title: Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery.
abstract: BACKGROUND
  Given the continued rise in cesarean birth rate and the increased risk of surgical site infections after cesarean birth compared with vaginal birth, effective interventions must be established for prevention of surgical site infections. Prophylactic intravenous (IV) antibiotic administration 60 minutes prior to skin incision is recommended for abdominal gynecologic surgery; however, administration of prophylactic antibiotics has traditionally been withheld until after neonatal umbilical cord clamping during cesarean delivery due to the concern for potential transfer of antibiotics to the neonate.
  
  
  OBJECTIVE
  To compare the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for both the mother and the neonate.
  
  
  METHODS
  We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2014) and reference lists of retrieved papers.
  
  
  METHODS
  Randomized controlled trials (RCTs) comparing maternal and neonatal outcomes following prophylactic antibiotics administered prior to skin incision versus after neonatal cord clamping during cesarean delivery. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCT and trials using a cross-over design were not eligible for inclusion in this review. Studies published in abstract form only were eligible for inclusion if sufficient information was available in the report.
  
  
  METHODS
  At least two review authors independently assessed the studies for inclusion, assessed risk of bias, abstracted data and checked entries for accuracy. We assessed the quality of evidence using the GRADE approach.
  
  
  RESULTS
  We included 10 studies (12 trial reports) from which 5041 women contributed data for the primary outcome. The overall risk of bias was low.When comparing prophylactic intravenous (IV) antibiotic administration in women undergoing cesarean delivery, there was a reduction in composite maternal infectious morbidity (risk ratio (RR) 0.57, 95% confidence interval (CI) 0.45 to 0.72, high quality evidence), which was specifically due to the reduction in endometritis (RR 0.54, 95% CI 0.36 to 0.79, high quality evidence) and wound infection (RR 0.59, 95% CI 0.44 to 0.81, high quality evidence) in those that received antibiotics preoperatively as compared to those who received antibiotics after neonatal cord clamping. There were no clear differences in neonatal sepsis (RR 0.76, 95% CI 0.51 to 1.13, moderate quality evidence).There were no clear differences for other maternal outcomes such as urinary tract infection (UTI), cystitis and pyelonephritis (moderate quality evidence), respiratory infection (low quality evidence), or any neonatal outcomes. Maternal side effects were not reported in the included studies.The quality of the evidence using GRADE was high for composite morbidity, endomyometritis, wound infection and neonatal intensive care unit admission, moderate for UTI/cystitis/pyelonephritis and neonatal sepsis, and low for maternal respiratory infection.
  
  
  CONCLUSIONS
  Based on high quality evidence from studies whose overall risk of bias is low, intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decreases the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. Women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be needed to elucidate short- and long-term adverse effects for neonates.
authors.affiliation: Division of Maternal Fetal Medicine, Women’s Health Service Line, Geisinger Health System, 100 N Academy Ave, Danville, PA, 17822, USA. dhanya80@hotmail.com.
authors.forename: A Dhanya
authors.initials: AD
authors.lastname: Mackeen
authors.forename: Roger E
authors.initials: RE
authors.lastname: Packard
authors.forename: Erika
authors.initials: E
authors.lastname: Ota
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Berghella
authors.forename: Jason K
authors.initials: JK
authors.lastname: Baxter
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis / Q000592:standards*; D002585:Cesarean Section / Q000009:adverse effects*; D004334:Drug Administration Schedule; D004716:Endometritis / Q000517:prevention & control; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D013530:Surgical Wound Infection / Q000517:prevention & control*; D014552:Urinary Tract Infections / Q000517:prevention & control
chemical_list: D000900:Anti-Bacterial Agents