Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.

DATA SOURCES

We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.

METHODS

We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.

RESULTS

The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I2, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I2, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I2, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I2, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I2, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.

CONCLUSION

In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.

Can Clean Delivery Kits Prevent Infections? Lessons from Traditional Birth Attendants in Nigeria

Background

In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as a tool to reduce the risk of infection-related deaths. This study aims to assess the acceptability and effectiveness of CDKs in preventing infections in deliveries attended by traditional birth attendants (TBAs) in Abeokuta, Nigeria.

Methods

The study was a cluster-randomized trial with 67 birth centres/clusters, 453 births/mothers, and 457 babies randomized to intervention or control arms; intervention involved supplementation of delivery with JANMA CDKs. Interviews were conducted at the birth homes, and the primary outcomes were neonatal infection and puerperal fever. The association between infection and perinatal risk factors was tested using the Chi-square and Fisher's exact tests.

Results

CDKs were well accepted by TBAs. The incidence of puerperal fever and neonatal infection was 1.1% and 11.2%, respectively. Concurrent infection was found in 1 (0.22%) of the mother-neonate pair. There was no significant association between any of the sociodemographic factors and infection for both mothers and neonates. PROM and prolonged labour were significantly associated with puerperal infection. All mothers with puerperal fever were from the control group. Compared to the control group, the relative risk of puerperal infection and neonatal infection in the intervention group was 0.08 (0.004 -1.35, p = 0.079) and 0.64 (0.37 to 1.1, p = 0.10), respectively.

Conclusion

CDKs hold promising results in attenuating maternal infections in resource-poor settings. Larger studies with greater statistical power are required to establish statistically reliable information.

Antibiotic Recommendations After Postpartum Uterine Exploration or Instrumentation

Importance

Multiple postpartum scenarios require uterine exploration or instrumentation. These may introduce bacteria into the uterus, increasing the risk of endometritis. Data on the use of antibiotics in these scenarios is limited, resulting in few guidelines and divergent care.

Objective

To describe postpartum scenarios requiring uterine exploration and/or instrumentation, review data on antibiotic prophylaxis, and delineate antibiotic recommendations for each scenario.

Evidence Acquisition

Original articles were obtained from literature search in PubMed, MEDLINE, and OVID; pertinent articles were reviewed.

Results

These recommendations are based on published evidence and professional society guidelines. Antibiotic prophylaxis following manual placenta removal should include 1-time combination of ampicillin 2 g intravenously (IV) or cefazolin 1 g IV, plus metronidazole 500 mg IV. Antibiotic prophylaxis before postpartum dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade should include 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. If the patient in any of the above scenarios has received group B Streptococcus prophylaxis, then only metronidazole is recommended. Further randomized clinical trials are needed to optimize these regimens.

Conclusions

Uterine exploration or instrumentation increases the risk of postpartum endometritis and requires antibiotic prophylaxis. For manual placenta removal, we recommend 1-time combination of ampicillin 2 g IV or cefazolin 1 g IV, plus metronidazole 500 mg IV. For dilation and curettage, manual vacuum aspiration, and intrauterine balloon tamponade, we recommend 1-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV. For patients who already received antibiotic prophylaxis for group B Streptococcus, we recommend 1-time dose of metronidazole 500 mg IV.

Relevance

Providers can utilize our guidelines to prevent postpartum endometritis in these scenarios requiring postpartum uterine exploration and/or instrumentation.

Assisted vaginal births: women who tear or have a surgical cut need prompt antibiotics

The studyHumphries ABC, Linsell L, Knight M. Factors associated with infection after operative vaginal birth-a secondary analysis of a randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth. AJOG 2023;228:328.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/assisted-vaginal-births-women-need-prompt-antibiotics/.

Pre-Caesarean Section Vaginal Preparation with Chlorhexidine Solution in Preventing Puerperal Infectious Morbidities: A Randomized Controlled Trial

BACKGROUND

Globally, peripartum or puerperal infections account for about one tenth of maternal mortality, most of which occur in low income countries. Therefore, vaginal preparation with an antiseptic prior to a caesarean delivery could be considered an additional measure to prevent subsequent infectious morbidities.

OBJECTIVES

To evaluate vaginal preparation with 0.3% chlorhexidine solution in the prevention of endometritis, surgical site infection and post-operative fever following emergency caesarean section.

METHODS

This prospective randomized controlled trial (RCT) was conducted among 240 participants planned for emergency caesarean sections (CS) at term in the University of Medical Sciences Teaching Hospital Complex, Ondo State, Nigeria. Participants were randomised into either group "A" (study) or "B" (control). The former had vaginal preparation with 0.3% chlorhexidine gluconate immediately after anaesthesia while the latter received normal saline. Participants were followed up post-operatively during which clinical features of puerperal infectious morbidities were observed for each during admission as well as 8th and 14th days after delivery.

RESULTS

The rate and risk of endometritis were significantly lower in the study group compared to the control; 5.0% versus 13.3%, respectively (chi squared =5.004; p=0.042, RR = 0.38; 95% CI = 0.15-0.94; p = 0.042; RRR = 0.62). Post-operative fever and surgical site infection, were also lower in the study group compared to the controls, but the difference was not statistically significant.

CONCLUSION

When compared to placebo, pre-caesarean section vaginal preparation with 0.3% chlorhexidine solution significantly reduced only the rate and risk of post-operative endometritis among infectious morbidities.

Preincision adjunctive prophylaxis for cesarean deliveries a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically review the relative effectiveness of preincision cefazolin with or without adjunctive prophylaxis (macrolides or metronidazole) vs cefazolin alone in decreasing the incidence of postcesarean delivery surgical site infections.

DATA SOURCES

We performed a systematic search on PubMed, Ovid EMBASE, Google Scholar, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from October 25, 2020, to November 25, 2020, to identify studies comparing cefazolin with adjunctive macrolides or metronidazole with cefazolin alone. The reference lists were reviewed, and a manual search of articles published after the last database search was performed.

STUDY ELIGIBILITY CRITERIA

Overall, 3 randomized controlled trials and 1 prospective observational study of reproductive-age women undergoing cesarean deliveries were included in the study. We excluded studies of women who were immunocompromised (eg, patients who were HIV positive) or women with a diagnosis of chorioamnionitis before cesarean delivery. All patients received first-line cefazolin (either cefazolin 1 g or 2 g). We compared preincision cefazolin alone with preincision cefazolin plus adjunctive therapy (500 mg, oral or intravenous formulations of azithromycin, metronidazole, or clarithromycin).

METHODS

A total of 6 review authors independently assessed the risk of bias for each study, using the Cochrane Risk of Bias criteria. Synthesis and further appraisal were done using the Grading of Recommendations, Assessment, Development, and Evaluation levels and the American College of Obstetricians and Gynecologists appraisal guidelines. Disagreements were resolved by discussion. Treatment effects were evaluated using meta-analysis, and pooled relative risks and 95% confidence intervals were generated using random-effects models using the Review Manager 5 software (version 5.4.1).

RESULTS

Overall, 3 randomized controlled trials and 1 prospective observational study representing 2613 women met the criteria for inclusion. Significant reductions in surgical site infections (relative risk, 0.46; 95% confidence interval, 0.34-0.63; 3 randomized controlled trials) and the duration of hospital stay (weighted mean difference, -1.46; 95% confidence interval, -2.21 to -0.71; 2 randomized controlled trials) were observed with preincision cefazolin and adjunctive prophylaxis compared with cefazolin alone. No significant difference was observed in maternal febrile morbidity (relative risk, 0.38; 95% confidence interval, 0.11-1.25; 2 randomized controlled trials).

CONCLUSION

Our findings have provided evidence for the use of preincision adjunctive extended-spectrum prophylaxis with cefazolin over cefazolin alone. However, future investigations are required to establish the relative efficacies of different adjunctive antibiotic options.

SARS-CoV-2 (COVID-19) and the Teaching of Ignaz Semmelweis and Florence Nightingale: a Lesson of Public Health from History, after the "Introduction of Handwashing" (1847)

Ignác Fülöp Semmelweis (1818-1865) and Florence Nightingale (1820-1910) were two important personalities in the history of medicine and public health. They dealt with the problem of handwashing. Semmelweis is also known as the "father of hand hygiene"; just in 1847 he discovered the etiology and prophylaxis of puerperal sepsis and imposed a new rule mandating handwashing with chlorine for doctors. He also tried to persuade European scientific community of the advantages of handwashing. During the Crimean War, in Scutary (Turkey), Florence Nightingale strengthened handwashing and other hygiene practices in the war hospital where she worked and her handwashing practices reached a reductions in infections. Unfortunately the hygiene practices promoted by Semmelweis and Nightingale were not widely adopted. In general handwashing promotion stood still for over a century. During current pandemic SARS-CoV-2 (COVID-19) one of the most important way to prevent the spread of the virus is still to wash the hands frequently.

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.

Management of clinical chorioamnionitis: an evidence-based approach

This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.

Routine uterine culture swab during cesarean section and its clinical correlations: A retrospective comparative study

OBJECTIVES

Cesarean sections, particularly non-elective cesareans, are an important risk factor for the development of postpartum endometritis, a leading cause of postpartum febrile morbidity. We evaluated the yield of obtaining routine intrauterine culture during elective and non-elective cesarean sections, in the prevention and management of postpartum endometritis.

STUDY DESIGN

A retrospective comparative study investigating the distribution of uterine cultures obtained immediately after fetus and placenta delivery during cesarean sections performed in a single tertiary hospital during 2017. True pathogenic bacteria were included in the study analysis and considered as positive results, while other contaminant bacteria were excluded.

RESULTS

Positive uterine cultures were identified in 10.7 % (88/821) of cesarean sections, with no significant difference in prevalence between elective and non-elective cesareans. Escherichia coli (E.coli), isolated in 40.9 % of the positive cultures of all women, was the most common organism in non-elective cesareans vs. Group B Streptococcus (GBS) in elective cesareans. Higher rate of positive cultures was found in term vs. preterm cesareans (17.5 % vs 10.5 %, respectively, p-value = 0.04). E.coli was the most frequent pathogen reported in both women with intact membranes or premature rupture of membranes (46.3 % and 47.3 % respectively). Eight women (9.1 %) with positive cultures presented with postpartum fever; all had undergone non-elective cesarean section. In one-third of these cases the empirical antibiotic treatment was adjusted according to the uterine culture results and susceptibility testing results.

CONCLUSIONS

Obtaining routine intrauterine cultures during non-elective cesarean sections might be useful for detecting significant pathogens and tailoring the antibiotic treatment in postpartum endometritis.

Antibiotic prophylaxis for operative vaginal delivery

BACKGROUND

Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017.

OBJECTIVES

To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium).

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach.

MAIN RESULTS

Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials.

AUTHORS' CONCLUSIONS

Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.

Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial

BACKGROUND

Risk factors for maternal infection are clearly recognised, including caesarean section and operative vaginal birth. Antibiotic prophylaxis at caesarean section is widely recommended because there is clear systematic review evidence that it reduces incidence of maternal infection. Current WHO guidelines do not recommend routine antibiotic prophylaxis for women undergoing operative vaginal birth because of insufficient evidence of effectiveness. We aimed to investigate whether antibiotic prophylaxis prevented maternal infection after operative vaginal birth.

METHODS

In a blinded, randomised controlled trial done at 27 UK obstetric units, women (aged ≥16 years) were allocated to receive a single dose of intravenous amoxicillin and clavulanic acid or placebo (saline) following operative vaginal birth at 36 weeks gestation or later. The primary outcome was confirmed or suspected maternal infection within 6 weeks of delivery defined by a new prescription of antibiotics for specific indications, confirmed systemic infection on culture, or endometritis. We did an intention-to-treat analysis. This trial is registered with ISRCTN, number 11166984, and is closed to accrual.

FINDINGS

Between March 13, 2016, and June 13, 2018, 3427 women were randomly assigned to treatment: 1719 to amoxicillin and clavulanic acid, and 1708 to placebo. Seven women withdrew, leaving 1715 in the amoxicillin and clavulanic acid group and 1705 in the placebo groups. Primary outcome data were missing for 195 (6%) women. Significantly fewer women allocated to amoxicillin and clavulanic acid had a confirmed or suspected infection (180 [11%] of 1619) than women allocated to placebo (306 [19%] of 1606; risk ratio 0·58, 95% CI 0·49-0·69; p<0·0001). One woman in the placebo group reported a skin rash and two women in the amoxicillin and clavulanic acid reported other allergic reactions, one of which was reported as a serious adverse event. Two other serious adverse events were reported, neither was considered causally related to the treatment.

INTERPRETATION

This trial shows benefit of a single dose of prophylactic antibiotic after operative vaginal birth and guidance from WHO and other national organisations should be changed to reflect this.

FUNDING

NIHR Health Technology Assessment programme.

[200th birth anniversary of Ignatius Philipp Semmelweis]

Ignaz Phillip Semmelweis's significance for the history of medicine lies in his discovery of the cause of puerperal fever. He discovered it during his work at the First Obstetrics Clinic of the Vienna's Allgemeines Krankenhaus. Since the mentioned Clinic, led by the doctors, had much higher mortality rates of the child-bearing women than the Second Obstetrics Clinic, led by the midwives, he wanted to determine the causes of such a state. He came to the conclusion that puerperal sepsis was transmitted by the doctors and medical students, who after performing the anatomical sections started to perform the births with their hands beforehand washed only with soap. Semmelweis instead proposed a mandatory hand washing in a potassium-hypochlorite solution thus making the mortality at the First equivalent to the mortality at the Second Obstetrics Clinic. Despite this, his discovery was rejected by the established medical circuits.

Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity

BACKGROUND

Infectious morbidities contribute to considerable maternal and perinatal morbidity and mortality, including women at no apparent increased risk of infection. To reduce the incidence of infections, antibiotics are often administered to women after uncomplicated childbirth, particularly in settings where women are at higher risk of puerperal infectious morbidities.

OBJECTIVES

To assess whether routine administration of prophylactic antibiotics to women after normal (uncomplicated) vaginal birth, compared with placebo or no antibiotic prophylaxis, reduces postpartum maternal infectious morbidities and improves outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2017), LILACS, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (22 August 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised trials evaluating the use of prophylactic antibiotics versus placebo or no antibiotic prophylaxis. Trials using a cluster-randomised design would have been eligible for inclusion, but we found none.In future updates of this review, we will include studies published in abstract form only, provided sufficient information is available to assess risks of bias. We will consider excluded abstracts for inclusion once the full publication is available, or the authors provide more information.Trials using a cross-over design are not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors conducted independent assessment of trials for inclusion and risks of bias. They independently extracted data and checked them for accuracy, resolving differences in assessments by discussion. They evaluated methodological quality using standard Cochrane criteria and the GRADE approach.We present the summaries as risk ratios (RRs) and mean difference (MDs) using fixed- or random-effect models. For one primary outcome we found considerable heterogeneity and interaction. We explored further using subgroup analysis to investigate the effects of the randomisation unit. All review authors discussed and interpreted the results.

MAIN RESULTS

One randomised controlled trial (RCT) and two quasi-RCTs contributed data on 1779 women who had uncomplicated vaginal births, comparing different antibiotic regimens with placebo or no treatment. The included trials took place in the 1960s (one trial) and 1990s (two trials). The trials were conducted in France, the USA and Brazil. Antibiotics administered included: oral sulphamethoxypyridazine or chloramphenicol for three to five days, and intravenous amoxicillin and clavulanic acid in a single dose one hour after birth. We rated most of the domains for risk of bias as high risk, with the exception of reporting bias and other potential bias.The quality of evidence ranged from low to very low, based on the GRADE quality assessment, given very serious design limitations of the included studies, few events and wide confidence intervals (CIs) of effect estimates.We found a decrease in the risk of endometritis (RR 0.28, 95% CI 0.09 to 0.83, two trials, 1364 women,very low quality). However, one trial reported zero events for this outcome and we rate the evidence as very low quality. There was little or no difference between groups for the risk of urinary tract infection (RR 0.25, 95% CI 0.05 to 1.19, two trials, 1706 women,low quality), wound infection after episiotomy (reported as wound dehiscence in the included trials) (RR 0.78, 95% CI 0.31 to 1.96, two trials, 1364 women, very low quality) and length of maternal hospital stay in days (MD -0.15, 95% CI -0.31 to 0.01, one trial, 1291 women, very low quality). Cost of care in US dollar equivalent was 2½ times higher in the control group compared to the group receiving antibiotics prophylaxis (USD 3600: USD 9000, one trial, 1291 women). There were few or no differences between treated and control groups for adverse effects of antibiotics (skin rash) reported in one woman in each of the two trials (RR 3.03, 95% CI 0.32 to 28.95, two trials, 1706 women, very low quality). The incidence of severe maternal infectious morbidity, antimicrobial resistance or women's satisfaction with care were not addressed by any of the included studies.

AUTHORS' CONCLUSIONS

Routine administration of antibiotics may reduce the risk of endometritis after uncomplicated vaginal birth. The small number and nature of the trials limit the interpretation of the evidence for application in practice, particularly in settings where women may be at higher risk of developing endometritis. The use of antibiotics did not reduce the incidence of urinary tract infections, wound infection or the length of maternal hospital stay. Antibiotics are not a substitute for infection prevention and control measures around the time of childbirth and the postpartum period. The decision to routinely administer prophylactic antibiotics after normal vaginal births needs to be balanced by patient features, childbirth setting and provider experience, including considerations of the contribution of indiscriminate use of antibiotics to raising antimicrobial resistance. Well-designed and high-powered randomised controlled trials would help to evaluate the added value of routine antibiotic administration as a measure to prevent maternal infections after normal vaginal delivery.

Antibiotic prophylaxis for operative vaginal delivery

BACKGROUND

Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear.

OBJECTIVES

To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps deliveries, or both.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (12 July 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (12 July 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age undergoing vacuum or forceps delivery for any indications. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and methodological quality. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the one included trial using the GRADE approach.

MAIN RESULTS

One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. The trial compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. This trial reported only two out of the nine outcomes specified in this review. Seven women in the group given no antibiotics had endomyometritis and none in prophylactic antibiotic group, the risk reduction was 93% (risk ratio (RR) 0.07; 95% confidence interval (CI) 0.00 to 1.21; low-quality evidence). There was no difference in the length of hospital stay between the two groups (mean difference (MD) 0.09 days; 95% CI -0.23 to 0.41; low-quality evidence). Overall, the risk of bias was judged to be unclear. The quality of the evidence using GRADE was low for both endometritis and maternal length of stay.

AUTHORS' CONCLUSIONS

One small trial was identified reporting only two outcomes. Evidence from this single trial suggests that antibiotic prophylaxis may lead to little or no difference in endometritis or maternal length of stay. There were no data on any other outcomes to evaluate the impact of antibiotic prophylaxis after operative vaginal delivery. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Puerperal sepsis and maternal mortality: what role can new technologies play?

OBJECTIVE

To identify new and underutilized technologies to reduce maternal mortality related to puerperal sepsis in developing countries.

METHOD

Review of current medical literature.

RESULT

The literature indicates that infection-control protocols and evidence-based procedures--including prophylactic antibiotics for cesarean section or preterm rupture of membranes, and updated antibiotic regimens--should be widely adopted. Devices such as hand rubs, needle-disposal systems, and rapid microbiological diagnostic tests can improve compliance and efficiency. Operational research on promising developments like vaginal cleansing with antiseptics, vitamin A supplementation, and prophylactic antibiotics in high-risk women is needed.

CONCLUSION

Sepsis management continues to depend on good implementation of established technologies. Program-based approaches are required to improve uptake.

Endometritis: Managing Persistent Post-Breeding Endometritis

Endometritis was rated as the third most common medical problem encountered in adult horses in North America. It is the leading cause of subfertility in broodmares and is a major contributor to economic loss in the horse breeding industry, with pregnancy rates reported to be as low as 21% in mares with severe endometritis. Endometritis may be categorized as: endometrosis (chronic degenerative endometritis), acute, chronic, active, dormant, subclinical, clinical, and persistent post-breeding. These classifications are not mutually exclusive, and mares may change categories within breeding seasons or estrous cycles or may fit in multiple classifications. This chapter will focus on discussing etiology and management strategies for mares affected by persistent post-breeding endometritis. Overall, these mares are considered subfertile but acceptable pregnancy and foaling rates can be achieved with appropriate breeding management.

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 .).

The Pre-Anschluss Vienna School of Medicine--The surgeons: Ignaz Semmelweis (1818-1865), Theodor Billroth (1829-1894) and Robert Bárány (1876-1936)

A brief history of the Vienna School of Medicine is sketched out from its founding in the mid-18th century by Gerard van Swieten until the Anschluss in March 1938. The pioneering work of Ignaz Semmelweis on the causes and the prevention of puerperal fever is discussed. This is followed by ground-breaking innovations, particularly in abdominal surgery, by Theodor Billroth and by Robert Bárány's Nobel Prize winning work inter alia on defining the pathology and physiology of the human vestibular apparatus. The lives and work of these three outstanding medical practitioners are described, together with their successes and failures. Only Billroth's achievements were appreciated in Vienna during their lifetimes. Semmelweis' work was belittled during his lifetime and he died obscurely in a mental institution. Bárány had to immigrate to Sweden to achieve recognition.

Puerperal infections of the genital tract: a clinical review

Puerperal genital tract infections, although less common in the 21st century, continue to affect maternal mortality and morbidity rates in the United States. Puerperal genital tract infections include endometritis as well as abdominal and perineal wound infections. These infections interrupt postpartum restoration, increase the potential for readmission to a health care facility, and can interfere with maternal-infant bonding. In addition, unrecognized or improperly treated genital tract infection could extend to other sites via venous circulation or the lymphatic system and increase the risk of severe complications or sepsis. Midwives are leaders in education, low rates of intervention, and prompt recognition of deviation from normal. Because puerperal genital tract infection usually begins after discharge, detailed education for women will encourage preventative health care, prompt recognition, and treatment.

[Surviving handwritten signatures of Ignác Semmelweis]

We know only rather few samples of Semmelweis's handwriting and therefore it is important to carefully preserve those we have. The first collection of his manuscripts was published by Antall et al in 1968. During the following 47 years only rather few further samples of his handwriting have been published. Our present collection completes the former list with two previously unknown letters and with an earlier unpublished document signed by Semmelweis. The first document is a certificate written by Semmelweis in 1854 regarding the age of a woman who delivered her child at Szent Rókus Hospital in Pest. The second document includes a request from the Court of Justice towards the Medical Faculty's of the University of Pest regarding the body's opinion in a case of infanticide. The third document is a registration book of a student at the University of Medicine signed by Semmelweis in 1859. Present work attempts to list all of Semmelweis's handwritings known at this moment. The list includes 29 documents written by Semmelweis and further 16 documents signed by him.

[Semmelweis Memorial Speech on the 150. Anniversary of His Death]

Two questions emerge as regards Semmelweis's reception and public memory: 1. How and why could turn Semmelweis into an emblematic representative of 19th-20th century science and medicine? 2. What sort of values and ideals does the fate of Semmelweis represent for us? Author calls our attention to the fact, that in Semmelweis's case, not only his discoveries and thought proved to be of abiding value, but during the last 120 years also his fate inspired a number of scientific, popular, non fictional and fictional analysis all over the world. Semmelweis, as a mythic representative of the modern "scientist" still owes a peculiar place in the common memory. His manipulated and partly intentionally coined story--based however on empirical facts--even today represents a relevant message and plays an important role in the making of the myth of modern physician. Author however emphasizes, that Semmelweis myth represent a somewhat different message for the international public and for the Hungarian one.

Prophylactic antibiotics for manual removal of retained placenta in vaginal birth

BACKGROUND

Retained placenta is a potentially life-threatening condition because of its association with postpartum hemorrhage. Manual removal of placenta increases the likelihood of bacterial contamination in the uterine cavity.

OBJECTIVES

To compare the effectiveness and side-effects of routine antibiotic use for manual removal of placenta in vaginal birth in women who received antibiotic prophylaxis and those who did not and to identify the appropriate regimen of antibiotic prophylaxis for this procedure.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014).

SELECTION CRITERIA

All randomized controlled trials comparing antibiotic prophylaxis and placebo or non antibiotic use to prevent endometritis after manual removal of placenta in vaginal birth.

DATA COLLECTION AND ANALYSIS

There are no included trials. In future updates, if we identify eligible trials, two review authors will independently assess trial quality and extract data

MAIN RESULTS

No studies that met the inclusion criteria were identified.

AUTHORS' CONCLUSIONS

There are no randomized controlled trials to evaluate the effectiveness of antibiotic prophylaxis to prevent endometritis after manual removal of placenta in vaginal birth.

Antibiotic prophylaxis for operative vaginal delivery

BACKGROUND

Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear.

OBJECTIVES

To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps deliveries, or both.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014).

SELECTION CRITERIA

All randomised trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age undergoing vacuum or forceps delivery for any indications. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and methodological quality. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. For this update, we assessed methodological quality of the one included trial using the standard Cochrane criteria and the GRADE approach. We calculated the risk ratio (RR) and mean difference (MD) using a fixed-effect model and all the review authors interpreted and discussed the results.

MAIN RESULTS

One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. This trial identified only two out of the nine outcomes specified in this review. It reported seven women with endomyometritis in the group given no antibiotic and none in prophylactic antibiotic group. This difference did not reach statistical significance, but the risk reduction was 93% (risk ratio (RR) 0.07; 95% confidence interval (CI) 0.00 to 1.21). There was no difference in the length of hospital stay between the two groups (mean difference (MD) 0.09 days; 95% CI -0.23 to 0.41). Overall, the risk of bias was judged as low. The quality of the evidence using GRADE was low for both endometritis and maternal length of stay.

AUTHORS' CONCLUSIONS

The data were too few to make any recommendations for practice. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Enemas during labour

BACKGROUND

Although the use of enemas during labour usually reflects the preference of the attending healthcare provider, enemas may cause discomfort for women.

OBJECTIVES

To assess the effects of enemas applied during the first stage of labour on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013), the Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effectiveness (The Cochrane Library 2013, Issue 5), PubMed (1966 to 31 May 2013), LILACS (31 May 2013), the Search Portal of the International Clinical Trials Registry Platform (ICTRP) (31 May 2013), Health Technology Assessment Program, UK (31 May 2013), Medical Research Council, UK (31 May 2013), The Wellcome Trust, UK (31 May 2013) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion.

MAIN RESULTS

Four RCTs (1917 women) met the inclusion criteria. One study was judged as having a low risk of bias. In the meta-analysis we conducted of two trials, we found no significant difference in infection rates for puerperal women (two RCTs; 594 women; risk ratio (RR) 0.66, 95% confidence (CI) 0.42 to 1.04). No significant differences were found in neonatal umbilical infection rates (two RCTs; 592 women; RR 3.16, 95% CI 0.50 to 19.82; I(2) 0%. In addition, meta-analysis of two studies found that there were no significant differences in the degree of perineal tear between groups. Finally, meta-analysis of two trials found no significant differences in the mean duration of labour.

AUTHORS' CONCLUSIONS

The evidence provided by the four included RCTs shows that enemas do not have a significant beneficial effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction. These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged.

Enemas during labour

BACKGROUND

Although the use of enemas during labour usually reflects the preference of the attending healthcare provider, enemas may cause discomfort for women.

OBJECTIVES

To assess the effects of enemas applied during the first stage of labour on maternal and neonatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 May 2012), the Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effectiveness (The Cochrane Library 2012, Issue 5), PubMed (1966 to 17 May 2012), LILACS (17 May 2012), the Search Portal of the International Clinical Trials Registry Platform (ICTRP) (17 May 2012), Health Technology Assessment Program, UK (17 May 2012), Medical Research Council, UK (17 May 2012), The Wellcome Trust, UK (17 May 2012) and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. 

MAIN RESULTS

Four RCTs (1917 women) met the inclusion criteria. One study was judged as having a low risk of bias. In the meta-analysis we conducted of two trials, we found no significant difference in infection rates for puerperal women (two RCTs; 594 women; risk ratio (RR) 0.66, 95% confidence (CI) 0.42 to 1.04). No significant differences were found in neonatal umbilical infection rates (two RCTs; 592 women; RR 3.16, 95% CI 0.50 to 19.82; I² 0%. In addition, meta-analysis of two studies found that there were no significant differences in the degree of perineal tear between groups. Finally, meta-analysis of two trials found no significant differences in the mean duration of labour.

AUTHORS' CONCLUSIONS

The evidence provided by the four included RCTs shows that enemas do not have a significant beneficial effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction. These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged.

Vigilance must be a priority: maternal genital tract sepsis

Although very rare in the UK, sepsis was the leading cause of direct maternal deaths during 2006-2008, with an increase in community acquired Group A streptococcal infection (CMACE 2011). Most deaths occurred in the postnatal period and were often preceded by a sore throat or other upper respiratory infection, with a clear seasonal pattern. An associated factor was women of BME origin (black or minority ethnic origin). More than half of the deaths followed birth by caesarean section. All antenatal and postnatal women should be offered advice on the signs and symptoms of life threatening conditions, including sepsis. Information should include the importance of good hand and perineal hygiene and of the need to seek immediate medical care if feeling unwell. Relevant NICE guidance should be disseminated and implemented as widely as possible. Greater priority should be given to ensuring all women, particularly those in the most vulnerable groups, are aware of how to access timely and appropriate care.

Use of A Clean Delivery Kit and Factors Associated with Cord Infection and Puerperal Sepsis in Mwanza, Tanzania

Our objective was to determine the effectiveness of an intervention that incorporated education about the "six cleans" with the use of a clean delivery kit in preventing cord infection and puerperal sepsis. A stepped-wedge, cross-sectional study was conducted in 10 surveillance sites across two rural districts of Mwanza Region, Tanzania. A total of 3262 pregnant women between the ages of 17 and 45 years were enrolled in the study. Village health workers administered questionnaires to each mother at 5 days postpartum and inspected the infants' umbilical cord stumps for signs of infection. Newborns whose mothers used the delivery kit were 13.1 times less likely to develop cord infection than infants whose mothers did not use the kit. Furthermore, women who used the kit for delivery were 3.2 times less likely to develop puerperal sepsis than women who did not use the kit. Women who bathed before delivery were 2.6 times less likely to develop puerperal sepsis than women who did not bathe, and their infants were 3.9 times less likely to develop cord infection. Single-use delivery kits, when combined with education about clean delivery, can have a positive impact on the health of women and their newborns by significantly decreasing the likelihood of developing puerperal sepsis or cord infection.

Ampicillin/sulbactam versus cefuroxime as antimicrobial prophylaxis for cesarean delivery: a randomized study

BACKGROUND

The efficacy and safety of a single dose of ampicillin/sulbactam compared to a single dose of cefuroxime at cord clamp for prevention of post-cesarean infectious morbidity has not been assessed.

METHODS

Women scheduled for cesarean delivery were randomized to receive a single dose of either 3 g of ampicillin-sulbactam or 1.5 g of cefuroxime intravenously, after umbilical cord clamping. An evaluation for development of postoperative infections and risk factor analysis was performed.

RESULTS

One hundred and seventy-six patients (median age 28 yrs, IQR: 24-32) were enrolled in the study during the period July 2004-July 2005. Eighty-five (48.3%) received cefuroxime prophylaxis and 91 (51.7%) ampicillin/sulbactam. Postoperative infection developed in 5 of 86 (5.9%) patients that received cefuroxime compared to 8 of 91 (8.8%) patients that received ampicillin/sulbactam (p=0.6). In univariate analyses 6 or more vaginal examinations prior to the operation (p=0.004), membrane rupture for more than 6 hours (p=0.08) and blood loss greater than 500 ml (p=0.018) were associated with developing a postoperative surgical site infection (SSI). In logistic regression having 6 or more vaginal examinations was the most significant risk factor for a postoperative SSI (OR 6.8, 95% CI: 1.4-33.4, p=0.019). Regular prenatal follow-up was associated with a protective effect (OR 0.04, 95% CI: 0.005-0.36, p=0.004).

CONCLUSIONS

Ampicillin/sulbactam was as safe and effective as cefuroxime when administered for the prevention of infections following cesarean delivery.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01138852.

[András Jósa, the physician]

András Jósa was the most important and renowned physician in county Szabolcs (Hungary) in the 19th-20th centuries. Author outlines his biography and analyses his medical activity. Present article is based on a memorial lecture given at the meeting of the Hungarian Society for the History of Medicine in Budapest 24th September 2009.

[Clinical statistical study on puerperal sepsis risk factors]

The aim of this study was to assess some risk factors involved in puerperal sepsis, such as: cesarean delivery, diabetes mellitus, preterm delivery and obesity, history of infections and anemia. The authors highlighted that new prevention methods and techniques could reduce the incidence and severity of post-cesarean puerperal sepsis (uterine infarction, peritonitis, toxic shock syndrome with Group A streptococcus).

Impact of clean delivery-kit use on newborn umbilical cord and maternal puerperal infections in Egypt

This cross-sectional cohort study explored the impact of the use of clean delivery-kit (CDK) on morbidity due to newborn umbilical cord and maternal puerperal infections. Kits were distributed from primary-care facilities, and birth attendants received training on kit-use. A nurse visited 334 women during the first week postpartum to administer a structured questionnaire and conduct a physical examination of the neonate and the mother. Results of bivariate analysis showed that neonates of mothers who used a CDK were less likely to develop cord infection (p = 0.025), and mothers who used a CDK were less likely to develop puerperal sepsis (p = 0.024). Results of multiple logistic regression analysis showed an independent association between decreased cord infection and kit-use [odds ratio (OR) = 0.42, 95% confidence interval (CI) 0.18-0.97, p = 0.041)]. Mothers who used a CDK also had considerably lower rates of puerperal infection (OR = 0.11, 95% CI 0.01-1.06), although the statistical strength of the association was of borderline significance (p = 0.057). The use of CDK was associated with reductions in umbilical cord and puerperal infections.

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.

[Evaluation of antimicrobial prophylaxis after normal delivery]

In Japan, as a measure to prevent puerperal infection, oral antimicrobial prophylaxis has been conducted after delivery in many maternity clinics. However, there are only a few reports on the evidence supporting the validity of antimicrobial prophylaxis following normal delivery. There is concern that unnecessary antimicrobial administration may be conducted in such clinics. In the present study, the puerperal females after normal delivery were placed on different treatments. A group of females received no oral antimicrobial administration. The remaining females were given cefteram pivoxil (CFTM-PI) in the two different doses. In this manner, we evaluated usefulness of antimicrobial prophylaxis. We compared three treatment groups with respect to the incidence of infection for the period until the first week after discharge, and obtained the following results: non-antimicrobial prophylaxis group (group A), 5.83%; antimicrobial prophylaxis group (group B), 1.77%; antimicrobial prophylaxis group (group C), 0%. In group B, the puerperal females were orally given CFTM-PI in a total daily dose of 300 mg, three times daily for three days. In group C, the puerperal females were orally given CFTM-PI in a total daily dose of 300 mg, three times daily for five days. The incidence of infection was the lowest in group C which was followed by group B and group A in this order and the significant intergroup difference was recognized (p=0.004). We also compared the total counts of bacteria, aerobes and anaerobes in lochia on the fifth day during the puerperal period with those on the first day in each treatment group. The decrease in bacterial count was the largest in group C, which was followed by group B and group A in this order. Compared with the total bacterial counts obtained on the first day, those obtained on the fifth day decreased significantly (p<0.001). The results of the present study showed usefulness of antimicrobial prophylaxis after normal delivery. As one of the factors, a significant decrease in the count of bacteria in lochia seems to contribute toward producing the satisfactory outcome.

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.

Oliver Wendell Holmes (1809-1894) and his essay on puerperal fever

Doctor, teacher of anatomy, conversationalist, essayist, and poet, in 1843 Holmes combined his medical and literary skills in a masterly dissertation on the epidemiology and prevention of puerperal fever.