Antibiotics Before Cesarean Delivery Cut Infections in Half
August 7, 2012 — Giving prophylactic antibiotics within 1 hour before cesarean incision instead of after umbilical cord clamping reduced surgical site infections by 48%, according to a 96-month retrospective cohort study.
The study, by Nupur D. Kittur, PhD, MPH, from the Department of Medicine and the Department of Obstetrics and Gynecology at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis, Missouri, and colleagues, included of 8668 women who underwent cesarean delivery from January 2003 to December 2010 in a US tertiary-care hospital. The results are published in the August issue of Obstetrics & Gynecology.
Traditionally, prophylactic antibiotics have been given after clamping the newborn's umbilical cord to avoid masking signs of neonatal sepsis in the infant, but studies have shown that prophylactic antibiotics provide the best protection when tissue levels are adequate before incision, the authors explain.
During the study period, several infection control measures were either changed or implemented at the hospital, and the authors examined their effect on infection rates. In January 2004, the hospital instituted a policy directing antibiotic administration to change from after umbilical cord clamping to within 60 minutes before cesarean incision, and the anesthesiologists assumed responsibility for antibiotic administration.
In addition, in February 2004, a new policy banned artificial nails in surgical staff. In February 2007, operating room environmental cleaning and disinfection processes were streamlined.
Meanwhile, in May 2006, the obstetric unit of another hospital closed, which left the study hospital the only obstetric care facility in the city of St. Louis.
Dr. Kittur and colleagues used time series analysis to estimate whether any of these developments had any effect on surgical site infection rates after they adjusted for underlying secular trends in patient mix.
"Methods to evaluate strategies to reduce surgical site infection rates must adjust for multiple factors that could account for changing rates such as changes in patient case mix as well as the relationship between surgical site infection rates in consecutive months," the authors write.
Of the 8668 women who had cesarean deliveries, 303 (3.5%; 95% confidence interval, 3.1% - 3.9%) developed surgical site infections.
Implementation of the prophylactic antibiotics policy resulted in a 48% reduction in surgical site infections (Δ = −5.4 surgical site infections/100 cesarean deliveries; P < .001).
Body mass index (BMI) data were available for 8008 women. Of those patients, 3093 (35.7%) had BMIs of 35 kg/m2 or greater; the median BMI of the women was 32.7 kg/m2 (range, 13.4 - 103.0 kg/m2).
In a univariable analysis, the researchers found a significant association between the incidence of surgical site infection and white race, age 35 years or older, BMI of 35 kg/m2 or greater, the antibiotic prophylaxis policy, and the artificial nails policy.
However, a multivariable analysis showed that the antibiotic prophylaxis policy was the only factor that had a significant association with postcesarean surgical site infection rates. The policy banning artificial nails in surgical staff and the streamlining of operating room cleaning and disinfection processes did not affect surgical site infection rates.
"Our results support the administration of prophylactic antibiotics before incision in patients undergoing cesarean delivery. Future research should aim at understanding adherence to this policy and best practices for delivering prophylactic antibiotics in a timely manner in both routine and emergency obstetric situations," the authors write.
In 2011, the American College of Obstetricians and Gynecologists recommended a similar change in practice, with antibiotics to be delivered in the 60 minutes before incision.
The authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2012;120:246-251. Abstract
Medscape Medical News © 2012 WebMD, LLC
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