Download Antimicrobial prophylaxis for CS - SGAR-SSAR

Swiss Association of Obstetric Anesthesia (SAOA)
Fall meeting / SSAR 2011
Interlaken, October 27th, 2011
Antimicrobial prophylaxis
for Cesarean delivery:
before or after cord clamping?
Dr Emmanuel Boselli
Anesthesiology and Intensive Care Department
Édouard Herriot Hospital, HCL
Lyon, France
[email protected]
Cesaeran section
Risk factor for :
– post-partum infection
– maternal morbidity
–  length of stay
Fall meeting / SSAR 2011, Interlaken, October 27th, 2011
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 stay
Smaill 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
Optimal timing?
Surgery = before skin incision
Cesarean = after cord clamping
– modification of neonatal flora?
– risk of neonatal necrotic enterocolitis?
Recent data : better before?
Thigpen BD et al. Am J Obstet Gynecol 2005;192:1864–71
Sullivan SA et al. Am J Obstet Gynecol 2007;196:455[e1–e5]
Fall meeting / SSAR 2011, Interlaken, October 27th, 2011
Methods
3 electronic databases
• Pubmed
• Cochrane
• Embase
Period: 1966-2008
Keywords:
• antibiotics, antimicrobial
• cesarean
• prophylactic, prophylaxis
Fall meeting / SSAR 2011, Interlaken, October 27th, 2011
Flow chart
201 potential trials
10 exclusions
(Non RCTs)
191 RCTs
concerning prophylaxis
25 exclusions
(Non IV prophylaxis)
166 RCTs
concerning IV prophylaxis
161 exclusions
(Efficacy studies)
5 RCTs
comparing timing
(n = 1108)
Fall meeting / SSAR 2011, Interlaken, October 27th, 2011
Results
Fall meeting / SSAR 2011, Interlaken, October 27th, 2011
Maternal outcome
Neonatal outcome
Results before vs after cord clamping
Outcome
OR [95% CI]
Maternal
Endometritis
Wound infection
Total infectious morbidity
0.59 [0.39-0.98]
0.58 [0.29-1.16]
0.51 [0.32-0.82]
Neonatal
Infection
Suspected sepsis
Documented 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 prophylaxis
before 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
Antimicrobial prophylaxis for
Cesarean section
before cord clamping:
To be recommended?
Fall meeting / SSAR 2011, Interlaken, October 27th, 2011