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Liu G, Liang J, Bai L, Dou G, Tan K, He X, Zhang J, Ma X, Du X. Different methods of vaginal preparation before cesarean delivery to prevent postoperative infection: a systematic review and network meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100990. [PMID: 37178722 DOI: 10.1016/j.ajogmf.2023.100990] [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] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Precesarean vaginal antisepsis can benefit pregnant women with ruptured membranes. However, in the general population, recent trials have shown mixed results in reducing postoperative infections. This study aimed to systematically review clinical trials and summarize the most suitable vaginal preparations for cesarean delivery in preventing postoperative infection. DATA SOURCES We searched PubMed, Web of Science, Cochrane Library, SinoMed databases, and the ClinicalTrials.gov clinical trials registry for randomized controlled trials and conference presentations (past 20 years, 2003-2022). Reference lists of previous meta-analyses were searched manually. In addition, we conducted subgroup analysis on the basis of whether the studies were conducted in developed or developing countries, whether the membranes were ruptured, and whether patients were in labor. STUDY ELIGIBILITY CRITERIA We included randomized controlled trials comparing vaginal preparation methods for the prevention of postcesarean infection with each other or with negative controls. METHODS Two reviewers independently extracted data and assessed the risk of bias and the certainty of the evidence. The effectiveness of prevention strategies was assessed by frequentist-based network meta-analysis models. The outcomes were endometritis, postoperative fever, and wound infection. RESULTS A total of 23 trials including 10,026 cesarean delivery patients were included in this study. Vaginal preparation methods included 19 iodine-based disinfectants (1%, 5%, and 10% povidone-iodine; 0.4% and 0.5% iodophor) and 4 guanidine-based disinfectants (0.05% and 0.20% chlorhexidine acetate; 1% and 4% chlorhexidine gluconate). Overall, vaginal preparation significantly reduced the risks of endometritis (3.4% vs 8.1%; risk ratio, 0.41 [0.32-0.52]), postoperative fever (7.1% vs 11.4%; risk ratio, 0.58 [0.45-0.74]), and wound infection (4.1% vs 5.4%; risk ratio, 0.73 [0.59-0.90]). With regard to disinfectant type, iodine-based disinfectants (risk ratio, 0.45 [0.35-0.57]) and guanidine-based disinfectants (risk ratio, 0.22 [0.12-0.40]) significantly reduced the risk of endometritis, and iodine-based disinfectants reduced the risk of postoperative fever (risk ratio, 0.58 [0.44-0.77]) and wound infection (risk ratio, 0.75 [0.60-0.94]). With regard to disinfectant concentration, 1% povidone-iodine was most likely to simultaneously reduce the risks of endometritis, postoperative fever, and wound infection. CONCLUSION Preoperative vaginal preparation can significantly reduce the risk of postcesarean infectious diseases (endometritis, postoperative fever, and wound infection); 1% povidone-iodine has particularly outstanding effects.
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Affiliation(s)
- Guan Liu
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liu, Bai, Dou, Tan, He, and Du)
| | - Jia Liang
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liang, Zhang, and Ma)
| | - Liangliang Bai
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liu, Bai, Dou, Tan, He, and Du); Yan'an University, Yan'an, People's Republic of China (Dr Bai)
| | - Gang Dou
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liu, Bai, Dou, Tan, He, and Du); Xi'an Medical University, Xi'an, People's Republic of China (Dr Dou)
| | - Kai Tan
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liu, Bai, Dou, Tan, He, and Du)
| | - Xiaojun He
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liu, Bai, Dou, Tan, He, and Du)
| | - Junru Zhang
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liang, Zhang, and Ma)
| | - Xiangdong Ma
- Department of Obstetrics and Gynecology, Xijing Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liang, Zhang, and Ma)
| | - Xilin Du
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, People's Republic of China (Drs Liu, Bai, Dou, Tan, He, and Du).
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Tara F, Danesteh S, Rezaee M, Geraylow KR, Moodi Ghalibaf A, Moeindarbari S. Effectiveness of postoperative oral administration of cephalexin and metronidazole on surgical site infection among obese women undergoing cesarean section: a randomized, double-blind, placebo-controlled, parallel-group study-phase III. Antimicrob Resist Infect Control 2022; 11:150. [PMID: 36471429 PMCID: PMC9724355 DOI: 10.1186/s13756-022-01191-y] [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: 05/27/2022] [Accepted: 11/30/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Cesarean section (CS) is the most frequently performed surgery in the United States. Compared to vaginal delivery, CS has a higher risk of maternal and neonatal mortality, morbidities, and complications, among which surgical site infection (SSI) is the most common. We aimed at evaluating the effectiveness of postoperative oral administration of cephalexin and metronidazole on SSI among obese women undergoing CS. METHODS We conducted a randomized, double-blind clinical trial comparing the prophylactic effect of oral cephalexin and metronidazole vs cephalexin and placebo on SSI following CS among obese women. who had received preoperative prophylactic cephalosporin antibiotics. The study was conducted at the Ommolbanin Hospital, affiliated with Mashhad University of Medical Sciences from April 2019 to February 2020. RESULT The participants were randomized into the intervention group (n = 210) and the control group (n = 210). At week-1 follow-up, the outcomes were significantly lower in the intervention group as compared to the control group in terms of fever (9% vs 19%, p = 0.003), abnormal discharge from the incision (serous: 8.6% vs 10.5%, purulent: 2.9% vs 16.7%, p < 0.001), incision separation (1% vs 7.1%, p = 0.001), and cellulitis (4.8% vs 13.3%, p = 0.002). At week-2 follow-up, there were no patients in the intervention group with fever, abnormal discharge from the incision, incision separation, or cellulitis and there was a statistically significant difference for fever, abnormal discharge from the incision, and incision separation between the two groups (p < 0.001, p = 0.001, p = 0.014, respectively). CONCLUSION Post-operative administration of cephalexin and metronidazole for 48-h post-cesarean delivery among obese women, in addition to the standard pre-operative prophylaxis, reduced the overall rate of surgical site infection and wound infection symptoms in a 2-week follow-up. Trial registration The study protocol was approved by the Iranian Registry of Clinical Trials (IRCTID: IRCT20200608047685N2) on 2021-03-15.
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Affiliation(s)
- Fatemeh Tara
- grid.411583.a0000 0001 2198 6209Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sina Danesteh
- grid.411583.a0000 0001 2198 6209Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maral Rezaee
- grid.411583.a0000 0001 2198 6209Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kiarash Roustai Geraylow
- grid.411583.a0000 0001 2198 6209Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran ,grid.486769.20000 0004 0384 8779Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran
| | - AmirAli Moodi Ghalibaf
- grid.411701.20000 0004 0417 4622Student Research Committee, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Somayeh Moeindarbari
- grid.411583.a0000 0001 2198 6209Department of Obstetrics and Gynecology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Abstract
This review summarizes the importance of enhanced recovery after surgery (ERAS) implementation for cesarean deliveries (CDs) and explores ERAS elements shared with the non-obstetric surgical population. The Society for Obstetric Anesthesia and Perinatology (SOAP) consensus statement on ERAS for CD is used as a template for the discussion. Suggested areas for research to improve our understanding of ERAS in the obstetric population are delineated. Strategies and examples of anesthesia-specific protocol elements are included.
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Affiliation(s)
- Laura L Sorabella
- Vanderbilt University Medical Center, 1211 Medical Center Drive, VUH 4202, Nashville, TN 37232, USA.
| | - Jeanette R Bauchat
- Vanderbilt University Medical Center, 1211 Medical Center Drive, VUH 4202, Nashville, TN 37232, USA. https://twitter.com/jrbcpyw
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Stone J, Bianco A, Monro J, Overybey JR, Cadet J, Choi KH, Pena J, Robles BN, Mella MT, Matthews KC, Factor SH. Study To Reduce Infection Prior to Elective Cesarean Deliveries (STRIPES): a randomized clinical trial of chlorhexidine. Am J Obstet Gynecol 2020; 223:113.e1-113.e11. [PMID: 32407786 DOI: 10.1016/j.ajog.2020.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Surgical site infections after cesarean delivery are a cause of maternal morbidity and are typically caused by skin microbial flora. Preadmission application of chlorhexidine gluconate using impregnated cloths may decrease surgical site infections by decreasing the abundance of microbial flora. OBJECTIVE To determine whether the application of chlorhexidine gluconate cloths the night before and the morning of scheduled cesarean delivery decreases the risk of surgical site infections by 6 weeks postoperatively compared with placebo. STUDY DESIGN In this single-center, double-blind, placebo-controlled trial, patients were randomized (1:1) to receive either Sage 2% chlorhexidine cloths or Sage Comfort Bath fragrance-free cloths (placebo) to apply to 6 skin sites on the body (neck, shoulders and chest, armpits, arm and hands, abdomen and groin, left leg and foot, right leg and foot, back and buttocks) the night before and after a shower the morning of scheduled cesarean delivery. Routine clinical and operative procedures were followed. The primary outcome was surgical site infections (superficial or deep incisional with or without organ space endometritis) by 6 weeks after cesarean delivery. The secondary outcomes were surgical site infections by 2 weeks and other wound-related complications by 2 and 6 weeks after cesarean delivery. RESULTS From April 2015 to August 2019, 1356 patients were enrolled: 682 were assigned to the chlorhexidine group and 674 to the placebo group. The groups were similar in demographic and medical characteristics. A total of 14 patients were lost to follow-up before cesarean delivery (10 in chlorhexidine and 4 in placebo) and 33 were lost to follow-up after cesarean delivery (10 in chlorhexidine and 23 in placebo). Among the remaining 1309 (97%), no difference was found in surgical site infections by 6 weeks between the 2 groups (2.6% in chlorhexidine vs 3.7% in placebo; P=.24). There were no differences in secondary outcomes at 2 or 6 weeks and no differences in primary outcome in a per-protocol analysis. CONCLUSION Preadmission use of chlorhexidine gluconate cloths compared with placebo does not reduce the risk of surgical site infection after scheduled cesarean deliveries. Following the standard of care guidelines results in a low risk of surgical site infections in this group of patients.
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Roeckner JT, Sanchez-Ramos L, Mitta M, Kovacs A, Kaunitz AM. Povidone-iodine 1% is the most effective vaginal antiseptic for preventing post-cesarean endometritis: a systematic review and network meta-analysis. Am J Obstet Gynecol 2019; 221:261.e1-261.e20. [PMID: 30954518 DOI: 10.1016/j.ajog.2019.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/30/2019] [Accepted: 04/01/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Direct comparison metaanalyses have reported benefits with presurgical vaginal preparation before cesarean delivery for the reduction of endometritis. These reports did not perform a multitreatment comparison of the various antiseptic solutions assessed in previous studies. OBJECTIVE The purpose of this study was to review the literature systematically and quantitate and summarize indirectly the comparative efficacy of antiseptic formulations and their concentrations that are used for the preparation of the vagina before cesarean delivery in the prevention of endometritis and other infectious complications. STUDY DESIGN We used MEDLINE, EMBASE (from their inception to November 2018) and Cochrane databases, biographies, and conference proceedings. We used randomized clinical trials of patients who underwent surgical preparation of the vagina with antiseptic formulations before cesarean delivery with the aim of reducing the risk of infectious morbidity. Our systematic review was registered and followed the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for network meta-analysis guidelines. Network meta-analysis was performed with computerized software and used user-written programs to assess consistency, inconsistency, ranking probabilities, and graphing results. Direct and indirect pairwise comparisons of the various formulations and their concentrations were performed with the use of multivariate random-effects models and metaregression. A frequentist inference method was employed for the fitted model to estimate the ranking probabilities. Subgroup analyses for patients in labor, not in labor, and with ruptured membranes were conducted. RESULTS For the prevention of endometritis, we identified 23 studies that comprised 7097 women who were allocated to the following treatments: povidone-iodine (1%, 5%, 10%), chlorhexidine (0.2%, 0.4%), metronidazole gel, cetrimide, or normal saline solution/no treatment. Direct and indirect pairwise comparisons indicated that, when compared with saline solution or no treatment, all antiseptic formulations decreased rates of endometritis (5.2% vs 9.1%; odds ratio, 0.48; 95% confidence interval, 0.35-0.65; 22 studies/6994 women). Individually, povidone-iodine (odds ratio, 0.43; 95% confidence interval, 0.28-0.64; 16 studies/5968 women), cetrimide (odds ratio, 0.34; 95% confidence interval, 0.13-0.90; 1 study/200 women), and metronidazole (odds ratio, 0.38; 95% confidence interval, 0.16-0.90; 1 study/224 women) significantly reduced the risk of endometritis. Rankings of vaginal preparations indicated that povidone-iodine 1% had the highest probability (72.7%) of being the most effective treatment for the prevention of endometritis. For the secondary outcomes of postoperative wound infection and fever, a significant reduction was found only with povidone-iodine (odds ratio, 0.61; 95% confidence interval, 0.48-0.78; 16 studies/5968 women; and odds ratio, 0.58; 95% confidence interval, 0.40-0.83; 12 studies/4667 women). Subgroup analyses also found that povidone-iodine significantly reduced risk of endometritis for women in labor (odds ratio, 0.42; 95% confidence interval, 0.20-0.88; 5 studies/1211 women), with ruptured membranes(odds ratio, 0.21; 95% confidence interval, 0.10-0.44; 4 studies/476 women), and undergoing planned cesarean delivery (odds ratio, 0.39; 95% confidence interval, 0.27-0.57; 8 studies/1825 women). CONCLUSION Among patients who underwent cesarean delivery, presurgical vaginal irrigation with povidone-iodine had the highest probability of reducing the risk of endometritis, postoperative wound infections, and fever.
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Affiliation(s)
- Jared T Roeckner
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL.
| | - Luis Sanchez-Ramos
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Melanie Mitta
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Kovacs
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
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Abstract
Importance Surgical site infection (SSI) is a common complication of cesarean delivery. Seen in up to 12% of cesarean deliveries, it is a major cause of prolonged hospital stay and a burden to the healthcare system. Interventions and techniques must be identified to decrease the risk of cesarean delivery SSIs. Objective We review the categories of SSI, current studies that have focused on various interventions to decrease SSI, and preoperative, intraoperative, and postoperative recommendations for cesarean delivery SSI prevention. Evidence Acquisition A thorough search of PubMed for all current literature was performed. Various surgical interventions and techniques were reviewed. We included studies that looked at preoperative, intraoperative, and postoperative interventions for SSI prevention. Results We have summarized several surgical interventions and techniques as well as current consensus statements to aid the practitioner in preventing SSIs after cesarean delivery. Conclusions and Relevance Upon analysis of current data and consensus statements pertaining to cesarean deliveries, there are certain preoperative, intraoperative, and postoperative interventions and techniques that can be recommended to decrease the risk of cesarean delivery SSI.
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