Comparison of irrigation and intravenous antibiotic prophylaxis at cesarean section

Despite recent enthusiasm for antibiotic prophylaxis by uterine irrigation at the time of cesarean section, no data exists comparing the efficacy of this technique with standard intravenous antibiotic administration. Therefore, 124 patients about to undergo cesarean section were entered into a prospective, randomized, double-blind evaluation of uterine irrigation versus intravenous administration of either normal saline or cefoxitin. All women were considered to be at increased risk for postoperative infection because of the presence of labor or ruptured membranes. The incidence of endometritis and the fever index in patients receiving intravenous cefoxitin (3.2%, 4.6 degree hours) was significantly less than in patients receiving intravenous normal saline (21.2%, 22.3 degree hours). There was no significant difference between the use of intravenous normal saline and uterine irrigation with either cefoxitin (18.9%, 16.6 degree hours) or normal saline (17.4%, 24.6 degree hours). These results suggest that intravenous infusion is the most effective means of administering cefoxitin as a prophylactic antibiotic.     

Reduction of post-cesarean section infectious morbidity by means of antibiotic irrigation

The effectiveness of antibiotic irrigation in reducing post-cesarean section infectious morbidity was studied in a prospective, randomized, double-blind trial. One hundred twenty-eight patients were divided into three groups and irrigated with either cefoxitin solution, cephapirin solution, or saline. Following delivery of the placenta, the uterine cavity and incision, bladder flap, pelvic gutters, and subcutaneous tissue of the patients were irrigated. There was a significant reduction in total infectious morbidity (p less than 0.02) and wound infection (p less than 0.04) when antibiotic use was compared to the saline control. No statistical difference in the effectiveness of the two antibiotics could be demonstrated. No adverse effects were noted. Antibiotic irrigation is a safe and effective method in reducing infectious morbidity of the parturient patient.     

A comparison of postoperative morbidity following prophylactic antibiotic administration by combined irrigation and intravenous route or by intravenous route alone during cesarean section.

This study compared the efficacy of a single intravenous dose of Cefazolin alone or combined with an antibiotic containing preclosure-irrigation solution in patients undergoing cesarean section. A total of 308 patients were prospectively assigned to two groups by randomization. Group I received two grams of Cefazolin IV and abdomino-peritoneal irrigation with saline. Group II received one gram of Cefazolin IV and one gram in the saline irrigation solution. The rate of total postoperative morbidity was 2.3 times higher in Group I compared to Group II (16/154 or 10.4% vs 7/154 or 4.5%) and morbidity at the operative site was six times higher (13/154 or 8.4% vs 2/154 or 1.3%).     

Single-dose antibiotic prophylaxis during cesarean section

Objective: To compare single-dose antibiotic prophylaxis (cefotetan 1 g vs cefoxitin 2 g) in various subpopulations based upon risk factors for postsurgical infection following cesarean section.Methods: Patients undergoing cesarean section from April 1993 through March 1994 were included in a retrospective analysis if either of the above antibiotics were administered, surgery was non-emergent, gestational age was less than 32 weeks, absence of fever or prior antibiotics therapy within 72 hours, and no history of organ transplantation or HIV. Cases classified as high risk for infection: IDDM, obesity, autoimmune disease, sickle cell disease, or corticosteroid use. Cases classified as high risk for endometritis (any 2 factors): labor >12 hours, >4 vaginal examinations, ruptured membranes >9 hours, and internal fetal monitor. Cases were separated into 4 groups: elective vs non-elective, low vs high surgical risk. A χ² analysis was used to test for differences in infection rates between groups (P < .05).Results: Of 1383 cesarean sections, 385 met criteria for inclusion. Non-elective cases accounted for 77% of cases. Postsurgical infection rate was greater in non-elective cases, 7.4%, vs elective cases, 3.0% (P = .056) as was the rate of endometritis (3.2% vs 1.2%, P = .185). No differences were noted based on antibiotic regimen. Postsurgical infection rate was greater for 28 cases at high risk for both surgical infection and endometritis (17.9%) when compared to all 357 other cases (4.5%), P = .003. No difference was noted for endometritis. Of the 28 cases 28.6% of patients treated with cefoxitin and 7.1% of cases treated with cefotetan developed postsurgical infection (P = .13).Conclusion: Overall cefoxitin and cefotetan provided equivalent clinical outcome. A small subset of patients with multiple risk factors for infection may benefit from cefotetan.     

剖宫产围手术期抗生素的预防性应用

目的 探讨低感染风险剖宫产产妇围手术期预防性应用抗生素的必要性及最佳用药方案.方法 前瞻性随机对照研究低感染风险子宫下段剖宫产产妇围手术期抗生素应用与否以及不同用药方案与术后病率和术后感染的关系.抗生素选择头孢唑肟钠或克林霉素,均为静脉给药.共纳入2007年11月至2008年10月在南京大学医学院附属鼓楼医院妇产科分娩的产妇720例,随机分成4组:A组176例,围手术期不使用抗生素,B组190例,术前30 min一次给药,术后不再使用;C组180例,术前30 min开始给药,术后继续使用2 d;D组174例,手术结束后开始给药,共5d.比较4组产妇术后体温恢复正常的时间、术后病率、术后感染及术后住院天数.统计学分析采用方差分析、卡方检验及Fisher精确概率法. 结果 720例产妇术后感染率、术后病率分别为0.83%(6/720)和4.58%(33/720),4组产妇剖宫产术后感染发生率差异无统计学意义(P>0.05),B组和C组产妇术后体温恢复正常时间、术后病率及术后平均住院天数均分别显著低于A组和D组[B组:(41.9±31.6)h、1.05 oA(2/190)、(4.8±1.1)d;C组:(41.1±36.5)h、1.11%(2/180)、(4.7±0.9)d;A组:(67.0±40.6)h,7.39%(13/176)、(5.7±1.0)d,D组:(70.1±39.9)h、9.20%(16/174)、(5.9±1.1 d),P均<0.01].但B、C组之间和A,D组之间各项指标比较差异无统计学意义(P>0.05). 结论 低感染风险产妇剖宫产术前30 min静脉使用抗生素能显著降低术后病率的发生,且一次性用药即可,无需对低感染风险的剖宫产产妇在术后重复应用抗生素预防感染.     

Effect of anesthesia for primary cesarean section on postoperative infectious morbidity

It has been stated that general anesthesia is a risk factor for postcesarean infectious morbidity. A retrospective review of 252 women who had undergone primary cesarean section at the University of Iowa Hospital was conducted. Regional anesthesia was successfully administered to 170 patients, and general anesthesia was administered to 82 patients. Patients receiving general anesthesia were more likely to be indigent, to receive a vertical skin incision, and to be transfused intraoperatively and/or postoperatively. There were no statistically significant differences between the two groups with regard to multiple indexes of postoperative fever or infection, including febrile morbidity, diagnosis of infection, use of therapeutic antibiotics, fever index, and postoperative hospital stay. General anesthesia, as administered to patients in the present series, did not increase the risk of infectious morbidity after primary cesarean section. However, our surgeons apparently were influenced by the choice of anesthetic technique when selecting a skin incision.     

Effect of anesthesia for repeat cesarean section on postoperative infectious morbidity

It has been suggested that general anesthesia is a risk factor for postcesarean infectious morbidity. A retrospective review of 206 women who underwent repeat cesarean delivery at Duke University Medical Center was conducted. Group 1 consisted of 106 patients whose repeat cesarean section was performed with regional anesthesia, and group 2 included 100 patients whose repeat cesarean section was performed with general anesthesia. Group 2 patients were more likely to be of low socioeconomic status. There were no statistically significant differences between the two groups with regard to multiple indexes of postoperative fever or infection, including febrile morbidity, diagnosis of infection, use of therapeutic antibiotics, fever index, and postoperative hospital stay. General anesthesia, as administered to patients in the present series, does not increase the risk of infectious morbidity after repeat cesarean delivery.     

Perioperative antibiotic prophylaxis is cesarean section.

The effect of an 8-hour, 3-dose perioperative regimen of cefazolin or placebo was evaluated in 97 patients. Postoperative morbidity occurred in 13 patients (27.1%) in the cefazolin group and in 17 patients (34.7%) who received placebo. The clinical sites of infection were similar in both groups except that wound infections (2) and sepsis (2) were found only in patients receiving placebo. Aerobic organisms diminished and anaerobes increased in patients who received antibiotics. Aerobic isolates were essentially unchanged and fewer anaerobes were recovered from patients given placebo. Antibiotic levels observed at cesarean section were in the therapeutic range. The only risk factor which correlated with morbidity was the presence of ruptured membranes. This short course, single drug regimen did not significantly reduce morbidity although it was bacteriologically effective.     

Cost-effective use of antibiotic prophylaxis for cesarean section

Clinical experience has indicated that the prophylactic use of antibiotics reduces infectious morbidity in patients undergoing cesarean section. Several factors must be considered (for instance, in vivo and in vitro efficacy, patient allergies, side effect profiles, status of host defenses, the total cost of therapy, and the risk of selecting resistant organisms that cause superinfections) before prescribing prophylactic antibiotic drugs for this indication. Moreover, medical-legal consequences associated with potential postpartum infections must be considered in assessing the costs and impact of a prophylactic regimen. Results of comparative antibiotic trials in indigent patients undergoing cesarean section demonstrated differing rates of successful antibiotic prophylaxis: piperacillin, 98%; cefoxitin, 91%; cephalothin and ceftazidime, 82%; cefotaxime, 80%; and ampicillin, 77%. Although the acquisition costs of antibiotics vary greatly, these costs are dwarfed by the substantial cost savings that can be realized by use of broad-spectrum antibiotics, which, in our hands, have resulted in reduced laboratory and pharmacy expenses and decreased hospital stays for both mother and neonate. Controlled studies designed to investigate microbiologic as well as clinical efficacy of antibiotics are indicated. Further refinements in individualizing antibiotic regimens according to patient population should be sought.     

Comparison of lavage or intravenous antibiotics at cesarean section

The route of administration of prophylactic antibiotics was studied in a randomized prospective trial. Cefoxitin was administered to high-risk patients at cesarean section by three treatment regimens: intravenous antibiotic (2 g) for eight doses, irrigation of uterus and peritoneum with 2 g of antibiotic, and a combination of intravenous and irrigation as described. A control group received no antibiotic prophylaxis. The incidence of febrile morbidity was similar in each treatment group: intravenous, two of 39 (5%); irrigation, three of 42 (7%); intravenous and irrigation, two of 38 (5%), and were all significantly lower than the control group 14 of 39 (36%) (P less than .05). Similar results were found when prevention of endometritis was the end point: intravenous, two of 39 (5%); irrigation, two of 42 (5%); intravenous and irrigation, two of 38 (5%) compared with 13 of 39 (33%) in the control group (P less than .05). Administration of antibiotics by irrigation is equally effective in preventing postoperative febrile morbidity and endomyometritis as intravenous dosing and a combination of intravenous and irrigation. This affords a potential cost savings.     

Antibiotic irrigation prophylaxis in the high-risk cesarean section patient

Two hundred twenty-three women who underwent cesarean section delivery were studied to assess the effectiveness of operative antibiotic irrigation in preventing postoperative uterine infection. Patients were prospectively randomized into high-risk and low-risk groups according to length of labor, and received irrigation with either a 2 gm solution of cefamandole or normal saline solution, or no irrigation. Infection rates of 48.6% and 54.8% were observed in high-risk patients given either saline solution or no irrigation, respectively. Three of 27 high-risk patients (11.1%) given antibiotic irrigation developed metritis. The authors find this method of preventing infection to be advantageous in terms of both efficacy and minimization of antibiotic exposure.     

Prevention of endomyometritis using antibiotic irrigation during cesarean section

After double-blind controlled studies demonstrated cefamandole nafate irrigation of the uterus during cesarean section to be effective in reducing the rate of endomyometritis, antibiotic irrigation was adopted as a standard procedure at Tripler Army Medical Center. The present study analyzes the outcome in patients undergoing cesarean section before (comparison group) and after (treatment group) routine use of antibiotic irrigation began. The incidence of endomyometritis in 100 patients from the comparison group was 20% and in 298 patients from the treatment group 1.7% (P less than .0001). Serum analysis for cefamandole nafate demonstrated little systemic absorption of the antibiotic. Cefamandole nafate intrauterine irrigation at cesarean section effectively prevents endomyometritis.     

Single-dose antibiotic prophylaxis in high-risk patients undergoing cesarean section

A prospective, double-blind, placebo-controlled study was performed to determine the effectiveness of single-dose antibiotic prophylaxis in decreasing infectious complications after primary cesarean section. One hundred women at high risk for postoperative infectious morbidity were randomly assigned to receive either placebo or one 2-g dose of ceftizoxime at cord clamping. The incidence of endometritis in the antibiotic group was 6.0 versus 24.5% in the placebo group (P less than .05). The incidence of febrile morbidity in the group receiving one dose of ceftizoxime was 14.0 versus 32.7% in the placebo group (P less than .05). Single-dose ceftizoxime prophylaxis significantly reduced the incidence of endometritis and febrile morbidity in high-risk patients undergoing cesarean section.     

Once again: the perioperative antibiotic prophylaxis in cesarean section

In continuation of our clinical observations on perioperative prophylaxis by application of Halospor and Gentamicin the dosage of Halospor has been reduced to 2 grams once only. According to our experiences in 98 cases of cesarean section we can recommend these advance: fever in 12.2% (21.2% without prophylaxis), secondary wound-healing in 2% (6.7%) and therapeutical antibiotics in 13.3%, Metronidazol as often as not (36.6%).     

Careful surgical technique can reduce infectious morbidity after cesarean section

A total of 635 consecutive cesarean sections performed in private practices during the past 20 years are reviewed. In the course of this 20 year period, we have tried to alter gradually our surgical technique used for this procedure to conform to the principles of surgery developed by Halsted. The study is divided into three periods of time to examine the results of changes in technique. With the use of the standard definition of febrile morbidity (temperature of greater than or equal to 100.4 degrees F during any two 24-hour periods after the first postoperative 24 hours) the postoperative morbidity rate was 15% during 1967 to 1973, 5.4% during 1974 to 1979, and 0.7% during the period 1980 through 1986. Prophylactic antibiotics were used with decreasing frequency. It was clear that the reduction in morbidity was the result of the modifications in surgical technique.     

A randomized clinical trial of antibiotic prophylaxis in cesarean section: maternal morbidity, risk factors and bacteriological changes

In the United States, several well-designed studies have demonstrated the efficacy of short-course antibiotic prophylaxis in cesarean sections. The present prospective study was conducted on 150 patients in a Dutch university hospital in a randomized double-blind fashion. Cefoxitin was administered according to a three-dose, 12 h regimen, the first injection given immediately after clamping of the umbilical cord. The rate of infection among the patients was significantly reduced by prophylaxis, judging from febrile morbidity, endometritis, wound infections, urinary tract infections and need for postoperative antibiotic therapy. The prophylactic use of the cefoxitin was especially effective in the secondary cesarean section population. Three risk factors significantly correlated with increased risk of infection: labor, rupture of membranes and pelvic examination. Postoperative cervical cultures showed a significant reduction of bacteria in the cefoxitin group. No shift towards resistant pathogens was demonstrable.