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Optimal Antibiotic Prophylaxis for Cesarean Delivery



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Am Fam Physician. 2004 Feb 1;69(3):642.

The most common complication of cesarean delivery, endometritis, is believed to result from ascending infection caused by a mixture of organisms. Ureaplasma urealyticum is recognized increasingly as an important pathogen in local postpartum infections. Because the antibiotics routinely used for prophylaxis in cesarean delivery are not effective against this organism, Andrews and colleagues studied the effect of prophylaxis with extended-spectrum antibiotics with efficacy against U. urealyticum.

Antibiotic Prophylaxis in Cesarean Delivery: Selected Outcomes

Characteristic Cefotetan + doxycycline + azithromycin (%), n = 301 Cefotetan + placebo (%), n = 296 P value

Endometritis

51/304 (16.9)

73/296 (24.7)

.020

Wound infections

2/258 (0.8)

9/252 (3.6)

.030

Endometritis or wound infection

49/258 (19.0)

70/252 (27.8)

.019

Length of postoperative stay (hours)*

Overall

95 32

104 56

.016

In endometritis cases

127 46

146 52

.047


*—Mean standard deviation.

Reprinted with permission from Andrews WW, Hauth JC, Cliver SP, Savage K, Goldenberg RL. Randomized clinical trial of extended spectrum antibiotic prophylaxis with coverage for Ureaplasma urealyticum to reduce post-cesarean delivery endometritis. Obstet Gynecol 2003;101:1187.

Antibiotic Prophylaxis in Cesarean Delivery: Selected Outcomes

View Table

Antibiotic Prophylaxis in Cesarean Delivery: Selected Outcomes

Characteristic Cefotetan + doxycycline + azithromycin (%), n = 301 Cefotetan + placebo (%), n = 296 P value

Endometritis

51/304 (16.9)

73/296 (24.7)

.020

Wound infections

2/258 (0.8)

9/252 (3.6)

.030

Endometritis or wound infection

49/258 (19.0)

70/252 (27.8)

.019

Length of postoperative stay (hours)*

Overall

95 32

104 56

.016

In endometritis cases

127 46

146 52

.047


*—Mean standard deviation.

Reprinted with permission from Andrews WW, Hauth JC, Cliver SP, Savage K, Goldenberg RL. Randomized clinical trial of extended spectrum antibiotic prophylaxis with coverage for Ureaplasma urealyticum to reduce post-cesarean delivery endometritis. Obstet Gynecol 2003;101:1187.

About 600 mothers who gave birth by nonurgent cesarean delivery in a university hospital between 1996 and 1999 were included in the study. Exclusions included mothers with fever, an immunocompromised condition, allergy to study medications, or use of medications metabolized by cytochrome P450 systems. All mothers received intravenous cefotetan at the clamping of the umbilical cord. Mothers then were randomly assigned to treatment with doxycycline plus azithromycin or identical placebos. The study was double-blinded. Patients were monitored for fever (38°C [100.4°F]) or higher) and other indications of endometritis such as tachycardia, infected lochia, uterine tenderness, and leukocytosis.

The 301 women who received antibiotics were comparable with the 296 women who received placebo in all important variables, including those related to surgery. Overall, 122 (20.4 percent) mothers developed endometritis. The rate of endometritis was significantly lower in mothers treated with doxycycline plus azithromycin (16.9 percent) than it was in mothers in the placebo group (24.7 percent). Mothers treated with additional antibiotics were also four times less likely to develop wound infections and had a significant mean reduction of 18 hours in hospital stay (see accompanying table).

The authors conclude that extending prophylactic antibiotic coverage to include U. urealyticum was associated with significant reductions in clinical endometritis and wound infections following cesarean delivery. They recommend that this approach be more widely considered, especially in mothers at increased risk of postdelivery infectious morbidity.

Andrews WW, et al. Randomized clinical trial of extended spectrum antibiotic prophylaxis with coverage for Ureaplasma urealyticum to reduce post-cesarean delivery endometritis. Obstet Gynecol. June 2003;101:1183–9.



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