INFECTIOUS DISEASES
Preoperative Antibiotic Prophylaxis for Cesarean Delivery Preferred
Source: Costantine MM, Rahman M, Ghulmiyah L, et al. Timing
of perioperative antibiotics for cesarean delivery: a metaanalysis.
Am J Obstet Gynecol. 2008(3);199:301.e1-301.e6; doi: 10.1016/j.
ajog.2008.06.077
I
nvestigators from the Uni-
PICO
versity of Texas Medical Question: Among women who undergo
Branch, Galveston, con- C-section delivery and their newly-born
ducted a metaanalysis of the infants, does the use of preoperative
antibiotic prophylaxis increase or decrease
current evidence regarding tim- the risk for infection?
ing of antibiotic prophylaxis for
Question type: Intervention
cesarean section (C-section). Study design: Meta-analysis
A search of the literature in-
English was done using PubMed
to identify all published studies on the prophylactic use of antibiot-
ics for C-section, using cesarean delivery, antibiotics, prophylactic
antibiotics, and timing of antibiotics as key words. Bibliographies
of all the relevant articles were reviewed to identify additional refer-
ences.
Only randomized controlled trials (RCT) that compared the use of
antibiotics given at cord clamping to antibiotics given preoperatively
were included. Outcomes of interest included the rate of post-partum
endometritis (primary outcome measure) and wound infection,
other post-partum infection, suspected or confirmed neonatal sepsis,
and NICU admission.
Information about antibiotics used was also collected. More than
280 studies were identified; five trials included a comparison of tim-
ing of a single antibiotic dose, three of which were RCTs. The RCTs
were all performed between 1996 and 2007 and used cefazolin. These
three RCTs comprised the data set for the metaanalysis.
A total of 749 women were part of the three RCTs: 377 received
antibiotics preoperatively and gave birth to 387 infants while 372
received antibiotics at cord clamping and gave birth to 384 infants.
Preoperative antibiotic use resulted in a 53% overall reduction in
the risk of postpartum endometritis (RR=0.47; 95% CI, 0.26-0.85;
P=.012) and 50% reduction in the total risk of infections (RR=0.50;
95% CI, 0.33-0.78; P=.002) as compared to antibiotic administration
at cord clamping. When the non-randomized studies were included
the perioperative antibiotic prophylaxis was not as useful. There
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was also a trend towards lower risk of wound infection. Preopera-
tive administration of antibiotics did not impact rates of proven or
suspected neonatal sepsis or NICU admission.
The authors conclude that preoperative antibiotic administration
in C-section significantly decreases the incidence of postpartum
endometritis and total infectious morbidities without affecting
neonatal outcomes.
Commentary by
Mobeen H. Rathore, MD, FAAP, Pediatric Infectious Diseases and Immunol-
ogy, University of Florida and Wolfson Childrens Hospital, Jacksonville, FL
Dr. Rathore has disclosed no financial relationship relevant to this commentary. This commentary does not contain a
discussion of an unapproved/investigative use of a commercial product/device.
Prophylactic preoperative antibiotics are considered the standard
of care and are recommended to prevent postoperative infectious
complications.1
The timing of antibiotic use in C-section, however, has been a
subject of debate because of the concern that antibiotics adminis-
tered prior to cord clamping are transplacentally passed to infants
and can lead to difficulties in evaluating them for sepsis. As a result,
many obstetricians and pediatricians favor the use of prophylactic
antibiotics after cord clamping in cesarean deliveries.
While this may be beneficial for the infant, it places the mother
at risk for postoperative infections, especially endometritis. Because
of the lack of sufficiently powered, well-designed studies, the exact
timing of antibiotic prophylaxis in C-section has remained an unre-
solved issue.
Costantine, et al have attempted to address this issue by using
a sufficiently powered metaanalysis. Although a recent Cochrane
review concluded that preoperative use of antibiotic prophylaxis in
C-section is beneficial in preventing postoperative complications,
it could not answer questions about the impact of this practice on
neonatal sepsis.2 The current meta analysis found no increased
risk of confirmed neonatal sepsis, evaluation for neonatal sepsis, or
admission to the NICU related to the use of preoperative antibiotic
administration.
The combined report of the AAP and American College of Ob-
stetrics and Gynecology (ACOG) for perinatal care recommends
that antibiotic prophylaxis for C-section should be given after cord
clamping.3 The current study suggests that the AAP and ACOG rec-
ommendations need to be revisited.
References
1. Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29(suppl):S51-S61.
2. Smaill F, et al. Cochrane Database of Systematic Reviews. 2008, Issue 4. [doi:
10.1002/14651858.CD007482]
3. AAP, et al. Guidelines for Perinatal Care. 6th Edition. Elk Grove, IL: AAP; 2008.
Key words: meta analysis, C-section, antibiotics