Antimicrobial prophylaxis for Cesarean delivery: before or after cord clamping?

Antimicrobial prophylaxis for Cesarean delivery:

before or after cord clamping?Dr Emmanuel Boselli

Anesthesiology and Intensive Care DepartmentÉdouard Herriot Hospital, HCL

Lyon, France

emmanuel.boselli@chu-lyon.fr

Swiss Association of Obstetric Anesthesia (SAOA)

Fall meeting / SSAR 2011Interlaken, October 27th, 2011

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Cesaeran section

Risk factor for :

– post-partum infection

– maternal morbidity

– length of stay

Post-partum infection

No antimicrobial prophylaxis

Polymicrobial :– Gram + cocci– Gram - bacilli– Anaerobes

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Prevention of infection

Rigorous surgical technique

Skin disinfection

Antimicrobial prophylaxis

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Antimicrobial prophylaxis

infectious complications– endometritis– wound infection– bacteremia or severe infection

length of staySmaill F et al. Cochrane Database Syst Rev 2002;CD000933

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Antimicrobial agent

Single-dose cefazolin (1GC)– as efficient as larger-spectrum agents– as efficient as multiple-doses

Allergy : clindamycin

Hopkins L et al. Cochrane Database Syst Rev 2000;CD001136

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Surgery = before skin incision

Cesarean = after cord clamping– modification of neonatal flora?– risk of neonatal necrotic enterocolitis?

Recent data : better before?

Optimal timing?

Thigpen BD et al. Am J Obstet Gynecol 2005;192:1864–71Sullivan SA et al. Am J Obstet Gynecol 2007;196:455[e1–e5]

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Methods

3 electronic databases • Pubmed• Cochrane • Embase

Period: 1966-2008

Keywords:• antibiotics, antimicrobial• cesarean• prophylactic, prophylaxis

Flow chart

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

201 potential trials

191 RCTs concerning prophylaxis

166 RCTs concerning IV prophylaxis

5 RCTs comparing timing

(n = 1108)

10 exclusions(Non RCTs)

25 exclusions(Non IV prophylaxis)

161 exclusions(Efficacy studies)

Results

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Maternal outcome

Neonatal outcome

Results before vs after cord clamping

Outcome OR [95% CI]

MaternalEndometritis

Wound infectionTotal infectious morbidity

0.59 [0.39-0.98]0.58 [0.29-1.16]0.51 [0.32-0.82]

NeonatalInfection

Suspected sepsisDocumented sepsis

Admission in ICU

1.06 [0.57-1.96]1.02 [0.67-1.54]0.93 [0.43-2.02]0.97 [0.61-1.56]

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Conclusion

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Antimicrobial prophylaxisbefore cord clamping

endometritis

maternal infectious morbidity

No effect on neonatal outcome• Not primary outcome• β-lactams widely used during pregnancy

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Fall meeting / SSAR 2011, Interlaken, October 27th, 2011

Antimicrobial prophylaxis for Cesarean section

before cord clamping:

To be recommended?