiliation(s)
- Gillian ML Gyte
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
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