Single dose versus multiple dose of antibiotic prophylaxis in caesarean section: a systematic review and meta-analysis

A Retrospective Exploration of Pre-operative Antibiotic Prophylaxis with Cefazolin in Cesarean Sections: Implications for Obstetrics and Gynecologic Surgery

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.

Unraveling the Microbial Symphony: Impact of Antibiotics and Probiotics on Infant Gut Ecology and Antibiotic Resistance in the First Six Months of Life

We aimed to examine the effects of antibiotic and probiotic usage on the gut microbiota structure and the presence of antibiotic-resistance genes (ARGs) in infants during the first six months of life. Questionnaires and fecal samples were collected within three days of birth, two months, and six months to assess antibiotic and probiotic exposure. Gut microbiotas were sequenced via 16S rRNA, and ARGs were conducted by qPCR, including beta-lactam (mecA, blaTEM), tetracycline (tetM), fluoroquinolone (qnrS), aminoglycoside (aac(6')-Ib), and macrolide (ermB). Infants were categorized by antibiotic and probiotic usage and stratified by delivery mode, microbial composition, and ARG abundances were compared, and potential correlations were explored. A total of 189 fecal samples were analyzed in this study. The gut microbiota diversity (Chao1 index) was significantly lower in the "only probiotics" (PRO) group compared to the "neither antibiotics nor probiotics" (CON) group at six months for the CS stratification (p = 0.029). Compositionally, the abundance of core genus Bifidobacterium_pseudocatenulatum was less abundant for the antibiotic during delivery (IAP) group than that in the CON group within the first three days (p = 0.009), while core genus Enterococcus_faecium was more abundant in the PRO than that in the CON group (p = 0.021) at two months. ARGs were highly detected, with Enterococcus hosting tetM and Escherichia associated with blaTEM within three days of birth, though no correlation was found between Bifidobacterium and ARGs. These findings emphasized the critical importance of carefully managing antibiotic and probiotic exposures in early life, with implications for promoting lifelong health through preserving a healthy infant gut ecosystem.

GRADE Use in Evidence Syntheses Published in High-Impact-Factor Gynecology and Obstetrics Journals: A Methodological Survey

Objective: To identify and describe the certainty of evidence of gynecology and obstetrics systematic reviews (SRs) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Method: Database searches of SRs using GRADE, published between 1 January 2016 to 31 December 2020, in the 10 "gynecology and obstetrics" journals with the highest impact factor, according to the Journal Citation Report 2019. Selected studies included those SRs using the GRADE approach, used to determine the certainty of evidence. Results: Out of 952 SRs, ninety-six SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Sixty-seven SRs (7.04%) rated the certainty of evidence for specific outcomes. In total, we identified 946 certainty of evidence outcome ratings (n = 614 RCT ratings), ranging from very-low (42.28%) to low (28.44%), moderate (17.65%), and high (11.63%). High and very low certainty of evidence ratings accounted for 2.16% and 71.60% in the SRs of NRSs, respectively, compared with 16.78% and 26.55% in the SRs of RCTs. In the SRs of RCTs and NRSs, certainty of evidence was mainly downgraded due to imprecision and bias risks. Conclusions: More attention needs to be paid to strengthening GRADE acceptance and building knowledge of GRADE methods in gynecology and obstetrics evidence synthesis.

Role of short interpregnancy interval, birth mode, birth practices, and the postpartum vaginal microbiome in preterm birth

There have been widely documented beneficial role of vaginal Lactobacillus species as an important biomarker for vaginal health and healthy pregnancy progression. When translating this to clinical settings, pregnant women with low proportions of Lactobacillus and commensurately high proportion of rich and highly diverse abnormal microbiota are most likely to encounter negative pregnancy outcome such as preterm birth and postpartum complications. However, multiple literatures have also addressed this notion that the absence of a Lactobacillus-dominated microbiota does not appear to directly imply to a diseased condition and may not be a major determinant of negative obstetric outcome. Caesarian delivery is notably a risk factor for preterm birth and postpartum endometritis, yet recent data shows a trend in the overuse of CS across several populations. Growing evidence suggest the potential role of vaginal/uterine cleaning practice during CS procedures in influencing postpartum infections, however there is a controversy that this practice is associated with increased rates of postpartum endometritis. The preponderance of bacterial vaginosis associated bacteria vagitype at postpartum which persist for a long period of time even after lochia regression in some women may suggest why short interpregnancy interval may pose a potential risk for preterm birth, especially multigravidas. While specifically linking a community of microbes in the female reproductive tract or an exact causative infectious agent to preterm birth and postpartum pathologies remains elusive, clinical attention should also be drawn to the potential contribution of other factors such as short interpregnancy interval, birth mode, birth practices and the postpartum vaginal microbiome in preterm birth which is explicitly described in this narrative review.

Is a single dose of commonly used antibiotics effective in preventing maternal infection after cesarean section? A network meta-analysis

Objective

This study aimed to compare the efficacy of different antibiotic classes and dosages in preventing maternal infection after cesarean delivery.

Methods

Databases were searched for randomized controlled trials (RCTs) published between January 1980 and January 2021 on antibiotic use for the prevention of maternal infection after cesarean delivery. The outcomes were endometritis, febrile morbidity, and wound infection, reported as odds ratios (OR) and surface under the cumulative ranking curve analysis scores.

Results

A total of 31 RCTs met the inclusion criteria. In the network meta-analysis (NMA) for endometritis, pooled network OR values indicated that the following interventions were superior to placebo: cephalosporins (OR: 0.18, 95% credibility interval [CrI]: 0.07–0.45), penicillins (OR: 0.19, 95% CrI: 0.07–0.50), penicillins (multiple doses) (OR: 0.20, 95% CrI: 0.05–0.65), combination therapies (OR: 0.22, 95% CrI: 0.09–0.54), and cephalosporins (multiple doses) (OR: 0.25, 95% CrI: 0.08–0.74). In the NMA for febrile morbidity, placebo was more effective than the other interventions. In the NMA for wound infection, pooled network OR values indicated that the following interventions were superior to placebo: penicillin (OR: 0.14, 95% CrI: 0.05–0.37), cephalosporins (OR: 0.19, 95% CrI: 0.08–0.41), cephalosporins (multiple doses) (OR: 0.20, 95% CrI: 0.06–0.58), combination therapies (OR: 0.29, 95% CrI: 0.13–0.57), macrolides (OR: 0.33, 95% CrI: 0.15–0.74), and penicillins (multiple doses) (OR: 0.40, 95% CrI: 0.17–0.91).

Conclusions

Compared with placebo, a single dose of commonly used antibiotics may prevent maternal infection after cesarean delivery. However, the incidence of febrile morbidity was not reduced.

Multicentre point-prevalence survey of antibiotic use and healthcare-associated infections in Ethiopian hospitals

OBJECTIVE

Effective antimicrobial containment strategies such as Antimicrobial Stewardship Programs (ASPs) require comprehensive data on antibiotics use which are scarce in Ethiopia. This study sought to assess antibiotics use and healthcare-associated infections (HCAIs) in Ethiopian public hospitals.

DESIGN

We conducted a cross-sectional study using the WHO point-prevalence survey protocol for systemic antibiotics use and HCAIs for low/middle-income countries.

SETTING

The study was conducted among 10 public hospitals in 2021.

PARTICIPANTS

All patients admitted to adult and paediatric inpatient and emergency wards before or at 08:00 on the survey date were enrolled.

OUTCOME MEASURE

The primary outcome measures were the prevalence of antibiotic use, HCAIs and the hospitals' readiness to implement ASP.

RESULTS

Data were collected from 1820 patient records. None of the surveyed hospitals had functional ASP. The common indication for antibiotics was for HCAIs (40.3%). Pneumonia was the most common bacterial infection (28.6%) followed by clinical sepsis (17.8%). Most treatments were empiric (96.7%) and the overall prevalence of antibiotic use was 63.8% with antibiotics prescription per patient ratio of 1.77. Ceftriaxone was the most commonly prescribed antibiotic (30.4%) followed by metronidazole (15.4%). Age, having HIV infection, ward type, type of hospital, catheterisation and intubation history had significant association with antibiotic use. Patients who were treated in paediatric surgical wards were about four times more likely to be on antibiotics compared with patients treated at an adult emergency ward. Patients on urinary catheter (adjusted OR (AOR)=2.74, 95% CI: 2.04 to 3.68) and intubation device (AOR=2.62, 95% CI: 1.02 to 6.76) were more likely to be on antibiotics than their non-intubated/non-catheterised counterparts. Patients treated at secondary-level hospitals had 0.34 times lower odds of being on antibiotics compared with those in tertiary hospitals.

CONCLUSIONS

Antibiotic use across the surveyed hospitals was common and most were empiric which has both practical and policy implications for strengthening ASP and promoting rational antibiotics use.

Compliance with antibiotic prophylaxis guidelines in caesarean delivery: a retrospective, drug utilization study (indication-prescription type) at an Ecuadorian hospital

BACKGROUND

Preoperative antibiotic prophylaxis is essential for preventing surgical site infection (SSI). The aim of this study was to evaluate compliance with international and local recommendations in caesarean deliveries carried out at the Obstetrics and Gynaecology Service of the Ambato General Hospital, as well as any related health and economic consequences.

METHODS

A retrospective indication-prescription drug utilization study was conducted using data from caesarean deliveries occurred in 2018. A clinical pharmacist assessed guidelines compliance based on the following criteria: administration of antibiotic prophylaxis, antibiotic selection, dose, time of administration and duration. The relationship between the frequency of SSI and other variables, including guideline compliance, was analysed. The cost associated with the antibiotic used was compared with the theoretical cost considering total compliance with recommendations. Descriptive statistics, Odds Ratio and Pearson Chi Square were used for data analysis by IBM SPSS Statistics version 25.

RESULTS

The study included 814 patients with an average age of 30.87 ± 5.50 years old. Among the caesarean sections, 68.67% were emergency interventions; 3.44% lasted longer than four hours and in 0.25% of the deliveries blood loss was greater than 1.5 L. Only 69.90% of patients received preoperative antibiotic prophylaxis; however, 100% received postoperative antibiotic treatment despite disagreement with guideline recommendations (duration: 6.75 ± 1.39 days). The use of antibiotic prophylaxis was more frequent in scheduled than in emergency caesarean sections (OR = 2.79, P = 0.000). Nevertheless, the timing of administration, antibiotic selection and dose were more closely adhered to guideline recommendations. The incidence of surgical site infection was 1.35%, but tended to increase in patients who had not received preoperative antibiotic prophylaxis (OR = 1.33, P = 0.649). Also, a significant relationship was found between SSI and patient age (χ2 = 8.08, P = 0.036). The mean expenditure on antibiotics per patient was 5.7 times greater than that the cost derived from compliance with international recommendations.

CONCLUSIONS

Surgical antibiotic prophylaxis compliance was far below guideline recommendations, especially with respect to implementation and duration. This not only poses a risk to patients but leads to unnecessary expenditure on medicines. Therefore, this justifies the need for educational interventions and the implementation of institutional protocols involving pharmacists.

Antibiotic use among hospitalized patients in northern Nigeria: a multicenter point-prevalence survey

BACKGROUND

The evaluation of antibiotic use among hospitalized patients is a primary step required to design antibiotic stewardship intervention. There is paucity of data describing antibiotic use in hospitals across Northern Nigeria. This study evaluates the prevalence and indications for antibiotic use among inpatients in three acute care hospitals.

METHODS

A point-prevalence survey was conducted among patients in the wards before or at 8.00 a.m. on the day of the survey, using the point-prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals protocol. The survey was conducted between April and May 2019. The medical records of the patients were reviewed by a clinical pharmacist with the support of physicians and nurses.

RESULTS

Overall, 80.1% (257/321) of the patients used at least one antibiotic on the day of the survey. The prevalence of antibiotic use ranged from 72.9% in obstetrics and gynecology to 94.6% in pediatric medical specialty. Community acquired infections (38.7%) and surgical antibiotic prophylaxis (22.5%) were the most common indications. Surgical antibiotic prophylaxis was used or scheduled to be used for more than a day in all the cases. Metronidazole (30.5%), ciprofloxacin (17.1%), ceftriaxone (16.8%), amoxicillin-clavulanate (12.5%) and gentamicin (11.8%) were the most commonly prescribed antibiotics. Overall, broad spectrum antibiotics represented one-third of all the prescriptions. The change of initial antibiotic prescription was reported in one-third of the patients and the reasons include a switch to oral antibiotic (28.5%), escalation (4.5%) and de-escalation (3.6%). Of the 257 patients with an antibiotic prescription, 6.2% had redundant antibiotic combinations.

CONCLUSION

The prevalence of antibiotic use was high with one in three prescriptions having a broad spectrum antibiotic. Prolonged use of surgical antibiotic prophylaxis and redundant antibiotic combination were observed. Antimicrobial stewardship interventions are recommended in order to reduce the use of antibiotics and promote appropriate antibiotics prescribing.

The relevance of probiotics in Caesarean-born neonates

There is growing interest in the use of probiotics in neonates. In particular, Lactobacillus rhamnosus, L. acidophilus, Bifidobacterium breve and B. longum have been well studied. Caesarean-section (CS)-born infants often lack Lactobacillus spp. and Bifidobacterium spp., which showed increasing evidence in establishing the neonatal immune system. Furthermore, CS increases the difficulties for mothers in initiating and sustaining breastfeeding. Increasing evidence shows CS-born infants are more susceptible to allergy, infections and chronic inflammatory diseases later in life. The number of CS births has increased continuously, now accounting for 35% of all deliveries Australia wide. In this context, probiotics may have a role in establishing a healthy neonatal gut microbiome.

Reducing post-caesarean delivery surgical site infections: a narrative review

Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.

Infections complicating cesarean delivery

PURPOSE OF REVIEW

Cesarean sections are common surgical procedures performed in a healthy population and are unique because of a relatively high rate of postoperative infection. There have been many important advances in understanding the pathogenesis of infection and evaluation of interventions to prevent post cesarean section infections in the last few years. Our purpose in this review is to analyze these new data, discuss unanswered questions, and propose changes in standard of care.

RECENT FINDINGS

Wound closure techniques including subcuticular sutures and subcutaneous suturing have been shown to be effective at reducing surgical site infections. Wound dressings including negative pressure dressings likely do not decrease infection rates. The type, timing, and duration of preoperative prophylactic antibiotics, including adjunctive azithromycin for laboring women and multidose antibiotics in obese women, have also yielded mixed results. Our understanding of normal uterine microbiome and the impact of intrapartum antibiotics on the newborn is emerging.

SUMMARY

The pathogenesis of surgical site infections after Cesarean section is complex and multifactorial. Many interventions to reduce infections have been studied with varying degrees of effectiveness. Despite advances in the area, important questions remain unanswered.

Different regimens of penicillin antibiotics given to women routinely for preventing infection after cesarean section: A systematic review and meta analysis

BACKGROUND

Varied regimens of penicillin antibiotics were given to women for preventing infection after cesarean section, but there is no study compares the effectiveness and safety of them.

METHODS

We searched MEDLINE, Embase, CENTRAL, CNKI, Wanfang, VIP, and CBM Database, and contacted experts in the field and searched reference lists of retrieved studies. We included randomized controlled trials comparing different regimens of penicillin antibiotics given to women after cesarean section. Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction.

RESULTS

A total of 18 randomized controlled trails (involving 3287 pregnant women) were eligible. Compared with after umbilical cord clamping, penicillin antibiotics prophylaxis before skin incision could reduce the risk of endometritis for women undergoing cesarean. Compared with using penicillin antibiotics alone, using antibiotic-inhibitor combination could reduce the risk of endometritis or fever. No statistically significant difference was present between single-dose versus multidose, short term versus long term, intravenous injection versus lavag in the risk of reported outcomes.

CONCLUSION

There is insufficient evidence to draw certain conclusions on which regimen of penicillin antibiotics is the best in this review. Further studies should pay attention to the study design, and besides the outcomes of pregnant women, researchers should focus on the outcomes of newborns.

A Retrospective Surveillance of the Antibiotics Prophylactic Use of Surgical Procedures in Private Hospitals in Indonesia

Background: According to international guidelines, prophylactic antibiotics in elective surgery should be given as a single dose 30 to 60 minutes before the operation is conducted. Postoperative administration of antibiotics should be discontinued 24 hours after surgery to minimize bacterial resistance and to keep control over hospitalization costs. There is a lack of data on the actual antibiotic use around surgical procedures in Indonesia. Objective: This retrospective surveillance study aimed to obtain defined daily doses (DDD) and DDDs per 100 bed days (DDD-100BD) for prophylactically used antibiotics in two private hospitals in Surabaya, East Java. These hospitals are considered to be representative for the current situation in Indonesia. Method: Data from a total of 693 patients over a nearly 1-year period (2016) were collected and evaluated. Results: The overall DDD per patient was 1.5 for hospital A and 1.7 for hospital B. The overall DDD-100BD was 30 for hospital B. Of the 24 antibiotics given prophylactically, ceftriaxone was the most commonly used in both hospitals. Conclusion: There was a clear discrepancy between daily practice in both hospitals and the recommendations in the guidelines. This study shows that better adherence to antibiotic stewardship is needed in Indonesia. Substantial improvements need to be made toward guided precision therapy regarding quantity (dose and frequency), route of administration (prolonged intravenous), and choice of the type of antibiotic.

HIV Infection and risk of postpartum infection, complications and mortality in rural Uganda

HIV infection may increase risk of postpartum infection and infection-related mortality. We hypothesized that postpartum infection incidence and attributable mortality in Mbarara, Uganda would be higher in HIV-infected than HIV-uninfected women. We performed a prospective cohort study of 4231 women presenting to a regional referral hospital in 2015 for delivery or postpartum care. All febrile or hypothermic women, and a subset of randomly selected normothermic women were followed during hospitalization and with 6-week postpartum phone interviews. The primary outcome was in-hospital postpartum infection. Secondary outcomes included in-hospital complications (mortality, re-operation, intensive care unit transfer, need for imaging or blood transfusion) and 6-week mortality. We performed multivariable regression analyses to estimate adjusted differences in each outcome by HIV serostatus. Mean age was 25.2 years and 481 participants (11%) were HIV-infected. Median CD4+ count was 487 (IQR 325, 696) cells/mm³, and 90% of HIV-infected women (193/215 selected for in-depth survey) were on antiretroviral therapy. Overall, 5% (205/4231) of women developed fever or hypothermia. Cumulative in-hospital postpartum infection incidence was 2.0% and did not differ by HIV status (aOR 1.4, 95% CI 0.6-3.3, P = 0.49). However, more HIV-infected women developed postpartum complications (4.4% vs. 1.2%, P = 0.001). In-hospital mortality was rare (2/1768, 0.1%), and remained so at 6 weeks (4/1526, 0.3%), without differences by HIV serostatus (P = 1.0 and 0.31, respectively). For women in rural Uganda with high rates of antiretroviral therapy coverage, HIV infection did not predict postpartum infection or mortality, but was associated with increased risk of postpartum complications.