Systemic antibiotic prophylaxis in elective cesarean delivery

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean section. Although guidelines endorse the use of prophylactic antibiotics for women undergoing cesarean section, there is not uniform implementation of this recommendation. This is an update of a Cochrane review first published in 1995 and last updated in 2010.

OBJECTIVES

To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. The clinically important primary outcomes were wound infection, endometritis, serious maternal infectious complications and adverse effects on the infant. We presented dichotomous data as risk ratios (RR), with 95% confidence intervals (CIs) and combined trials in meta-analyses. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We identified 95 studies enrolling over 15,000 women. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection (RR 0.40, 95% CI 0.35 to 0.46, 82 studies, 14,407 women), endometritis (RR 0.38, 95% CI 0.34 to 0.42, 83 studies, 13,548 women) and maternal serious infectious complications (RR 0.31, 95% CI 0.20 to 0.49, 32 studies, 6159 women). When only studies that included women undergoing an elective cesarean section were analyzed, there was also a reduction in the incidence of wound infections (RR 0.62, 95% CI 0.47 to 0.82, 17 studies, 3537 women) and endometritis (RR 0.38, 95% CI 0.24 to 0.61, 15 studies, 2502 women) with prophylactic antibiotics. Similar estimates of effect were seen whether the antibiotics were administered before the cord was clamped or after. The effect of different antibiotic regimens was studied and similar reductions in the incidence of infections were seen for most of the antibiotics and combinations.There were no data on which to estimate the effect of maternal administration of antibiotics on infant outcomes. No studies systematically collected and reported on adverse infant outcomes nor the effect of antibiotics on the developing infant immune system. No studies reported on the incidence of oral candidiasis (thrush) in babies. Maternal adverse effects were also rarely described.We judged the evidence for antibiotic treatment compared with no treatment to be of moderate quality; most studies lacked an adequate description of methods and were assessed as being at unclear risk of bias.

AUTHORS' CONCLUSIONS

The conclusions of this review support the recommendation that prophylactic antibiotics should be routinely administered to all women undergoing cesarean section to prevent infection. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection, endometritis and serious infectious complications by 60% to 70%. There were few data on adverse effects and no information on the effect of antibiotics on the baby, making the assessment of overall benefits and harms difficult. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is beneficial for women but there is uncertainty about the consequences for the baby.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean section. Routine prophylaxis with antibiotics may reduce this risk and should be assessed in terms of benefits and harms.

OBJECTIVES

To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009).

SELECTION CRITERIA

Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

MAIN RESULTS

We identified 86 studies involving over 13,000 women. Prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of febrile morbidity (average risk ratio (RR) 0.45; 95% confidence interval (CI) 0.39 to 0.51, 50 studies, 8141 women), wound infection (average RR 0.39; 95% CI 0.32 to 0.48, 77 studies, 11,961 women), endometritis (RR 0.38; 95% CI 0.34 to 0.42, 79 studies, 12,142 women) and serious maternal infectious complications (RR 0.31; 95% CI 0.19 to 0.48, 31 studies, 5047 women). No conclusions can be made about other maternal adverse effects from these studies (RR 2.43; 95% CI 1.00 to 5.90, 13 studies, 2131 women). None of the 86 studies reported infant adverse outcomes and in particular there was no assessment of infant oral thrush. There was no systematic collection of data on bacterial drug resistance. The findings were similar whether the cesarean section was elective or non elective, and whether the antibiotic was given before or after umbilical cord clamping. Overall, the methodological quality of the trials was unclear and in only a few studies was it obvious that potential other sources of bias had been adequately addressed.

AUTHORS' CONCLUSIONS

Endometritis was reduced by two thirds to three quarters and a decrease in wound infection was also identified. However, there was incomplete information collected about potential adverse effects, including the effect of antibiotics on the baby, making the assessment of overall benefits and harms complicated. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is clearly beneficial for women but there is uncertainty about the consequences for the baby.

WITHDRAWAN. Antibiotic prophylaxis for cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is cesarean delivery.

OBJECTIVES

The objective of this review was to assess the effects of prophylactic antibiotic treatment on infectious complications in women undergoing cesarean delivery.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (January 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001).

SELECTION CRITERIA

Randomized trials comparing antibiotic prophylaxis or no treatment for both elective and non-elective cesarean section.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Eighty-one trials were included. Use of prophylactic antibiotics in women undergoing cesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after cesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups: the relative risk (RR) for endometritis for elective cesarean section (number of women = 2037) was 0.38 (95% confidence interval (CI) 0.22 to 0.64); the RR for non-elective cesarean section (n = 2132) was 0.39 (95% CI 0.34 to 0.46); and the RR for all patients (n = 11,937) was 0.39 (95% CI 0.31 to 0.43). Wound infections were also reduced: for elective cesarean section (n = 2015) RR 0.73 (95% CI 0.53 to 0.99); for non-elective cesarean section (n = 2780) RR 0.36 95% CI 0.26 to 0.51]; and for all patients (n = 11,142) RR 0.41 (95% CI 0.29 to 0.43).

AUTHORS' CONCLUSIONS

The reduction of endometritis by two thirds to three quarters and a decrease in wound infections justifies a policy of recommending prophylactic antibiotics to women undergoing elective or non-elective cesarean section.

Surgical site infection following elective Caesarian section: a case-control study of postdischarge surveillance

OBJECTIVES

To ascertain the incidence of postoperative surgical site infection (SSI) following elective Caesarean section (CS) and to compare demographic characteristics and antibiotic administration between infected cases and noninfected control subjects.

METHODS

We conducted a retrospective case-control study of patients undergoing elective CS between 1996 and 2002 at a tertiary centre. Infection-control personnel attempted to contact by telephone all women who had had Caesarean sections, 1 month after their surgery. The women they reached were asked to complete a questionnaire based on CDC-validated criteria for infection to determine whether SSI had occurred. Control subjects without SSI were matched on the basis of having had an elective CS and by date of surgery. We then reviewed the hospital records of both groups.

RESULTS

Over the study period, 1250 elective Caesarean sections were performed and 124 infected cases were identified, giving an overall SSI incidence of 9.9%. Of the 342 women reviewed (124 cases, 218 control subjects), 23% received prophylactic intraoperative antibiotics. Cases and control subjects differed significantly in terms of estimated blood loss, with fewer control subjects having excessive blood loss (P = 0.04). Among those women receiving postoperative antibiotics, case subjects received a significantly higher number of doses than did control subjects (P = 0.003). The groups did not differ significantly in terms of overall antibiotic administration or other demographic variables.

CONCLUSIONS

The incidence of SSI following elective CS according to postdischarge surveillance was 9.9%, which is higher than expected for a low-risk procedure. Because follow-up was not possible for all cases, this incidence may be an underestimate. Underuse of antimicrobial prophylaxis may also be a contributing factor, because prophylactic antibiotics were administered in less than 25% of cases.

A randomised controlled trial of antibiotic prophylaxis in elective caesarean delivery

OBJECTIVE

To determine whether prophylactic antibiotic administration using cefoxitin at the time of elective caesarean section significantly reduces infectious morbidity.

SETTING

A tertiary teaching hospital in a large urban city in South Africa.

PARTICIPANTS

Women undergoing elective caesarean section.

DESIGN

A prospective, double-blind randomised placebo-controlled trial.

METHODS

Four hundred and eighty women undergoing elective caesarean section had cefoxitin or placebo administration after umbilical cord clamping. Postpartum complications including febrile morbidity, wound infection, endometritis, urinary tract infection, pneumonia and transient postpartum fever were recorded, as were the duration of hospital stay and the need for therapeutic antibiotics.

RESULTS

Wound infection was the most common complication occurring in 13.3% and 12.5% of women in the placebo and cefoxitin groups, respectively. Prophylactic antibiotics did not decrease febrile morbidity, wound infection, endometritis, urinary tract infection and pneumonia. Women who received cefoxitin stayed on average a day less in hospital than those who received placebo (6.9 vs 7.8 days, risk difference 0.94 CI 1.57 - 0.31 days). Eleven women (4.6%) in the placebo group and eight (3.4%) in the cefoxitin group had microbiological evidence of wound infection. Staphylococcus aureus was the most common pathogen (43%) isolated. Similar proportions in both groups (6.3% placebo and 5.1% cefoxitin) required a course of therapeutic antibiotics.

CONCLUSION

Antibiotic prophylaxis with cefoxitin in elective caesarean section did not reduce post-operative infectious morbidity in this double-blind randomised placebo controlled trial.

Techniques for performing caesarean section

In many countries caesarean section has become the mode of delivery in over a quarter of all births. Safety of the mother and cost are the two main areas of concern. Various studies on the techniques of performing a caesarean section have focused on reducing the operating time, blood loss, wound infection and cost. Given the fact that caesarean section is the most commonly performed operation in obstetrics, it is important that trainers and trainees are familiar with the basic surgical techniques and that best practice is followed. At the same time surgeons should take necessary precautions to reduce their risk of exposure to Hepatitis B and HIV. The skin incision and entry into abdominal cavity is best achieved by the modified Cohen's incision. The lower segment transverse uterine incision has stood the test of time over a period of 75 years and remains the best way to enter the uterus. Closure of the uterus in single layer appears to be acceptable, whenever technically possible. Placental delivery should be by controlled cord traction after spontaneous expulsion. Closure of the visceral and parietal layers of the peritoneum no longer seems to be necessary. Obliteration of space in the subcutaneous layer, either by suture or by suction, seems to reduce wound disruption. These issues are being considered in the CAESAR randomized controlled trial of surgical techniques currently underway in England.Prophylactic antibiotics are mandatory in preventing post-operative morbidity. Many of the above mentioned steps have been tested in randomized trials. Further studies are needed to examine a wide range of questions arising from this review, e.g. best position of the patient, the value of exteriorization of the uterus whilst repairing the uterus, and the use of agents to relax the uterus in difficult deliveries.

The routine use of cefazolin in cesarean section

OBJECTIVE

To determine the effectiveness and safety of the routine use of antibiotic prophylaxis in women undergoing cesarean section.

METHOD

Four hundred and forty-one women undergoing cesarean sections were randomly assigned either to a single dose of 1 g intravenous cefazolin or placebo after clamping of the umbilical cord. The primary outcome was the development of post-operative febrile morbidity and the secondary outcomes were infection-related complications.

RESULT

There were 211 emergency and 230 elective cesarean sections. In the emergency cesarean sections, 34 (30.6%) women developed post-operative febrile morbidity in the placebo group compared to 11 (11%) women in the cefazolin group. This was a statistically significant difference (P = 0.001). Similarly, there were statistically significant differences between the two groups in the development of wound infection (P<0.001), use of therapeutic antibiotics (P = 0.001), and post-operative days in hospital (P = 0.003). No statistically significant differences were detected in the development of other infection-related complications. In the elective cesarean sections, no statistically significant differences were found in post-operative febrile morbidity and infection-related complications. There were no serious side effects related to the use of cefazolin.

CONCLUSION

The routine use of a single dose of cefazolin is safe and effective in emergency but not elective cesarean section.

Antibiotic prophylaxis for cesarean section

BACKGROUND

The single most important risk factor for postpartum maternal infection is Cesarean delivery.

OBJECTIVES

The objective of this review was to assess the effects of prophylactic antibiotic treatment on infectious complications in women undergoing Cesarean delivery.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register.

SELECTION CRITERIA

Randomised trials comparing antibiotic prophylaxis or no treatment for both elective and non-elective Cesarean section.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and extracted data.

MAIN RESULTS

Sixty-six trials were included. Use of prophylactic antibiotics in women undergoing Cesarean section substantially reduced the incidence of episodes of fever, endometritis, wound infection, urinary tract infection and serious infection after Cesarean section. The reduction in the risk of endometritis with antibiotics was similar across different patient groups. The relative risk for elective Cesarean section was 0.24, 95% confidence interval 0.11 to 0.48. The relative risk for non-elective Cesarean section was 0.30, 95% confidence interval 0.25 to 0.35. The relative risk for undefined or all patients together was 0.29, 95% confidence interval 0.26 to 0.33. Despite the large number of trials, different populations and different antibiotic regimens, there was no statistically significant heterogeneity.

REVIEWER'S CONCLUSIONS

The reduction of endometritis by two thirds to three quarters justifies a policy of administering prophylactic antibiotics to women undergoing elective or non-elective Cesarean section.