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Ekanem E, Ngene NC, Moodley J, Konje J. Prevention of surgical site infection and sepsis in pregnant obese women. Best Pract Res Clin Obstet Gynaecol 2023; 91:102406. [PMID: 37666023 DOI: 10.1016/j.bpobgyn.2023.102406] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/16/2023] [Accepted: 08/06/2023] [Indexed: 09/06/2023]
Abstract
Obesity is a major determinant of health outcomes and is on the increase in women worldwide. It predisposes to surgical site infection (SSI). Risk factors for the SSI include extremes of age, smoking, comorbidities such as hypertension and diabetes, inappropriate vertical abdominal and or uterine wall incisions, increased operating time, subcutaneous layer of 3 cm or more, and unnecessary use of subcutaneous drain. Most bacteria that cause SSIs are human commensals. Common organisms responsible for SSI include Staphylococcus aureus and coliforms such as Proteus mirabilis, and Escherichia coli. A surgeon's gloves post caesarean section in the obese has a preponderance of Firmicutes and Bacteroidetes, which increases SSI risk. The interaction of skin commensals and vaginal microbiome at the surgical incision site increases the risk of SSI in the obese compared to non-obese. Minimizing the risk of SSI involves modification of risk factors, timely treatment of SSI to prevent sepsis and compliance with the recommended care bundles.
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Affiliation(s)
- Emmanuel Ekanem
- Betsi Cadwaladr University Health Board, Ysbyty Gwynedd Hospital, Wales, UK.
| | - Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Obstetrics and Gynaecology, Leratong Hospital, Krugersdorp, South Africa
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of Kwa Zulu-Natal, Durban, South Africa
| | - Justin Konje
- Feto Maternal Center, Al Markhiya, Doha, Qatar; Weill Cornell Medicine, Qatar; Department of Health Sciences, University of Leicester, Leicester, UK
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2
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Coates M, Shield A, Peterson GM, Hussain Z. Prophylactic Cefazolin Dosing in Obesity-a Systematic Review. Obes Surg 2022; 32:3138-3149. [PMID: 35809198 PMCID: PMC9392691 DOI: 10.1007/s11695-022-06196-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 11/02/2022]
Abstract
Currently, there is no consensus on whether a standard 2-g prophylactic cefazolin dose provides sufficient antimicrobial coverage in obese surgical patients. This systematic review analysed both outcome and pharmacokinetic studies, aiming to determine the appropriate cefazolin dose. A systematic search was conducted using 4 databases. In total, 3 outcome and 15 pharmacokinetic studies met the inclusion criteria. All 3 outcome studies concluded that there is no need for increased dose. Also, 9 pharmacokinetic studies reached this conclusion; however, 6 pharmacokinetic studies recommended that 2-g dose is insufficient to achieve adequate plasma or tissue concentrations. The stronger body of evidence supports that 2-g dose of cefazolin is sufficient for surgery lasting up to 4 h; however, large-scale outcome studies are needed to confirm this evidence.
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Affiliation(s)
- Matthew Coates
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia
| | - Alison Shield
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia
| | - Gregory M Peterson
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia.,School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Australia
| | - Zahid Hussain
- Faculty of Health, University of Canberra, 1 Kirinari Street, Bruce, Canberra, ACT, 2617, Australia.
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3
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Application of a Physiologically Based Pharmacokinetic Model to Predict Cefazolin and Cefuroxime Disposition in Obese Pregnant Women Undergoing Caesarean Section. Pharmaceutics 2022; 14:pharmaceutics14061162. [PMID: 35745736 PMCID: PMC9229966 DOI: 10.3390/pharmaceutics14061162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 12/10/2022] Open
Abstract
Intravenous (IV) cefuroxime and cefazolin are used prophylactically in caesarean sections (CS). Currently, there are concerns regarding sub-optimal dosing in obese pregnant women compared to lean pregnant women prior to CS. The current study used a physiologically based pharmacokinetic (PBPK) approach to predict cefazolin and cefuroxime pharmacokinetics in obese pregnant women at the time of CS as well as the duration that these drug concentrations remain above a target concentration (2, 4 or 8 µg/mL or µg/g) in plasma or adipose tissue. Cefazolin and cefuroxime PBPK models were first built using clinical data in lean and in obese non–pregnant populations. Models were then used to predict cefazolin and cefuroxime pharmacokinetics data in lean and obese pregnant populations. Both cefazolin and cefuroxime models sufficiently described their total and free levels in the plasma and in the adipose interstitial fluid (ISF) in non–pregnant and pregnant populations. The obese pregnant cefazolin model predicted adipose exposure adequately at different reference time points and indicated that an IV dose of 2000 mg can maintain unbound plasma and adipose ISF concentration above 8 µg/mL for 3.5 h post dose. Predictions indicated that an IV 1500 mg cefuroxime dose can achieve unbound plasma and unbound ISF cefuroxime concentration of ≥8 µg/mL up to 2 h post dose in obese pregnant women. Re-dosing should be considered if CS was not completed within 2 h post cefuroxime administration for both lean or obese pregnant if cefuroxime concentrations of ≥8 µg/mL is required. A clinical study to measure cefuroxime adipose concentration in pregnant and obese pregnant women is warranted.
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Alrammaal HH, Batchelor HK, Chong HP, Hodgetts Morton V, Morris RK. Prophylactic perioperative cefuroxime levels in plasma and adipose tissue at the time of caesarean section (C-LACE): a protocol for a pilot experimental, prospective study with non-probability sampling to determine interpatient variability. Pilot Feasibility Stud 2021; 7:54. [PMID: 33602323 PMCID: PMC7890388 DOI: 10.1186/s40814-021-00794-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background The aim of the C-LACE study is to measure cefuroxime concentration in plasma and adipose tissue of non-obese and obese pregnant women undergoing caesarean section. Methods This study plans to compare maternal cefuroxime concentrations (plasma and adipose tissue), at the time of skin incision and time of skin closure during a caesarean section from non-obese (body mass index BMI < 30 kg/m2) and obese (BMI ≥ 30 kg/m2) pregnant women. The incidence of post-surgical site infection will also be measured. At least 15 participants are required for each arm (non-obese vs obese) with a total of 30 participants. The study participants will be followed up between 30 and 40 days post-caesarean section to record details of any post-caesarean surgical infection to explore correlations between BMI, measured cefuroxime concentrations and post-caesarean infection rates. Discussion This pilot study will allow the development of a model testing the inter-patient variability in plasma and adipose tissue concentrations of cefuroxime. The results will facilitate the development of a larger study to determine whether differences in cefuroxime plasma and tissue concentration in obese and non-obese women can support the development of a physiologically based pharmacokinetic model. This model can then be used to propose dosing adjustments that can be used in a further trial to optimise cefuroxime dosing for women undergoing caesarean section. Trial registration ISRCTN Registry, ISRCTN17527512. Registered on 26 October 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s40814-021-00794-3.
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Affiliation(s)
- Hanadi H Alrammaal
- School of Pharmacy, Institute of Clinical Sciences, Robert Aitken Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. .,Clinical Pharmacy Department, College of Pharmacy, Umm Al-Qura University, Makkah, Makkah Province, Saudi Arabia.
| | - Hannah K Batchelor
- School of Pharmacy, Institute of Clinical Sciences, Robert Aitken Building, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.,Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, UK
| | - Hsu P Chong
- Rosie Maternity Hospital, Robinson Way, Cambridge, CB2 0SQ, UK.,Department of Fetal and Maternal Medicine, Birmingham Women's and Children's NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK
| | - Victoria Hodgetts Morton
- Department of Fetal and Maternal Medicine, Birmingham Women's and Children's NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK.,Institute for Metabolic and Systems Research, University of Birmingham, Birmingham, UK
| | - R Katie Morris
- Department of Fetal and Maternal Medicine, Birmingham Women's and Children's NHS Foundation Trust, Edgbaston, Birmingham, B15 2TG, UK.,Institute for Metabolic and Systems Research, University of Birmingham, Birmingham, UK
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A Systematic Review and Meta-Analysis of Wound Complications after a Caesarean Section in Obese Women. J Clin Med 2021; 10:jcm10040675. [PMID: 33578671 PMCID: PMC7916387 DOI: 10.3390/jcm10040675] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 12/16/2022] Open
Abstract
(1) Background: Caesarean sections in obese patients are associated with an increased risk of surgical wound complications, including hematomas, seromas, abscesses, dehiscence, and surgical site infections. The aim of the present study is to perform a meta-analysis and systematic review of the current literature focusing on the strategies available to decrease wound complications in this population. (2) Methods: We reviewed the data available from the PubMed and the Science Direct databases concerning wound complications after caesarean sections in obese women. The following key words were used: “caesarean section”, “cesarean section”, “wound complication”, “wound morbidity”, and “wound infection”. A total of 540 papers were retrieved, 40 of which were selected for the final systematic review and whereas 21 articles provided data for meta-analysis. (3) Results: The conducted meta-analyses revealed that the use of prophylactic drainage does not increase the risk of wound complications in obese women after a caesarean sections (pooled OR = 1.32; 95% CI 0.64–2.70, p = 0.45) and that vertical skin incisions increase wound complications (pooled OR = 2.48; 95% CI 1.85–3.32, p < 0.01) in obese women, including extremely obese women. (4) Conclusions: Subcutaneous drainage does not reduce the risk of a wound complications, wound infections, and fever in obese women after caesarean sections. Negative prophylactic pressure wound therapy (NPWT) may reduce the risk of surgical site infections. The evidence of using a prophylactic dose of an antibiotic before the caesarean section is still lacking.
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Allegaert K, Muller AE, Russo F, Schoenmakers S, Deprest J, Koch BCP. Pregnancy-related pharmacokinetics and antimicrobial prophylaxis during fetal surgery, cefazolin and clindamycin as examples. Prenat Diagn 2020; 40:1178-1184. [PMID: 32441341 DOI: 10.1002/pd.5753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 11/09/2022]
Abstract
Antimicrobial prophylaxis during surgery aims to prevent post-operative site infections. For fetal surgery, this includes the fetal and amniotic compartments. Both are deep compartments as drug equilibrium with maternal blood is achieved relatively late. Despite prophylaxis, chorio-amnionitis or endometritis following ex utero intrapartum treatment or fetoscopy occur in 4.13% and 1.45% respectively of the interventions. This review summarizes the observations on two commonly administered antimicrobials (cefazolin, clindamycin) for surgical prophylaxis during pregnancy, with emphasis on the deep compartments. For both compounds, antimicrobial exposure is on target when we consider the maternal and fetal plasma compartment. In contrast, amniotic fluid concentrations-time profiles display a delayed and much more blunted pattern, behaving as deep compartment. For cefazolin, there are data that document further dilution in the setting of polyhydramnios. Along this deep compartment concept, there is some accumulation during repeated administration, modeled for cefazolin and observed for clindamycin. The relative underexposure to antimicrobials in amniotic fluid may be reflected in the pattern of maternal-fetal complications after fetal surgery, and suggest that antimicrobial prophylaxis practices for fetal surgery should be reconsidered. Further studies should be designed by a multidisciplinary team (fetal surgeons, clinical pharmacologists and microbiologists) to facilitate efficient evaluation of antimicrobial prophylaxis.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden MC, The Hague, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Francesca Russo
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Sam Schoenmakers
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium.,Institute for Woman's Health, University College London, London, UK
| | - Birgit C P Koch
- Department of Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
Antimicrobial medications are the most commonly used medications in the neonatal intensive care unit. Antibiotics are used for infection prophylaxis, empiric treatment, and definitive treatment of confirmed infection. The choice of medication should be informed by the epidemiology and microbiology of infection in specific clinical scenarios and by the clinical condition of the infant. Understanding evolving pathogen susceptibility to antimicrobials and key pharmacotherapy determinants in neonates can inform optimal antibiotic use.
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Affiliation(s)
- Sagori Mukhopadhyay
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Kelly C Wade
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Karen M Puopolo
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA.
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Theis KR, Romero R, Winters AD, Greenberg JM, Gomez-Lopez N, Alhousseini A, Bieda J, Maymon E, Pacora P, Fettweis JM, Buck GA, Jefferson KK, Strauss JF, Erez O, Hassan SS. Does the human placenta delivered at term have a microbiota? Results of cultivation, quantitative real-time PCR, 16S rRNA gene sequencing, and metagenomics. Am J Obstet Gynecol 2019; 220:267.e1-267.e39. [PMID: 30832984 DOI: 10.1016/j.ajog.2018.10.018] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND The human placenta has been traditionally viewed as sterile, and microbial invasion of this organ has been associated with adverse pregnancy outcomes. Yet, recent studies that utilized sequencing techniques reported that the human placenta at term contains a unique microbiota. These conclusions are largely based on the results derived from the sequencing of placental samples. However, such an approach carries the risk of capturing background-contaminating DNA (from DNA extraction kits, polymerase chain reaction reagents, and laboratory environments) when low microbial biomass samples are studied. OBJECTIVE To determine whether the human placenta delivered at term in patients without labor who undergo cesarean delivery harbors a resident microbiota ("the assemblage of microorganisms present in a defined niche or environment"). STUDY DESIGN This cross-sectional study included placentas from 29 women who had a cesarean delivery without labor at term. The study also included technical controls to account for potential background-contaminating DNA, inclusive in DNA extraction kits, polymerase chain reaction reagents, and laboratory environments. Bacterial profiles of placental tissues and background technical controls were characterized and compared with the use of bacterial culture, quantitative real-time polymerase chain reaction, 16S ribosomal RNA gene sequencing, and metagenomic surveys. RESULTS (1) Twenty-eight of 29 placental tissues had a negative culture for microorganisms. The microorganisms retrieved by culture from the remaining sample were likely contaminants because corresponding 16S ribosomal RNA genes were not detected in the same sample. (2) Quantitative real-time polymerase chain reaction did not indicate greater abundances of bacterial 16S ribosomal RNA genes in placental tissues than in technical controls. Therefore, there was no evidence of the presence of microorganisms above background contamination from reagents in the placentas. (3) 16S ribosomal RNA gene sequencing did not reveal consistent differences in the composition or structure of bacterial profiles between placental samples and background technical controls. (4) Most of the bacterial sequences obtained from metagenomic surveys of placental tissues were from cyanobacteria, aquatic bacteria, or plant pathogens, which are microbes unlikely to populate the human placenta. Coprobacillus, which constituted 30.5% of the bacterial sequences obtained through metagenomic sequencing of placental samples, was not identified in any of the 16S ribosomal RNA gene surveys of these samples. These observations cast doubt as to whether this organism is really present in the placenta of patients at term not in labor. CONCLUSION With the use of multiple modes of microbiologic inquiry, a resident microbiota could not be identified in human placentas delivered at term from women without labor. A consistently significant difference in the abundance and/or presence of a microbiota between placental tissue and background technical controls could not be found. All cultures of placental tissue, except 1, did not yield bacteria. Incorporating technical controls for potential sources of background-contaminating DNA for studies of low microbial biomass samples, such as the placenta, is necessary to derive reliable conclusions.
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