Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial

Standard-Dose Azithromycin in Class III Obese Patients Undergoing Unscheduled Cesarean Delivery

OBJECTIVE

Perioperative antibiotic prophylaxis reduces cesarean wound complications. This study investigates whether integration of standard-dose (500 mg) azithromycin prophylaxis reduced wound complications in patients with class III obesity (body mass index [BMI] ≥ 40 kg/m2) undergoing unscheduled cesarean delivery.

STUDY DESIGN

Retrospective cohort study of patients with class III obesity undergoing unscheduled cesarean delivery in single hospital system from January 1, 2017, to January 1, 2020. A standard dose (500 mg) of azithromycin was integrated into system order sets in 2018. Medical history and postoperative wound outcomes were compared in pre- and postintegration cohorts. Wound complication was defined as composite of wound seroma, hematoma, superficial or deep infection.

RESULTS

A total of 1,273 patients met inclusion criteria, 303 patients in the preorder set group, and 970 patients in the postorder set group. Demographics were similar between the pre- and postintegration cohorts, including BMI (median: 44.4 kg/m2, p = 0.84) and weight at delivery (mean: 121.2 ± 17.8 kg, p = 0.57). Patients in the postintegration cohort had lower rates of composite postpartum wound complication (7.9 vs. 13.9%, p = 0.002), superficial infection or deep infection/abscess (6.7 vs. 10.2%, p = 0.042), and postpartum readmission or unscheduled visits (18.7 vs. 24.4%, p < 0.029). Rates of chorioamnionitis and endometritis were similar between the pre- and postintegration groups (8.6 vs. 6.9%, p = 0.33, and 1.7 vs. 1.9%, p = 0.81, respectively). Patients in the postintegration cohort had lower risk of postoperative composite wound complication (unadjusted odds ratio [OR]: 0.54, confidence interval [CI]: 0.36-0.80, p = 0.002) and lower rates of wound infection (unadjusted OR: 0.63, 95% CI: 0.40-0.99, p = 0.044). When comparing patients who received azithromycin at delivery and patients who did not, standard-dose azithromycin reduced risk of postoperative wound complication (unadjusted OR: 0.67, 95% CI: 0.46-0.99, p = 0.043).

CONCLUSION

A standard dose of azithromycin provides adequate perioperative prophylaxis in class III obese patients, decreasing rates of postcesarean wound complications and unscheduled postpartum outpatient visits.

KEY POINTS

· Class III obese patients undergoing unscheduled cesarean have high rates of wound complications.. · Standard-dose azithromycin reduces risk of postcesarean wound infection in class III obese patients.. · Standard-dose azithromycin reduces readmission, unscheduled visits in class III obese patients..

Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery

Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.

Neonatal sepsis definitions from randomised clinical trials

INTRODUCTION

Neonatal sepsis is a leading cause of infant mortality worldwide with non-specific and varied presentation. We aimed to catalogue the current definitions of neonatal sepsis in published randomised controlled trials (RCTs).

METHOD

A systematic search of the Embase and Cochrane databases was performed for RCTs which explicitly stated a definition for neonatal sepsis. Definitions were sub-divided into five primary criteria for infection (culture, laboratory findings, clinical signs, radiological evidence and risk factors) and stratified by qualifiers (early/late-onset and likelihood of sepsis).

RESULTS

Of 668 papers screened, 80 RCTs were included and 128 individual definitions identified. The single most common definition was neonatal sepsis defined by blood culture alone (n = 35), followed by culture and clinical signs (n = 29), and then laboratory tests/clinical signs (n = 25). Blood culture featured in 83 definitions, laboratory testing featured in 48 definitions while clinical signs and radiology featured in 80 and 8 definitions, respectively.

DISCUSSION

A diverse range of definitions of neonatal sepsis are used and based on microbiological culture, laboratory tests and clinical signs in contrast to adult and paediatric sepsis which use organ dysfunction. An international consensus-based definition of neonatal sepsis could allow meta-analysis and translate results to improve outcomes.

The Association of Cesarean Skin Incision Length and Postoperative Wound Complications

OBJECTIVE

This study was aimed to evaluate the relationship between cesarean skin incision length and wound complications.

STUDY DESIGN

Planned secondary analysis of a multicenter double-blind randomized trial of adjunctive azithromycin versus placebo (in addition to standard cefazolin) in women ≥24 weeks undergoing cesarean delivery during labor or ≥4 hours after membrane rupture. Skin incision length (cm) was measured just prior to skin closure. The primary outcome was a composite of wound complications (wound infection, separation, seroma, hematoma, or dehiscence) up to 6 weeks of postpartum. Individual components of the composite were examined as secondary outcomes. Outcomes were compared between groups defined by the lowest (≤25th), middle (25-75th) and highest (>75th) incision length quartiles. Logistic regression was used to adjust for potential confounding variables.

RESULTS

Of the 2,013 women enrolled in the primary trial, 1,916 had recorded incision lengths and were included in this secondary analysis. The overall rate of composite wound complications was 7.8%. Median incision length was 15.0 cm (interquartile range: 14.0-16.5) with the lowest quartile defined as ≤14, middle as >14 to ≤16.5, and highest as >16.5 cm. Mean BMI, parity, use of staples, and duration of surgery differed significantly between the three incision length groups. In unadjusted analysis, the longest incision lengths were associated with an increased risk of the wound composite and wound infections (odds ratio [OR] = 2.27, 95% confidence interval [CI]: 1.43-3.60 and OR = 2.30, 95% CI: 1.27-4.15, respectively) compared with the shortest incision lengths. However, after multivariable adjustments, these associations were nullified. Additional analyses considering incision length as a continuous variable and using 10th/90th percentile cut-offs still did not suggest any associations with outcomes.

CONCLUSION

Increasing skin incision length is not independently associated with an increased risk of postoperative wound complications.

KEY POINTS

· After multivariable adjustments, skin incision length was not independently associated with an increased risk of postoperative wound complications.. · A reasonable incision length needed to safely perform the procedure should be used..

Effectiveness of antimicrobial prophylaxis at 30 versus 60 min before cesarean delivery

This study aimed to examine the effect of antibiotic prophylaxis (AP) given within 30 compared to 30–60 min before skin incision on the incidence of infectious morbidity after cesarean delivery (CD). A retrospective cohort study was conducted at a single institution on data between 2014 and 2018. Women who delivered by CD were divided into two groups according to AP timing before skin incision: group 1 within 30 min, and group 2 from 30 to 60 min. The primary outcome was the incidence of any infectious morbidity. Overall, 2989 women were eligible: 2791 in group 1 and 198 in group 2. The primary composite outcome occurred in 125 women (4.48%) in group 1 and 8 women (4.04%) in group 2 (OR, 1.11; 95% CI 0.54–2.31; P = 0.77). The rate of surgical site infection only, was 1.08% in group 1 and 0.51% in group 2 (OR, 2.13; 95% CI 0.29–15.70; P = 0.72). The incidence was comparable between the groups in a separate sub-analysis restricted to laboring CDs and obese women. The rate of infectious morbidity was similar among women who received AP within 30 min and from 30 to 60 min before skin incision.

Different classes of antibiotics given to women routinely for preventing infection at caesarean section

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.

Cesarean delivery: an evidence-based review of the technique

The cesarean section is utilized to deliver babies since the late 19^th 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.

Efficacy of Non-Beta-lactam Antibiotics for Prevention of Cesarean Delivery Surgical Site Infections

Objective  To examine the association between perioperative Beta ( β ))-lactam versus non- β -lactam antibiotics and cesarean delivery surgical site infection (SSI). Study Design  Retrospective cohort of women undergoing cesarean delivery from January 1 to December 31, 2014. All women undergoing cesarean after 34 weeks with a postpartum visit were included. Prevalence of SSI was compared between women receiving β -lactam versus non- β -lactam antibiotics. Bivariate analyses were performed using Pearson's Chi-square, Fisher's exact, or Wilcoxon's rank-sum tests. Logistic regression models were fit controlling for possible confounders. Results  Of the 929 women included, 826 (89%) received β -lactam prophylaxis and 103 (11%) received a non- β -lactam. Among the 893 women who reported a non-type I (low risk) allergy, 819 (92%) received β -lactam prophylaxis. SSI occurred in 7% of women who received β -lactam antibiotics versus 15% of women who received a non- β -lactam ( p  = 0.004). β -Lactam prophylaxis was associated with lower odds of SSI compared with non- β -lactam antibiotics (odds ratio [OR] = 0.43; 95% confidence interval [CI] = 0.22-0.83; p  = 0.01) after controlling for chorioamnionitis in labor, postlabor cesarean, endometritis, tobacco use, and body mass index (BMI). Conclusion   β -Lactam perioperative prophylaxis is associated with lower odds of a cesarean delivery surgical site infection compared with non- β -lactam antibiotics.

Is the efficacy of antibiotic prophylaxis for surgical procedures decreasing? Systematic review and meta-analysis of randomized control trials

OBJECTIVE

Rising antibiotic resistance could reduce the effectiveness of antibiotics in preventing postoperative infections. We investigated trends in the efficacy of antibiotic prophylaxis regimens for 3 commonly performed surgical procedures-appendectomy, cesarean section, and colorectal surgery-and 1 invasive diagnostic procedure, transrectal prostate biopsy (TRPB).

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed and Cochrane databases (through October 31, 2017) for randomized control trials (RCTs) that measured the efficacy of antibiotic prophylaxis for 4 index procedures in preventing postoperative infections (surgical site infections [SSIs] following the 3 surgical procedures and a combination of urinary tract infections [UTIs] and sepsis following TRPB).

RESULTS

Of 399 RCTs, 74 studies (9 appendectomy, 11 cesarean section, 39 colorectal surgery, and 15 TRPB) were included. Multilevel logistic regression models with random intercepts for each study showed no statistically significant increase in SSIs over time for appendectomy (adjusted odds ratio [aOR] per year, 1.03; 95% confidence interval [CI], 0.92-1.16; P=.57), cesarean section (aOR per year, 1.01; 95% CI, 0.96-1.05; P=.80), and TRPB (aOR per year, 0.95; 95% CI, 0.77-1.18; P=.67). However, there was a significant increase in SSIs proportion following colorectal surgery (aOR per year, 1.049; 95% CI, 1.03-1.07; P&lt;.001).

CONCLUSION

The efficacy of antibiotic prophylaxis agents in preventing SSIs following colorectal surgery has declined. Small number of RCTs and low infections rates limited our ability to assess true effect for simple appendectomy, cesarean section, or TRPB.

Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and strategies for implementation

Surgical site infections remain a common cause of morbidity, mortality, and increased length of stay and cost amongst hospitalized patients in the United States. This article summarizes the evidence used to inform the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017), and highlights key updates and new recommendations. We also present specific suggestions for how infection preventionists can play a central role in guideline implementation by translating these recommendations into evidence-based policies and practices in their facility.

Prophylactic antibiotics before cord clamping in cesarean delivery: a systematic review

INTRODUCTION

The number of clinical trials investigating the optimal timing of prophylactic antibiotics in cesarean section has increased rapidly over the last few years. We conducted a systematic review to inform up-to-date evidence-based guidelines to prevent postpartum infectious morbidity in the mother and rule out any safety issues related to antepartum antibiotic exposure in infants.

MATERIAL AND METHODS

Four bibliographic databases were searched for published reports of trials. Ongoing or unpublished studies were searched in Clinicaltrials.gov and the World Health Organization registry platform. Randomized controlled trials comparing antibiotic prophylaxis before and after cord clamping in cesarean section were eligible. Maternal and neonatal outcomes were assessed, and certainty of evidence graded.

RESULTS

In total, 18 randomized controlled trials met the inclusion criteria. Those women who received antibiotics preoperatively were 28% (relative risk 0.72, 95% confidence interval 0.56-0.92, nine studies, 4342 women, high quality of evidence) less likely to show infectious morbidity as compared with those who received antibiotics after cord clamping. The risk of endomyometritis and/or endometritis was reduced by 43% (relative risk 0.57, 95% confidence interval 0.40-0.82, 13 studies, 6250 women, high quality of evidence) and the risk of wound infection by 38% (relative risk 0.62, 95% confidence interval 0.47-0.81, 14 studies, 6450 women, high quality of evidence) in those who received antibiotics preoperatively as compared to those who received antibiotics after cord clamping. For other maternal infections no significant differences were identified. The risk for neonatal outcomes, such as deaths attributed to infection, sepsis, neonatal antibiotic treatment, intensive care unit admission or antibiotic-related adverse events, was not found to be different, either clinically or statistically, when antibiotics were given before or after cord clamping (moderate to low quality of evidence).

CONCLUSIONS

The evidence in favor of prophylactic antibiotic administration before, in comparison with after, cord clamping for major maternal infections was of high quality, meaning that further research would be unlikely to change the confidence in these findings. However, we recommend additional research reflecting the precision of the effect estimates for neonatal outcomes.

Surgical site infections after cesarean delivery: epidemiology, prevention and treatment

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system. SSIs complicate a significant number of patients who undergo CD - 2-7% will experience sound infections and 2-16% will develop endometritis. Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples. Implementation of surgical bundles in non-obstetric patients has been promising., Creating a similar patient care bundle comprised evidence-based elements in patients who undergo CD may decrease the incidence of this major complication. Each hospital has the opportunity to create its own CD surgical bundle to decrease surgical site infection.

Adjunctive Azithromycin Prophylaxis for Cesarean Delivery

BACKGROUND

The addition of azithromycin to standard regimens for antibiotic prophylaxis before cesarean delivery may further reduce the rate of postoperative infection. We evaluated the benefits and safety of azithromycin-based extended-spectrum prophylaxis in women undergoing nonelective cesarean section.

METHODS

In this trial conducted at 14 centers in the United States, we studied 2013 women who had a singleton pregnancy with a gestation of 24 weeks or more and who were undergoing cesarean delivery during labor or after membrane rupture. We randomly assigned 1019 to receive 500 mg of intravenous azithromycin and 994 to receive placebo. All the women were also scheduled to receive standard antibiotic prophylaxis. The primary outcome was a composite of endometritis, wound infection, or other infection occurring within 6 weeks.

RESULTS

The primary outcome occurred in 62 women (6.1%) who received azithromycin and in 119 (12.0%) who received placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). There were significant differences between the azithromycin group and the placebo group in rates of endometritis (3.8% vs. 6.1%, P=0.02), wound infection (2.4% vs. 6.6%, P<0.001), and serious maternal adverse events (1.5% vs. 2.9%, P=0.03). There was no significant between-group difference in a secondary neonatal composite outcome that included neonatal death and serious neonatal complications (14.3% vs. 13.6%, P=0.63).

CONCLUSIONS

Among women undergoing nonelective cesarean delivery who were all receiving standard antibiotic prophylaxis, extended-spectrum prophylaxis with adjunctive azithromycin was more effective than placebo in reducing the risk of postoperative infection. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; C/SOAP ClinicalTrials.gov number, NCT01235546 .).

[What's the optimal time of cesarean section antibiotic prophylaxis, before skin incision or after umbilical cord clamping? A prospective randomized study]

OBJECTIVES

To compare the effect of antibiotics prophylaxis within 30 mins before skin incision (A) and after umbilical cord clamping (C) on the incidence of postoperative infections in patients undergoing elective caesarean section at Farhat Hached university teaching hospital.

MATERIALS AND METHODS

We conducted a randomised clinical trial evaluating 279 patients undergoing elective caesarean section. Patients were randomly assigned a group number that allocated them to either arm of the study. They received the same prophylactic antibiotic (cefazol^® 2g) according to their allotment. They were followed up to detect infection up to 30 days postoperatively. The primary outcome was postoperative infection. The data collected were analysed with SPSS version 18.0 using univariate and bivariate analysis.

RESULTS

The risk of overall postoperative infection was not significantly lower when prophylaxis was given before skin incision (4.37 % (A) vs 9.85 % (C); P=0.07; OR=0.42 [0.15-1.12]). We also found wound infections to be significantly reduced in the pre-incision group (2.2 % [A] vs 8.45 % [C]; P=0.03; OR=0.24 [0.06-0.88]). However, there was no difference in the endometritis infectious. On the other hand, there was no negative impact on the neonatal features.

CONCLUSIONS

Giving prophylactic antibiotics before skin incision reduces risk of postoperative infection, in particular of wound infections.

A multifaceted prevention program to reduce infection after cesarean section: Interventions assessed using an intensive postdischarge surveillance system

BACKGROUND

We assessed the effects of the components of a multifaceted and evidence-based caesarean-section surgical site infection (SSI) prevention program on the SSI rate after cesarean section using a postdischarge surveillance (PDS) system.

METHODS

Multiple prevention interventions were serially implemented. SSI case finding was undertaken through active inpatient surveillance and intensive PDS using a standardized form at the 6-week postdischarge visit. SSI diagnosis was made using the Centers for Disease Control and Prevention standardized criteria. All cesarean deliveries between July 2007 and December 2012 were included. Changes in SSI rate were analyzed using segmented regression analysis.

RESULTS

Nine thousand four hundred forty-two cesarean sections were assessed during the study period. PDS forms were completed for 7,985 women (85%). SSI was detected in 451 cases (5.6%): 91% were superficial, 9% were deep/organ-space infections. The SSI rate decreased incrementally from 8.2% at baseline to 4.1%; significant decreases were observed after optimizing antibiotic prophylaxis timing, using a surgical safety checklist, and enhancing prenatal education to discourage prehospital self-removal of hair. Nonelective surgeries or those undertaken after >12 hours of rupture of membranes had a significantly higher rate compared with those without either risk factor (6.3% vs 3.2%; P < .001).

CONCLUSIONS

A multifaceted SSI prevention strategy, with periodic feedback of data, led to a significant reduction in SSI rates after cesarean section.

Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery

BACKGROUND

Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate.

OBJECTIVES

To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection.

AUTHORS' CONCLUSIONS

Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.

Different classes of antibiotics given to women routinely for preventing infection at caesarean section

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.

Pharmacokinetics of prophylactic cefazolin in parturients undergoing cesarean delivery

The objectives of this work were (i) to characterize the pharmacokinetics of cefazolin in pregnant women undergoing elective cesarean delivery and in their neonates; (ii) to assess cefazolin transplacental transmission; (iii) to evaluate the dosing and timing of preoperative, prophylactic administration of cefazolin to pregnant women; and (iv) to investigate the impact of maternal dosing on therapeutic duration and exposure in newborns. Twenty women received 1 g of cefazolin preoperatively. Plasma concentrations of total cefazolin were analyzed from maternal blood samples taken before, during, and after delivery; umbilical cord blood samples obtained at delivery; and neonatal blood samples collected 24 h after birth. The distribution volume of cefazolin was 9.44 liters. [corrected] The values for pre- and postdelivery clearance were 7.18 and 4.12 liters/h, respectively. Computer simulations revealed that the probability of maintaining free cefazolin concentrations in plasma above 8 mg/liter during scheduled caesarean surgery was <50% in the cord blood when cefazolin was administered in doses of <2 g or when it was administered <1 h before delivery. Therapeutic concentrations of cefazolin persisted in neonates >5 h after birth. Cefazolin clearance increases during pregnancy, and larger doses are recommended for surgical prophylaxis in pregnant women to obtain the same antibacterial effect as in nonpregnant patients. Cefazolin has a longer half-life in neonates than in adults. Maternal administration of up to 2 g of cefazolin is effective and produces exposure within clinically approved limits in neonates.

Risk factors for wound infection after lower segment cesarean section

The incidence of post caesarean wound infection and independent risk factors associated with wound infection were retrospectively studied at a tertiary care hospital. A retrospective case controlled study of 107 patients with wound infection after lower segment caesarean section (LSCS) was undertaken between January 1998 and December 2007. The control group comprised of 340 patients selected randomly from among those who had LSCS during the study period with no wound infection. Chart reviews of patients with wound infection were identified using the definitions from the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance Systems. Comparisons for categorical variables were performed using the X (2) or Fisher exact test. Continuous variables were compared using the 2-tailed Student t test. P < 0.05 was considered significant. Logistic regression determined the independent risk factors. The overall wound infection rate in the study was 4.2% among 2 541 lower transverse CS. The independent risk factors identified for wound infection were, obesity, duration of labor >12 hours, and no antenatal care. Patients' age and parity, diabetes mellitus, premature rupture of membranes (PROM) >8 hours and elective vs. emergency surgery was not found to be significantly associated with wound infection.

CONCLUSION

The independent risk factors could be incorporated into the policies for surveillance and prevention of wound infection. Antibiotic prophylaxis may be utilized in high risk patients such as PROM, obese patients and prolonged labor.

Evidence-based surgery for cesarean delivery: an updated systematic review

The objective of our systematic review was to provide updated evidence-based guidance for surgical decisions during cesarean delivery (CD). We performed an English-language MEDLINE, PubMed, and COCHRANE search with the terms, cesarean section, cesarean delivery, cesarean, pregnancy, and randomized trials, plus each technical aspect of CD. Randomized control trials (RCTs) involving any aspect of CD technique from Jan. 1, 2005, to Sept. 1, 2012, were evaluated to update a previous systematic review. We also summarized Cochrane reviews, systematic reviews, and metaanalyses if they included additional RCTs since this review. We identified 73 RCTs, 10 metaanalyses and/or systematic reviews, and 12 Cochrane reviews during this time frame. Recommendations with high levels of certainty as defined by the US Preventive Services Task Force favor pre-skin incision prophylactic antibiotics, cephalad-caudad blunt uterine extension, spontaneous placental removal, surgeon preference on uterine exteriorization, single-layer uterine closure when future fertility is undesired, and suture closure of the subcutaneous tissue when thickness is 2 cm or greater and do not favor manual cervical dilation, subcutaneous drains, or supplemental oxygen for the reduction of morbidity from infection. The technical aspect of CD with high-quality, evidence-based recommendations should be adopted. Although 73 RCTs over the past 8 years is encouraging, additional well-designed, adequately powered trials on the specific technical aspects of CD are warranted.

Timing of prophylactic antibiotic at cesarean section: a double-blinded, randomized trial

OBJECTIVE

The purpose was to determine the effect of the timing of prophylactic antibiotics for cesarean section on post-operative infectious complications.

STUDY DESIGN

This was a prospective, double-blinded, randomized controlled trial in which patients were randomized to receive cefazolin or clindamycin either before skin incision or after cord clamp. The primary outcome was maternal infectious morbidity at 6 weeks postpartum, a composite infectious outcome, which included endometritis, urinary tract infection, wound infection and pneumonia.

RESULT

Data on 896 women were analyzed; 449 randomized to skin incision, 447 to cord clamp. Postpartum infections were seen in a total of 8.4% of patients. Timing of antibiotic administration did not significantly affect any maternal postpartum infection rates or selected neonatal outcomes.

CONCLUSION

Our results suggest that, in a largely non-laboring population, the timing of prophylactic antibiotic administration does not impact post-operative infectious complications of the mother. Despite being one of the largest randomized controlled trials to address this question, our study still lacked sufficient power to make definitive conclusions.

Concerning the timing of antibiotic administration in women undergoing caesarean section: a systematic review and meta-analysis

OBJECTIVE

To assess the effects on maternal infectious morbidity and neonatal outcomes of the timing of antibiotic prophylaxis in women undergoing caesarean section. A recent National Institute for Health and Clinical Excellence (NICE) guideline reported that antibiotic administration before skin incision reduces the risk of maternal infection; this recommendation was based on a meta-analysis, however one including trials that were not double blind and not including a trial published recently.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Searches of PubMed and EMBASE and reference lists of the retrieved articles.

INCLUSION CRITERIA

Randomised double-blind controlled trials comparing the administration of antibiotics before skin incision with administration after cord clamping.

DATA EXTRACTION AND ANALYSIS

Data on maternal total infectious morbidity, endometritis and wound infection, as well as neonatal intensive care unit admission, neonatal infection and neonatal sepsis were extracted and combined using random effects meta-analysis.

RESULTS

Five studies reporting on 1777 parturients were included in our systematic review. The relative risk (RR) for maternal total infectious morbidity for antibiotic administration before incision compared with antibiotic administration after cord clamping was 0.64 (95% CI 0.36 to 1.15). Likewise, there was no difference in the risk of wound infection (RR 0.72, 95% CI 0.41 to 1.27). Parturients receiving the antibiotic preoperatively had a significantly reduced risk of endometritis (RR 0.48, 95% CI 0.27 to 0.87; number needed to treat 41, 95% CI 23 to 165). Analyses of the neonatal outcome parameters revealed no differences between the regimens of antibiotic administration, but were based on few studies.

CONCLUSIONS

In contrast to a recent NICE guideline, we did not find a reduction in total infectious morbidity with antibiotic administration before skin incision; we confirmed a reduction in the risk of endometritis and a lack of effect on the risk for wound infection.

Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta-analysis

Background

Prophylactic antibiotics reduce infectious morbidity from caesarean section. The timing of their administration, however, is a matter of controversy.

Objectives

To examine maternal and neonatal infectious morbidity in women receiving preoperative prophylaxis compared with those receiving intraoperative administration.

Search strategy

Medline, Embase, Current Controlled Trials and Cochrane Central were searched from their inception dates to December 2011.

Selection criteria

Randomised controlled trials of a single dose of any antibiotic comparing preoperative with intraoperative administration were selected.

Data collection and analysis

Trial characteristics, outcomes and quality measures, based on the Cochrane tool for risk of bias, were independently extracted. The random effect model of DerSimonian and Laird to estimate relative risks (RRs) for maternal and neonatal outcomes was used.

Main results

Six trials met the inclusion criteria, reporting on 2313 women and 2345 newborns. Preoperative administration was associated with a significant 41% reduction in the rate of endometritis compared with intraoperative administration (RR 0.59; 95% confidence interval [95% CI] 0.37–0.94; I² 0%). In the preoperative group, there were nonsignificant reductions in the rates of wound infection (RR 0.71; 95% CI 0.44–1.14; I² 0%), maternal febrile morbidity (RR 0.94; 95% CI 0.46–1.95; I² 0%), neonatal sepsis (RR 0.81; 95% CI 0.47–1.41; I² 0%), neonatal septic work-up (RR 0.93; 95% CI 0.71–1.21; I² 0%) and neonatal intensive-care unit admission (RR 0.92; 95% CI 0.65–1.28; I² 0%). There were nonsignificant increases in the rates of maternal pyelonephritis (RR 1.09; 95% CI 0.49–2.43; I² 0%) and neonatal pneumonia (RR 3.36; 95% CI 0.55–20.47; I² 0%).

Conclusions

Compared with intraoperative administration, preoperative antibiotics significantly reduce the rate of endometritis. The lack of neonatal adverse effects should be cautiously interpreted given the limited power of the trials to detect such effects.

Antibiotic prophylaxis for cesarean delivery: survey of maternal-fetal medicine physicians in the U.S

OBJECTIVE

To describe practices concerning antibiotic prophylaxis for cesarean delivery among maternal-fetal medicine (MFM) physicians in the United States.

METHODS

A 10-item self-administered survey about their routine use of antibiotics for cesarean delivery was mailed once only to a random sample of 1000 US-based fellows of the Society of Maternal-Fetal Medicine in November 2009.

RESULTS

There were a total of 250 respondents from 40 US states between 10/09 and 4/2010, corresponding to a response rate of 25%. Among respondents, 95.5% reported routine use of a cephalosporin only (including 84.4% who reported use of cefazolin) as antibiotic prophylaxis for cesarean delivery; less than 3% reported use of an extended spectrum regimen such as cefazolin + azithromycin. Preoperative administration of antibiotic prophylaxis was reported by 84.6% compared to 15.0% who reported giving antibiotic prophylaxis after umbilical cord clamping. Administration of a single dose of antibiotic was reported by 96%.

CONCLUSION

The majority of MFM specialists in the US report routine and preoperative use of a single prophylactic dose of a 1st generation cephalosporin for cesarean delivery.

The National Institute for Health and Clinical Excellence (NICE) guidelines for caesarean section, 2011 update: implications for the anaesthetist

In 2004 the first National Institute for Health and Clinical Excellence guidelines on caesarean section were published with the aim of providing evidence-based recommendations for best practice. With the publication of new evidence, the guidelines have been revised with the second edition released in 2011. This review highlights the changes that have been made which are of specific relevance to obstetric anaesthetists including planned caesarean section compared with vaginal birth in healthy women with an uncomplicated pregnancy; management of the morbidly adherent placenta; mother-to-child transmission of maternal infections; maternal request for caesarean section; decision-to-delivery interval for emergency caesarean section; timing of antibiotic administration and childbirth after caesarean section.

A randomized controlled trial comparing two different antibiotic regimens for prophylaxis at cesarean section

OBJECTIVES

To compare the efficacy of intravenous single dose, less costly cefotaxime and more expensive amoxycillin-clavulanic acid combination for prophylaxis at cesarean section.

METHOD

A double blind randomized controlled trial was undertaken on 760 subjects with two parallel treatment groups. Data were analyzed using Graphpad Instat 3 McIntosh software by Student's t test, Mann-Whitney U test, the Chi-squared test or fisher's exact test.

RESULTS

Comparatively narrow spectrum low cost cefotaxime is as effective as more expensive commonly used amoxicillin-clavulanic acid with no significant difference of infectious morbidity and hospital stay (p = 0.27 and 0.11 in elective and emergency cases respectively).

CONCLUSION

Less costly cefotaxime should be preferred compared to more costly amoxicillin-clavulanic acid combination for prophylaxis at cesarean section.

Timing of antibiotic administration and infectious morbidity following cesarean delivery: incorporating policy change into workflow

PURPOSE

To evaluate the success of a multidisciplinary approach to policy change regarding timing of antibiotic administration for the prevention of surgical-site infection after cesarean delivery.

METHODS

After review of the evidence, our multidisciplinary Obstetrics Leadership Committee decided to change policy on the timing of antibiotic prophylaxis for cesarean delivery. Using a combination of meetings, email communications, and local champions, 100% compliance with the new policy was achieved in 5 weeks. The effect of this policy change was investigated through a prospective cohort study of consecutive patients undergoing cesarean delivery at one institution from January 2009 through May 2009. Approximately halfway through the study period our department implemented a practice change that required antibiotic administration before skin incision rather than after clamping the umbilical cord. We compared the incidence of surgical-site infection, including endometritis, cellulitis, and total infectious morbidity, among women who received antibiotics before skin incision to those who received antibiotics after umbilical cord clamp.

RESULTS

There were 533 consecutive women who underwent cesarean delivery during the study period. Two hundred forty (45.0%) women received antibiotics after cord clamping, and 285 (53.5%) women received antibiotics before skin incision; timing could not be determined for 8 (1.5%) women. Within 5 weeks of the policy change, 100% of the women undergoing cesarean delivery received perioperative prophylactic antibiotics before skin incision. The incidence of infectious morbidity fell from 5.4 to 2.5% when antibiotics were given before skin incision. Compared to the administration of antibiotics before skin incision, receiving antibiotics after cord clamp yielded a crude relative risk (RR) of 2.21 (95% CI 0.89-5.44) for total infectious morbidity and 3.56 (95% CI 0.73-17.49) for endometritis. Although not statistically significant, there was an increased risk of cellulitis (RR 1.66; 95% CI 0.53-5.17) when antibiotics were administered after cord clamping.

CONCLUSIONS

A multidisciplinary approach was successful in achieving 100% adherence to our institution's policy change regarding timing of prophylactic antibiotics. This approach was necessary in order to incorporate this type of change into the labor and delivery workflow and may serve as a paradigm for success in implementing labor and delivery quality improvement projects. In addition, administration of prophylactic antibiotics before skin incision resulted in fewer surgical-site infections following cesarean delivery. As the clinical and economic impact of surgical-site infections is considerable, the once common practice of administering antibiotics after cord clamping should be avoided.

Current debate on the use of antibiotic prophylaxis for caesarean section

Caesarean delivery is frequently complicated by surgical site infections, endometritis and urinary tract infection. Most surgical site infections occur after discharge from the hospital, and are increasingly being used as performance indicators. Worldwide, the rate of caesarean delivery is increasing. Evidence-based guidelines recommended the use of prophylactic antibiotics before surgical incision. An exception is made for caesarean delivery, where narrow-range antibiotics are administered after umbilical cord clamping because of putative neonatal benefit. However, recent evidence supports the use of pre-incision, broad-spectrum antibiotics, which result in a lower rate of maternal morbidity with no disadvantage to the neonate.

Different classes of antibiotics given to women routinely for preventing infection at caesarean section

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 STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010) 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 29 studies of which 25 provided data on 6367 women. There was a lack of good quality data and important outcomes often included only small numbers of women. 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 looked at outcomes on the baby, nor did they report 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.

Adherence to perinatal group B streptococcal prevention guidelines

OBJECTIVE

To estimate compliance with the 2002 revised perinatal group B streptococci (GBS) prevention guidelines in Tennessee, which recommend universal GBS screening of pregnant women at 35-37 weeks of gestation and, when indicated, administration of intrapartum chemoprophylaxis.

METHODS

Active Bacterial Core surveillance conducts active, population-based surveillance for invasive GBS disease in 11 Tennessee counties. A retrospective case-cohort study was conducted using a stratified random sample of all live births in surveillance hospitals during 2003-2004, including all early-onset GBS cases. Factors associated with GBS screening and lack of optimal GBS chemoprophylaxis were analyzed using logistic regression.

RESULTS

Screening was performed for 84.7% of pregnant women, but 26.3% of prenatal tests with documented test dates were performed before 35 weeks of gestation. Among women with an indication for GBS prophylaxis, 61.2% received optimal chemoprophylaxis, defined as initiation of a recommended antibiotic 4 hours or more before delivery. When the analysis was restricted to women who were admitted 4 hours or more before delivery, 70.9% received optimal chemoprophylaxis. Women not receiving optimal chemoprophylaxis were more likely to have penicillin allergy (11.7% compared with 2.5%, adjusted odds ratio [OR] 8.58, 95% confidence interval [CI] 1.57-47.04) or preterm delivery (45.5% compared with 13.2%, adjusted OR 5.52, 95% CI 2.29-13.30) and were less likely to have received the recommended prenatal serologic testing for other infectious diseases (77.9% compared with 91.1%, adjusted OR 0.30, 95% CI 0.09-0.98). Forty cases of early-onset GBS were identified (0.36 per 1,000 live births); 25% of these neonates were born to women who received screening at 35 weeks of gestation or later and, when indicated, optimal chemoprophylaxis.

CONCLUSION

Universal prenatal GBS screening was implemented widely in Tennessee, although the timing of screening and administration of chemoprophylaxis often were not optimal. A substantial burden of early-onset GBS disease occurs despite optimal prenatal screening and chemoprophylaxis, suggesting that alternative strategies, such as vaccination, are needed.

LEVEL OF EVIDENCE

II.

Effect of prenatal and perinatal antibiotics on maternal health in Malawi, Tanzania, and Zambia

OBJECTIVE

We assessed the effect of prenatal and peripartum antibiotics on maternal morbidity and mortality among HIV-infected and uninfected women.

METHODS

A multicenter trial was conducted at clinical sites in 4 Sub-Saharan African cities: Blantyre and Lilongwe, Malawi; Dar es Salaam, Tanzania; and Lusaka, Zambia. A total of 1558 HIV-infected and 271 uninfected pregnant women who were eligible to receive both the prenatal and peripartum antibiotic/placebo regimens were enrolled. Pregnant women were interviewed at 20-24 weeks of gestation and a physical examination was performed. Women were randomized to receive either antibiotics or placebo. At the 26-30 week visit, participants were given antibiotics or placebo to be taken every 4 hours beginning at the onset of labor and continuing after delivery 3 times a day until a 1-week course was completed. Logistic regression and Cox proportional hazards models were used.

RESULTS

There were no significant differences between the antibiotic and placebo groups for medical conditions, obstetric complications, physical examination findings, puerperal sepsis, and death in either the HIV-infected or the uninfected cohort.

CONCLUSION

Administration of study antibiotics during pregnancy had no effect on maternal morbidity and mortality among HIV-infected and uninfected pregnant women.

Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review

OBJECTIVE

To review the current status of antibiotic prophylaxis for cesarean delivery, emerging strategies to enhance the effectiveness of antibiotic prophylaxis in reducing postcesarean infection, and the implications of the emerging practices.

DATA SOURCES

We conducted a full PubMed (January 1966 to July 2008) search using the key words "cesarean" and "antibiotic prophylaxis." A total of 277 articles were identified and supplemented by a bibliographic search.

METHODS OF STUDY SELECTION

We selected a total of 15 studies, which included all published clinical trials, meta-analyses of clinical trials, and observational studies evaluating either the timing of antibiotics or the use of extended-spectrum prophylaxis. We also reviewed nine reports involving national recommendations or technical reviews supporting current standards for antibiotic prophylaxis.

TABULATION, INTEGRATION, AND RESULTS

We conducted an analytic review and tabulation of selected studies without further meta-analysis. Although current guidelines for antibiotic prophylaxis recommend the administration of narrow-spectrum antibiotics (cefazolin) after clamping of the umbilical cord, the data suggest that antibiotic administration before surgical incision or the use of extended-spectrum regimens (involving azithromycin or metronidazole) after cord clamp may reduce postcesarean maternal infection by up to 50%. However, these two strategies have not been compared with each other. In addition, their effect on neonatal infection or infection with resistant organisms warrants further study.

CONCLUSION

The use of either cefazolin alone before surgical incision or an extended-spectrum regimen after cord clamp seems to be associated with a reduction in postcesarean maternal infection. Confirmatory studies focusing additionally on neonatal outcomes and the effect on resistant organisms, as well as studies comparing both strategies, are needed.

When should we perform prophylactic antibiotics in elective cesarean cases?

OBJECTIVE

The aim of this study was to determine whether the timing of prophylactic antibiotics at cesarean delivery influences maternal and neonatal infectious morbidity.

STUDY DESIGN

This was a prospective, randomized trial. Four hundred patients that underwent elective cesarean section between June and December 2007 formed the study population. Eleven patients were excluded from the study because they needed transfusion during the cesarean section. The population was divided into two groups: Group A, antibiotic prophylaxis was applied to 194 women before skin incision and Group B, antibiotic prophylaxis was applied to 195 women after umbilical cord clamping. The occurrence of endomyometritis/endometritis, wound infection, febrile morbidity, total infectious morbidity, and neonatal complications were compared.

RESULTS

There were 389 patients enrolled. No demographic differences were observed between groups. No significant difference was found between the groups for total infectious morbidity [relative risk (RR) 1.39, 95% confidence interval (CI) 0.71-2.69] and endometritis (RR 1.40, 95% CI 0.43-4.51). There was no increase in neonatal sepsis (RR 1.47, 95% CI 0.61-3.53), sepsis workup (RR 1.35, 95% CI 0.75-2.42), need for neonatal intensive care (RR 1.77, 95% CI 0.51-6.16), and intensive care stay period (P = 0.16).

CONCLUSIONS

Time of antibiotic prophylaxis application does not change maternal infectious morbidity in cesarean section deliveries. Preoperative prophylaxis application does not affect neonate morbidity rates as stated in literature.

Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections

OBJECTIVE

The purpose of this study was to examine the effect of a change in policy regarding the timing of antibiotic administration on the rates of postcesarean delivery surgical-site infections (SSI).

STUDY DESIGN

This was a retrospective cohort study of 1316 term, singleton cesarean deliveries at 1 institution. A policy change was instituted wherein prophylactic antibiotics were given before skin incision rather than after cord clamp. The primary outcome that was examined was SSI; secondary outcomes were the rates of endometritis and cellulitis. Multivariable regression was performed to control for potential confounders.

RESULTS

The overall rate of SSI fell from 6.4-2.5% (P = .002). When we controlled for potential confounders, there was a decline in overall SSI with an adjusted odds ratio (aOR) of 0.33 (95% CI, 0.14,0.76), a decrease in endometritis (aOR, 0.34; 95% CI, 0.13,0.92), and a trend towards a decrease in cellulitis (aOR, 0.22; 95% CI, 0.05,1.22).

CONCLUSION

At our institution, a change in policy to administer prophylactic antibiotics before skin incision led to a significant decline in postcesarean delivery SSIs.

Timing of perioperative antibiotics for cesarean delivery: a metaanalysis

OBJECTIVE

The purpose of this study was to summarize the available evidence on timing of perioperative antibiotics for cesarean delivery.

STUDY DESIGN

We searched the literature for studies that compare prophylactic antibiotics for cesarean delivery that are given before the procedure vs at cord clamping. Only randomized controlled trials were included.

RESULTS

Preoperative administration significantly reduced the risk of postpartum endometritis (relative risk [RR], 0.47; 95% CI, 0.26-0.85; P = .012) and total infectious morbidity (RR, 0.50; 95% CI, 0.33-0.78; P = .002). There was a trend toward lower risk of wound infection (RR, 0.60; 95% CI, 0.30-1.21; P = .15). Preoperative administration of antibiotics did not significantly affect suspected neonatal sepsis that requires a workup (RR, 1; 95% CI, 0.70-1.42), proven sepsis (RR, 0.93; 95% CI, 0.45-1.96), or neonatal intensive care unit admissions (RR, 1.07 95% CI, 0.51-2.24). There was no significant heterogeneity between the randomized controlled trials.

CONCLUSION

There is strong evidence that antibiotic prophylaxis for cesarean delivery that is given before skin incision, rather than after cord clamping, decreases the incidence of postpartum endometritis and total infectious morbidities, without affecting neonatal outcomes.