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Am Fam Physician. 2004;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.

CharacteristicCefotetan + doxycycline + azithromycin (%), n = 301Cefotetan + placebo (%), n = 296P value
Endometritis51/304 (16.9)73/296 (24.7).020
Wound infections2/258 (0.8)9/252 (3.6).030
Endometritis or wound infection49/258 (19.0)70/252 (27.8).019
Length of postoperative stay (hours)*
Overall95 32104 56.016
In endometritis cases127 46146 52.047

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.

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