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Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery.
Cochrane Database Syst Rev. 2014 Dec 05CD

Abstract

BACKGROUND

Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate.

OBJECTIVES

To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection.

AUTHORS' CONCLUSIONS

Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.

Links

Publisher Full Text (DOI)

Authors+Show Affiliations

Mackeen AD
Division of Maternal Fetal Medicine, Women’s Health Service Line, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17822, USA. dhanya80@hotmail.com.
Packard RE
No affiliation info available
Ota E
No affiliation info available
Berghella V
No affiliation info available
Baxter JK
No affiliation info available

MeSH

Anti-Bacterial AgentsAntibiotic ProphylaxisCesarean SectionDrug Administration ScheduleEndometritisFemaleHumansInjections, IntravenousPregnancyRandomized Controlled Trials as TopicSurgical Wound InfectionUrinary Tract Infections

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

Language

eng

PubMed ID

25479008

Clinical Trial Links

Azithromycin-Prevention in Labor Use Study (A-PLUS)
Tissue Adhesive vs. Sterile Strips After Cesarean Delivery
Vaginal Preparation and Azithromycin to Reduce Post Cesarean Infections

Citation

Mackeen, A Dhanya, et al. "Timing of Intravenous Prophylactic Antibiotics for Preventing Postpartum Infectious Morbidity in Women Undergoing Cesarean Delivery." The Cochrane Database of Systematic Reviews, 2014, p. CD009516.
Mackeen AD, Packard RE, Ota E, et al. Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. Cochrane Database Syst Rev. 2014.
Mackeen, A. D., Packard, R. E., Ota, E., Berghella, V., & Baxter, J. K. (2014). Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. The Cochrane Database of Systematic Reviews, (12), CD009516. https://doi.org/10.1002/14651858.CD009516.pub2
Mackeen AD, et al. Timing of Intravenous Prophylactic Antibiotics for Preventing Postpartum Infectious Morbidity in Women Undergoing Cesarean Delivery. Cochrane Database Syst Rev. 2014 Dec 5;(12)CD009516. PubMed PMID: 25479008.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. AU - Mackeen,A Dhanya, AU - Packard,Roger E, AU - Ota,Erika, AU - Berghella,Vincenzo, AU - Baxter,Jason K, Y1 - 2014/12/05/ PY - 2014/12/6/entrez PY - 2014/12/6/pubmed PY - 2015/1/30/medline SP - CD009516 EP - CD009516 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 12 N2 - BACKGROUND: Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate. OBJECTIVES: To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers. SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS: We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection. AUTHORS' CONCLUSIONS: Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/25479008/Timing_of_intravenous_prophylactic_antibiotics_for_preventing_postpartum_infectious_morbidity_in_women_undergoing_cesarean_delivery_ DB - PRIME DP - Unbound Medicine ER -