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When Should We Perform Prophylactic Antibiotics in Elective Cesarean Cases?

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When Should We Perform Prophylactic Antibiotics in Elective Cesarean Cases? Arch Gynecol Obstet (2009) 280:13–18 DOI 10.1007/s00404-008-0845-7 ORIGINAL ARTICLE When should we perform prophylactic antibiotics in elective cesarean cases? Gokhan Yildirim · Kemal Gungorduk · Hamit Zafer Guven · Halil Aslan · Özgü Celikkol · Sinem Sudolmus · Yavuz Ceylan Received: 9 August 2008 / Accepted: 3 November 2008 / Published online: 26 November 2008 © Springer-Verlag 2008 Abstract 1.77, 95% CI 0.51–6.16), and intensive care stay period Objective The aim of this study was to determine whether (P =0.16). the timing of prophylactic antibiotics at cesarean delivery Conclusions Time of antibiotic prophylaxis application inXuences maternal and neonatal infectious morbidity. does not change maternal infectious morbidity in cesarean Study design This was a prospective, randomized trial. section deliveries. Preoperative prophylaxis application Four hundred patients that underwent elective cesarean sec- does not aVect neonate morbidity rates as stated in litera- tion between June and December 2007 formed the study ture. population. Eleven patients were excluded from the study because they needed transfusion during the cesarean sec- Keywords Antibiotic prophylaxis · Cesarean delivery · tion. The population was divided into two groups: Group A, Maternal/neonatal infection antibiotic prophylaxis was applied to 194 women before skin incision and Group B, antibiotic prophylaxis was applied to 195 women after umbilical cord clamping. The Introduction occurrence of endomyometritis/endometritis, wound infec- tion, febrile morbidity, total infectious morbidity, and neo- The most important risk factor in postpartum maternal natal complications were compared. infection is cesarean delivery [1]. Women undergoing Results There were 389 patients enrolled. No demo- cesarean section (C/S) are at 5- to 20-fold greater risk of graphic diVerences were observed between groups. No sig- infection than are women delivering vaginally. Infectious niWcant diVerence was found between the groups for total complications after cesarean delivery are an important infectious morbidity [relative risk (RR) 1.39, 95% conW- cause of maternal morbidity, and can prolong length of hos- dence interval (CI) 0.71–2.69] and endometritis (RR 1.40, pital stay. These include wound infection, postpartum 95% CI 0.43–4.51). There was no increase in neonatal sep- endometritis, and urinary tract infection [2–4]. sis (RR 1.47, 95% CI 0.61–3.53), sepsis workup (RR 1.35, Antibiotic prophylaxis in women who undergo cesarean 95% CI 0.75–2.42), need for neonatal intensive care (RR delivery has been proven to be beneWcial in decreasing infectious morbidities both in high-risk women (e.g., labor- ing, after rupture of membranes), and low-risk patients (e.g., nonlaboring, intact membranes). The 60–70% reduc- G. Yildirim · K. Gungorduk · H. Z. Guven · H. Aslan · tion in endometritis and the 30–65% reduction in wound Ö. Celikkol · S. Sudolmus · Y. Ceylan infection rate prompted the Cochrane library to recommend Department of Obstetrics and Gynecology, Istanbul Bakirkoy Women and Children Hospital, prophylactic antibiotics to women who undergo both elec- Istanbul, Turkey tive and nonelective cesarean delivery [5–9]. First-generation cephalosporin antibiotics are the most & K. Gungorduk ( ) commonly used, agents and are usually administered Kartaltepe Mah. BÂtÂsÂkbaglarorta Sok., No: 13/7 BakÂrköy, Istanbul, Turkey following delivery of the infant after the cord is clamped e-mail: [email protected] [10]. Neither the use of broad-spectrum antimicrobials nor 123 14 Arch Gynecol Obstet (2009) 280:13–18 the administration of additional doses postoperatively has diVerence in postoperative infections, with = 0.05. Four been shown to be superior to a single-dose cephalosporin hundred women who fulWlled the inclusion criteria were regimen [11]. randomly (two parts, block random using sealed, sequen- Optimal timing for prophylactic antibiotic administra- tially distributed envelopes to which the letters A and B had tion is based on animal studies that demonstrate a maxi- been allocated: the letter A to the antibiotic prophylaxis mum protective eVect when adequate tissue antibiotic before skin incision group and the letter B to the antibiotic levels are present prior to bacterial contamination [5]. How- prophylaxis after clamping umbilical cord group; the ever, many clinicians prefer to prevent exposure of the baby patients chose the envelops which were opened by the to antibiotics by starting them after the umbilical cord has investigator, and according to the letters, the group of been clamped. Because, if antibiotics are given before patients were determined) divided into two groups: 200 delivery of the infant and clamping of the umbilical cord, women represented the antibiotic prophylaxis before skin pre-existing neonatal infections might be masked, or there incision group (Group A), and 200 women the antibiotic might be an increased risk for the development of resistant prophylaxis after clamping umbilical cord group (Group organisms [12]. A recent randomized trails found no diVer- B). ence in neonatal septic workups or complications [13, 14]. One gram of cefazolin sodium (cephamezin 1 g There are few randomized controlled studies on timing EczacÂbaoÂ) was used for antibiotic prophylaxis during of antibiotic prophylaxis in cesarean section. Thigpen et al. cesarean section. One gram of cefazolin sodium was [13] concluded that there was no diVerence in infectious applied by mixing it with 50 cm3 normal saline for at least morbidity between preoperative antibiotics and those given 10 min, at most 45 min before skin incision or after clamp- at cord-clamp. On the other hand, Sullivan et al. [14] ing umbilical cord according to the determined prophylaxis reported decrease in both endomyometritis and total post method. No other antimicrobial agents were given unless a cesarean infectious morbidity in a prospective randomized postoperative infection was diagnosed. trial with use of preoperative cefazolin prophylaxis. Before cesarean section, a Foley catheter was inserted, In this prospective randomized study, our aim was to and the abdomen cleaned with Providon-Iod solution. determine whether the timing of prophylactic antibiotics at Pfannenstiel incisions were done on all patients. Thereafter, cesarean delivery inXuences maternal and neonatal infec- the cesarean followed our standard procedure: transverse tious morbidity. lower uterine segment incision and delivery of the fetus and placenta. Suturing of the uterine incision was performed without exteriorization of the uterus. The abdominal wall Methods was closed in two layers. Skin incisions were closed. The postpartum care for both groups was identical, and A randomized controlled study was conducted between included vital signs every 4 h, discontinuation of the Foley June 2007 and December 2007 in the Bakirkoy Maternity catheter and advancement of diet on the Wrst postoperative and Children Diseases Hospital in Istanbul, a tertiary care day. All patients in both groups were observed daily in center for obstetrics and gynecology and pediatrics. This order to assess the following variables: any sign of wound hospital has 16,000 deliveries annually. Women undergo- infection (erythema, swelling, discharge or tenderness) ing elective cesarean section in the hospital without exclu- vaginal discharge, uterine consistency and height, and peri- sion criteria were eligible for this study. Elective cesarean toneal reaction for peritonitis. Clinical signs of urinary tract section was deWned as C/S performed before the presence infection were checked and urinalysis was performed. A of labor. The exclusion criteria were: use of antibiotics dur- complete blood count was assessed 24 h after delivery. The ing the last 24 h, pathology that should be treated with anti- patients were discharged on third postoperative day if there biotics, pre-existing maternal diseases (such as diabetes, was no infection or complication. Patients were followed collagen vascular disease, immune system problems), cho- for 6 weeks postpartum so that infectious complications in rioamnionitis, fever on admission, need of transfusion the puerperium period following abdominal delivery were before or during the cesarean section, ruptured membranes, all included. emergency cesarean section, and preterm cesarean section. The rates of postoperative infectious morbidity (endo- Women who satisWed the inclusion criteria were invited to metritis, wound infection, febrile morbidity, urinary tract participate, and they signed a consent form approved by the infection), estimated blood loss at surgery, and operative institutional review board. time were compared between the two groups. We also eval- In the year preceding this investigation, our institution uated neonatal outcomes including need for admission to had a 20% postcesarean endometritis rate. Using the the neonatal intensive care unit, Apgar score less than 7 at program “Med Calc,” we calculated that a sample size of 5 min, neonatal sepsis and sepsis workup. Neonatal sepsis 197 subjects would provide 80% power to detect a 50% was suspected if tachycardia and/or tachypnea, as well as 123 Arch Gynecol Obstet (2009) 280:13–18 15 an increased white count with bands, was present and was Table 1 Demographic characteristics of the study groups conWrmed by positive blood cultures. Length of stay, Group A Group B P value admission status, and decision to undertake a sepsis workup (n=194) (n = 195) were determined by the neonatologists.
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