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“Emerging Concepts in Antibiotic Prophylaxis for Cesarean Delivery “

“Emerging Concepts in Antibiotic Prophylaxis for Cesarean Delivery “. Journal Article Review Diana S Wolfe, MFM Fellow Year 1 Mentor: Dr. Carol Archie. Background. Prophylactic antibiotics ↓ surgical site infection National guidelines recommend administration prior to surgical incision

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“Emerging Concepts in Antibiotic Prophylaxis for Cesarean Delivery “

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  1. “Emerging Concepts in Antibiotic Prophylaxis for Cesarean Delivery “ Journal Article Review Diana S Wolfe, MFM Fellow Year 1 Mentor: Dr. Carol Archie

  2. Background • Prophylactic antibiotics ↓ surgical site infection • National guidelines recommend administration prior to surgical incision • Cesarean Section is the Exception

  3. Burden Of Disease

  4. Burden of Disease • Pregnancy-Related Mortality and Morbidity • Infections remain among the top five causes • Risk factor for postpartum infection • Cesarean: single most important risk factor • Most common sites: endometritis and wound • Mode of Delivery • Cesareans ↑ risk of postpartum infection 5-20x

  5. ACOG Practice Bulletin 47 currently withdrawn • Antibiotic prophylaxis recommended • All who have a cesarean delivery • Narrow Spectrum Antibiotic • “such as a first-generation cephalosporin”

  6. Public Health Priority • Despite Antibiotic Prophylaxis Protocols • 10% of Cesarean Deliveries → Infection • 15% of Cesarean Deliveries → Fever • This is an Underestimation • 15-80% of postcesarean infections occur after d/c • Cesarean Delivery is Rising → Prevention of Infection is a Public Health Priority

  7. Methods: Data Collection • Data Search • January, 1966-July, 2008 • “cesarean” and “antibiotic prophylaxis” • 15 Studies found • Clinical trials/Meta-analysis/Observational studies • Evaluated timing of antibiotics or extended-spectrum prophylaxis • 9 Studies found • National recommendations/Meta-analyses • Support current standards for antibiotic prophylaxis • Outcome Measure • Postcesarean maternal infection (endometritis and wound infection) • Neonatal sepsis and sepsis workups

  8. Pre-incision Antibiotic Prophylaxis • Administration within 30-60 mins of surgery • Max tissue and blood [antibiotic] at surgical site • Transfer to fetal compartment • 2 hours for Cefazolin • Concern for fetal exposure to antibiotic • Mask infection in the neonate • Promote selection of resistant organisms • Subsequent Decision to Administer Antibiotics • After delivery of the infant and clamping of cord

  9. Review of Studies • Two nonrandomized studies • Pre-incision administration did not ↓ infection • It did ↑ neonatal sepsis evaluations and costs • Three randomized control trials • Prophylactic antibiotics before incision • Prevent post-cesarean infection • None of the studies had sig power to assess neonatal sepsis → 4,800 cesarean deliveries would be needed to ascertain a 33% difference in neonatal sepsis with 80% power → Assuming a baseline incidence of 5%

  10. Timing of Antibiotic Prophylaxis for Cesarean Delivery

  11. Owens, Stephanie M., et al. Obstetrics & Gynecology 114(3) Antimicrobial Prophylaxis for Cesarean Delivery Before Skin Incision September, 2009 Magee-Women's Hospital

  12. Mitchell, T.F., et. Al. Obstetrics and Gynecology 2001; 98 Maternal and Transplacental Pharmacokinetics of Cefazolin 2001 University of Michigan

  13. Association of Extended-Spectrum Antibiotic Prophylaxis with ↓ Infx • Polymicrobial Infection • Aerobes/Anaerobes/Ureaplasma [Mycoplasma] • Most Common Organisms from Wound Infx • Ureaplasma/Staphlococci/Enterococci • Most Common Organism from Amniotic Fluid • Ureaplasma/Mycoplasma

  14. Extended Spectrum Antibiotic Prophylaxis • Extended Spectrum Regimen: Both • Standard narrow-spectrum antibiotic • Second antibiotic of a different class i.e. azithromycin, gentamycin or metronidazole • Sig more effective in ↓ post-cesarean infx

  15. Studies on Extended-Spectrum Antibiotic Prophylaxis

  16. Annual Incidence of Postcesarean Endometritis for Three Periods

  17. Limitations • Review Findings are Biased • Studies with negative findings not published • Information re safety of pre-incision prophylactic antibiotics is inconclusive • Effect on Rate of Neonatal Infections • Emergence of Antimicrobial resistance • Selection of Known Resistant Organisms • Extended-Spectrum Data • Single Centers with Varied Regimens

  18. Conclusion • Use of Cefazolin alone before incision or Extended-Spectrum regimen after cord clamp → Association with ↓ Post-cesarean Maternal Infx • Future Studies • Neonatal Outcomes • Comparing Time of Antibiotic Administration

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