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Meta-Analysis
. 2014 Oct 28;2014(10):CD007482.
doi: 10.1002/14651858.CD007482.pub3.

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

Fiona M Smaill  1 , Rosalie M Grivell
Affiliations
Meta-Analysis

Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section

Fiona M Smaill et al. Cochrane Database Syst Rev. .

Abstract

Background: The single most important risk factor for postpartum maternal infection is cesarean section. Although guidelines endorse the use of prophylactic antibiotics for women undergoing cesarean section, there is not uniform implementation of this recommendation. This is an update of a Cochrane review first published in 1995 and last updated in 2010.

Objectives: To assess the effects of prophylactic antibiotics compared with no prophylactic antibiotics on infectious complications in women undergoing cesarean section.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014) and reference lists of retrieved papers.

Selection criteria: Randomized controlled trials (RCTs) and quasi-RCTs comparing the effects of prophylactic antibiotics versus no treatment in women undergoing cesarean section.

Data collection and analysis: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. The clinically important primary outcomes were wound infection, endometritis, serious maternal infectious complications and adverse effects on the infant. We presented dichotomous data as risk ratios (RR), with 95% confidence intervals (CIs) and combined trials in meta-analyses. We assessed the quality of evidence using the GRADE approach.

Main results: We identified 95 studies enrolling over 15,000 women. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection (RR 0.40, 95% CI 0.35 to 0.46, 82 studies, 14,407 women), endometritis (RR 0.38, 95% CI 0.34 to 0.42, 83 studies, 13,548 women) and maternal serious infectious complications (RR 0.31, 95% CI 0.20 to 0.49, 32 studies, 6159 women). When only studies that included women undergoing an elective cesarean section were analyzed, there was also a reduction in the incidence of wound infections (RR 0.62, 95% CI 0.47 to 0.82, 17 studies, 3537 women) and endometritis (RR 0.38, 95% CI 0.24 to 0.61, 15 studies, 2502 women) with prophylactic antibiotics. Similar estimates of effect were seen whether the antibiotics were administered before the cord was clamped or after. The effect of different antibiotic regimens was studied and similar reductions in the incidence of infections were seen for most of the antibiotics and combinations.There were no data on which to estimate the effect of maternal administration of antibiotics on infant outcomes. No studies systematically collected and reported on adverse infant outcomes nor the effect of antibiotics on the developing infant immune system. No studies reported on the incidence of oral candidiasis (thrush) in babies. Maternal adverse effects were also rarely described.We judged the evidence for antibiotic treatment compared with no treatment to be of moderate quality; most studies lacked an adequate description of methods and were assessed as being at unclear risk of bias.

Authors' conclusions: The conclusions of this review support the recommendation that prophylactic antibiotics should be routinely administered to all women undergoing cesarean section to prevent infection. Compared with placebo or no treatment, the use of prophylactic antibiotics in women undergoing cesarean section reduced the incidence of wound infection, endometritis and serious infectious complications by 60% to 70%. There were few data on adverse effects and no information on the effect of antibiotics on the baby, making the assessment of overall benefits and harms difficult. Prophylactic antibiotics given to all women undergoing elective or non-elective cesarean section is beneficial for women but there is uncertainty about the consequences for the baby.

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Conflict of interest statement

None known.

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Funnel plot of comparison: 1 Antibiotic versus no antibiotics, outcome: 1.1 Maternal febrile morbidity/fever.
4
4
Funnel plot of comparison: 1 Antibiotic versus no antibiotics, outcome: 1.2 Maternal wound infection.
5
5
Funnel plot of comparison: 1 Antibiotic versus no antibiotics, outcome: 1.3 Maternal endometritis.
6
6
Funnel plot of comparison: 1 Antibiotic versus no antibiotics, outcome: 1.4 Maternal serious infectious complications.
1.1
1.1. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 1 Maternal febrile morbidity/fever.
1.2
1.2. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 2 Maternal wound infection.
1.3
1.3. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 3 Maternal endometritis.
1.4
1.4. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 4 Maternal serious infectious complications.
1.5
1.5. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 5 Maternal urinary tract infection.
1.6
1.6. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 6 Maternal adverse effects.
1.7
1.7. Analysis
Comparison 1 Antibiotic versus no antibiotics, Outcome 7 Maternal days in hospital.
2.1
2.1. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 1 Maternal febrile morbidity/fever.
2.2
2.2. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 2 Maternal wound infection.
2.3
2.3. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 3 Maternal endometritis.
2.4
2.4. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 4 Maternal serious infectious complications.
2.5
2.5. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 5 Maternal urinary tract infection.
2.6
2.6. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 6 Maternal adverse effects.
2.7
2.7. Analysis
Comparison 2 Antibiotic versus no antibiotic ‐ subgroup by class of antibiotic, Outcome 7 Maternal days in hospital.
3.1
3.1. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 1 Maternal febrile morbidity/fever.
3.2
3.2. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 2 Maternal wound infection.
3.3
3.3. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 3 Maternal endometritis.
3.4
3.4. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 4 Maternal serious infectious complications.
3.5
3.5. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 5 Maternal urinary tract infection.
3.6
3.6. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 6 Maternal adverse effects.
3.7
3.7. Analysis
Comparison 3 Antibiotics versus no antibiotics ‐ subgroup by type of cesarean section, Outcome 7 Maternal days in hospital.
4.1
4.1. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 1 Maternal febrile morbidity/fever.
4.2
4.2. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 2 Maternal wound infection.
4.3
4.3. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 3 Maternal endometritis.
4.4
4.4. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 4 Maternal serious infectious complications.
4.5
4.5. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 5 Maternal urinary tract infections.
4.6
4.6. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 6 Maternal adverse effects.
4.7
4.7. Analysis
Comparison 4 Antibiotics versus no antibiotics ‐ subgroup by timing of administration, Outcome 7 Maternal days in hospital.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Gerstner 1980 {published data only}
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Gibbs 1972 {published data only}
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Gibbs 1973 {published data only}
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Gibbs 1981 {published data only}
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Gordon 1979 {published data only}
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Gummerus 1984 {published data only}
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Hager 1983 {published data only}
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Hagglund 1989 {published data only}
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Harger 1981 {published data only}
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Hawrylyshyn 1983 {published data only}
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Heilmann 1984 {published data only}
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Huam 1997 {published data only}
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Ismail 1990 {published data only}
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Lewis 1990 {published data only}
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Ruiz‐Moreno 1991 {published data only}
    1. Ruiz‐Moreno JA, Garcia‐Rojas JM, Lozada‐Leon JD. Prevention of post cesarean infectious morbidity with a single dose of intravenous metronidazole. International Journal of Gynecology & Obstetrics 1991;34:217‐20. - PubMed
Saltzman 1985 {published data only}
    1. Saltzman DH, Eron LJ, Kay HH, Sites JG. Single‐dose antibiotic prophylaxis in high‐risk patients undergoing cesarean section. Obstetrics & Gynecology 1985;65:655‐7. - PubMed
Scarpignato 1982 {published data only}
    1. Scarpignato C, Caltabiano M, Condemi V, Mansani FE. Short‐term vs long‐term cefuroxime prophylaxis in patients undergoing emergency cesarean section. Clinical Therapeutics 1982;5:186‐92. - PubMed
Schedvins 1986 {published data only}
    1. Schedvins K, Moberg PJ. Prevention of postoperative infection in cesarean section after rupture of the membranes. International Journal of Gynecology & Obstetrics 1986;24:165‐8. - PubMed
Shah 1998 {published data only}
    1. Shah S, Mazher Y, John IS. Single or triple dose piperacillin prophylaxis in elective cesarean section. International Journal of Gynecology & Obstetrics 1998;62(1):23‐9. - PubMed
Sokolowski 1989 {published data only}
    1. Sokolowski VH, Canzler E, Brotzmann C. Influence of vagimid prophylaxis on course of puerperium and healing of the wound after caesarean section in comparison with a control group. Zentralblatt fur Gynakologie 1989;111:461‐5. - PubMed
Stage 1982 {published data only}
    1. Stage AH, Glover DD, Vaughan JE. Low‐dose cephradine prophylaxis in obstetric and gynecologic surgery. Journal of Reproductive Medicine 1982;27:113‐9. - PubMed
Stiver 1983 {published data only}
    1. Stiver HG, Forward KR, Livingstone RA, Fugere P, Lemay M, Verschelden G, et al. Multicenter comparison of cefoxitin vs cefazolin for prevention of infectious morbidity after nonelective cesarean section. American Journal of Obstetrics and Gynecology 1983;145:158‐63. - PubMed
    1. Stiver HG, Forward KR, Tyrrell DL, Krip G, Livingstone RA, Fugere P, et al. Comparative cervical microflora shifts after cefoxitin or cefazolin prophylaxis against infection following cesarean section. American Journal of Obstetrics and Gynecology 1984;149(7):718‐21. - PubMed
Sziller 1994 {published data only}
    1. Sziller I, Karovits J, Erdosi F, Beke A, Oszoli G. Postoperative infectious morbidity after perioperative ampicillin /sulbactam prophylaxis in women undergoing elective caesarean section. Magyar Norvosok Lapja 1994;57:101‐4.
Tully 1983 {published data only}
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Turner 1990 {published data only}
    1. Turner MJ, Egan DM, Qureshi WA, Skehan M, Black A, Darrell JH, et al. Use of cephradine prophylaxis of infection after caesarean section: stepwise logistic regression analysis of relevant factors. Journal of Obstetrics and Gynaecology 1990;10:204‐9.
Tzingounis 1982 {published data only}
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Ujah 1992 {published data only}
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    1. Ujah IAO, Olarewaju RS, Otubu JAM. Prophylactic amoxicillin‐clavulanic acid in elective cesarean section. Current Therapeutic Research, Clinical and Experimental 1992;52(5):647‐51.
Walss Rodriguez 1990 {published data only}
    1. Walss Rodriguez R, Avila Esparza M. Prophylactic antimicrobial therapy in cesarean section [Antibioticoterapia profilactica en operacion cesarea]. Ginecologia y Obstetricia de Mexico 1990;58:79‐83.
Weissberg 1971 {published data only}
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Witt 2011 {published data only}
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Wong 1978 {published data only}
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Work 1977 {published data only}
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Wu 1991 {published data only}
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    1. Wu Y, Zhan L, Jing Y. Prevention of post‐operative infection by uterine and intraperitoneal irrigation with ampicillin during cesarean section. International Journal of Experimental and Clinical Chemotherapy 1991;4(3):132‐6.
Yip 1997 {published data only}
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Young 1983 {published data only}
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References to studies excluded from this review

Ahued 1994 {published data only}
    1. Ahued Ahued RA, Leal del Rosal JA, Rocha del Valle G, Sereno Colo JA. The efficacy of sulbactam‐ampicillin in preventing postoperative infections in gynecology and obstetrics. A comparative open study [Eficacia de sulbactam/ampicilina en la profilaxis de infecciones postquirurgicas en gineco‐obstetricia. Estudio abierto comparativo]. Ginecologia y Obstetricia de Mexico 1994;62(9):282‐4. - PubMed
Andrews 2003 {published data only}
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Cormier 1988 {published data only}
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Elliott 1982 {published data only}
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Kosus 2010 {published data only}
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Krasnodebski 1997 {published data only}
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Louie 1982 {published data only}
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Petersen 1985 {published data only}
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Roex 1987 {published data only}
    1. Roex AJM, Loenen AC, Puyenbroek JI, Arts NFT. Secretion of cefoxitin in breast milk following short‐term prophylactic administration in caesarean section. European Journal of Obstetrics & Gynecology and Reproductive Biology 1987;25:299‐302. - PubMed
Sanchez‐Ramos 1999 {published data only}
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Sengupta 1976 {published data only}
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Skryten 1988 {published data only}
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Spreafico 1987 {published data only}
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Voto 1986 {published data only}
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Wallace 1984 {published data only}
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Wells 1994 {published data only}
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Yamagishi 2009 {published data only}
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Yildirim 2009 {published data only}
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References to other published versions of this review

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    1. Smaill F. Prophylactic antibiotics for elective Caesarean section [revised 06 May 1993]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Smaill 1995b
    1. Smaill F. Prophylactic antibiotics in Caesarean section (all trials) [revised 03 August 1994]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.
Smaill 2002
    1. Hofmeyr GJ, Smaill FM. Antibiotic prophylaxis for cesarean section. Cochrane Database of Systematic Reviews 2002, Issue 3. [DOI: 10.1002/14651858.CD000933] - DOI - PubMed
Smaill 2010
    1. Smaill FM, Gyte GML. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD007482.pub2] - DOI - PMC - PubMed

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