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Choice of Prophylactic Antibiotics and Surgical Site Infections After Cesarean Delivery.

ABSTRACT: OBJECTIVE:To examine the rate of surgical site infection according to the choice of antibiotics in women undergoing cesarean delivery. METHODS:We conducted a retrospective cohort study of women undergoing cesarean delivery (labored, unlabored, and scheduled) from 2012 to 2017. Women with chorioamnionitis and those who did not receive any antibiotics were excluded. Our primary outcome was defined a priori as a composite of cellulitis, endometritis, deep wound infection, abdominopelvic abscess, and sepsis. Outcomes were examined according to the choice of antibiotics: cefazolin, a standard alternative (both clindamycin and gentamicin), and inappropriate alternatives (such as clindamycin only). A multivariable logistic regression model was used to calculate the propensity score for each observation, which was the probability of receiving a particular antibiotic regimen. The propensity score-adjusted logistic regression models were conducted to calculate adjusted odds ratios (ORs) and 95% CIs. Firth's penalized likelihood approach was applied to address issues of rare events. RESULTS:Among 6,584 selected women, 6,163 (93.6%), 274 (4.2%), and 147 (2.2%) received cefazolin, a standard alternative, and inappropriate alternatives, respectively. Use of standard alternative antibiotics compared with cefazolin was not associated with increased odds of the primary outcome (crude OR 1.50 [0.92-2.46]; adjusted OR 1.63 [0.97-2.60]) but was associated with increased odds of cellulitis (crude OR 2.07 [1.16-3.70]; adjusted OR 1.93 [1.03-3.31]). Use of inappropriate alternative antibiotics compared with cefazolin was associated with increased odds of the primary outcome (crude OR 4.37 [2.80-6.83]; adjusted OR 4.13 [2.59-6.36]) as well as some components of the composite outcome such as endometritis before discharge (crude OR 6.85 [3.94-11.90]; adjusted OR 6.68 [3.69-11.44]) and cellulitis (crude OR 3.36 [1.78-6.34]; adjusted OR 3.23 [1.63-5.81]). CONCLUSION:Both standard alternative and inappropriate alternatives were associated with increased odds of surgical site infections compared with cefazolin.

SUBMITTER: Kawakita T

PROVIDER: S-EPMC6353631 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Choice of Prophylactic Antibiotics and Surgical Site Infections After Cesarean Delivery.

Kawakita Tetsuya T Huang Chun-Chih CC Landy Helain J HJ

Obstetrics and gynecology 20181001 4

<h4>Objective</h4>To examine the rate of surgical site infection according to the choice of antibiotics in women undergoing cesarean delivery.<h4>Methods</h4>We conducted a retrospective cohort study of women undergoing cesarean delivery (labored, unlabored, and scheduled) from 2012 to 2017. Women with chorioamnionitis and those who did not receive any antibiotics were excluded. Our primary outcome was defined a priori as a composite of cellulitis, endometritis, deep wound infection, abdominopel ...[more]

PMID: 30204697

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Project description:OBJECTIVE:To examine the association of a resident-driven quality initiative with cesarean delivery surgical site infections. METHODS:This was a quasi-experimental, preintervention and postintervention study of women undergoing cesarean delivery at 23 weeks of gestation or greater between January 2015 and June 2018 at a single tertiary care center. We implemented a resident-driven, evidence-based surgical bundle, excluding women who underwent emergency cesarean or had chorioamnionitis. The bundle included routine prophylactic antibiotics (both cefazolin and azithromycin), chlorhexidine alcohol skin preparation, use of clippers instead of a razor, vaginal cleansing with povidone iodine, placental removal by umbilical cord traction, subcutaneous tissue closure if wound thickness greater than 2 cm, suture skin closure, dressing removal between 24 and 48 hours, and use of postoperative chlorhexidine soap. Our primary outcome was surgical site infections (superficial incisional, deep incisional, and organ or space surgical site infections) occurring up to 6 weeks postpartum. Outcomes were compared between the preimplementation period (January 2015-August 2016) and postimplementation period (December 2016-June 2018). Coarsened Exact Matching with k-to-k solution was performed using age, race-ethnicity, body mass index, rupture of membranes, and labor. RESULTS:In total, 1,624 underwent cesarean delivery in the preimplementation and 1,523 postimplementation periods, respectively; 1,100 women in the postimplementation period were matched to 1,100 women in the preimplementation period. The rate of surgical site infections in the unmatched cohort was significantly lower in the postimplementation period compared to those in the preimplementation period (2.2% [33/1,523] vs 4.5% [73/1,624]; odds ratio [OR] 0.47 [95% CI 0.31-0.71]; P<.001). This decrease in the rate of surgical site infections remained statistically significant after matching (1.9% [21/1,100] vs 4.1% [45/1,100]; OR 0.46 [0.27-0.77]; P<.001). CONCLUSION:After implementation of a resident-driven quality initiative using a surgical bundle, we observed a significant decrease in cesarean surgical site infections.

Project description:To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy.A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving ?-lactam antibiotics and those receiving alternatives to ?-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results.The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of "any surgical site infection" were 1.8%, 3.1%, and 3.7% for ?-lactam, ?-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the ?-lactam antibiotics (reference group), the risk of "any surgical site infection" was higher for the group receiving ?-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27-2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31-3.1).Compared with women receiving ?-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended ?-lactam alternative or nonstandard regimen.

Project description:BackgroundThe rate of cesarean delivery is increasing in North America. Surgical site infection following this operation can make it difficult to recover, care for a baby and return home. We aimed to determine the incidence of surgical site infection to 30 days following cesarean delivery, associated risk factors and whether risk factors differed for predischarge versus postdischarge infection.MethodsWe identified a retrospective cohort in Nova Scotia by linking the provincial perinatal database to hospital admissions and physician billings databases to follow women for 30 days after they had given birth by cesarean delivery between Jan. 1, 1997 and Dec. 31, 2012. Logistic regression with generalized estimating equations was used to determine risk factors for infection.ResultsA total of 25 123 women had 33 991 cesarean deliveries over the study period. Of the 25 123, 923 had surgical site infections, giving an incidence rate of 2.7% (95% CI 2.54%-2.89%); the incidence decreased over time. Risk factors for infection (adjusted odds ratios ≥ 1.5) were prepregnancy weight 87.0 kg or more, gaining 30.0 kg or more during pregnancy, chorioamnionitis, maternal blood transfusion, anticoagulation therapy, alcohol or drug abuse, second stage of labour before surgery, delivery in 1997-2000 and delivery in a hospital performing 130-1249 cesarean deliveries annually. Women who gave birth earlier in the study period, those who gave birth in a hospital with 130-949 cesarean deliveries per year and those with more than 1 fetus were at a significantly higher risk for surgical site infection before discharge; women who smoked were at significantly higher risk for surgical site infection after discharge.InterpretationMost risk factors are known before delivery, and some are potentially modifiable. Although the incidence of surgical site infection decreased over time, targeted clinical and infection prevention and control interventions could further reduce the burden of illness associated with this health-care-related infection.

Project description:ImportanceObesity increases the risk of both cesarean delivery and surgical-site infection. Despite widespread use, it is unclear whether prophylactic negative pressure wound therapy reduces surgical-site infection after cesarean delivery in obese women.ObjectiveTo evaluate whether prophylactic negative pressure wound therapy, initiated immediately after cesarean delivery, lowers the risk of surgical-site infections compared with standard wound dressing in obese women.Design, setting, and participantsMulticenter randomized trial conducted from February 8, 2017, through November 13, 2019, at 4 academic and 2 community hospitals across the United States. Obese women undergoing planned or unplanned cesarean delivery were eligible. The study was terminated after 1624 of 2850 participants were recruited when a planned interim analysis showed increased adverse events in the negative pressure group and futility for the primary outcome. Final follow-up was December 18, 2019.InterventionsParticipants were randomly assigned to either undergo prophylactic negative pressure wound therapy, with application of the negative pressure device immediately after repair of the surgical incision (n = 816), or receive standard wound dressing (n = 808).Main outcomes and measuresThe primary outcome was superficial or deep surgical-site infection according to the Centers for Disease Control and Prevention definitions. Secondary outcomes included other wound complications, composite of surgical-site infections and other wound complications, and adverse skin reactions.ResultsOf the 1624 women randomized (mean age, 30.4 years, mean body mass index, 39.5), 1608 (99%) completed the study: 806 in the negative pressure group (median duration of negative pressure, 4 days) and 802 in the standard dressing group. Superficial or deep surgical-site infection was diagnosed in 29 participants (3.6%) in the negative pressure group and 27 (3.4%) in the standard dressing group (difference, 0.36%; 95% CI, -1.46% to 2.19%, P = .70). Of 30 prespecified secondary end points, 25 showed no significant differences, including other wound complications (2.6% vs 3.1%; difference, -0.53%; 95% CI, -1.93% to 0.88%; P = .46) and composite of surgical-site infections and other wound complications (6.5% vs 6.7%; difference, -0.27%; 95% CI, -2.71% to 2.25%; P = .83). Adverse skin reactions were significantly more frequent in the negative pressure group (7.0% vs 0.6%; difference, 6.95%; 95% CI, 1.86% to 12.03%; P < .001).Conclusions and relevanceAmong obese women undergoing cesarean delivery, prophylactic negative pressure wound therapy, compared with standard wound dressing, did not significantly reduce the risk of surgical-site infection. These findings do not support routine use of prophylactic negative pressure wound therapy in obese women after cesarean delivery.Trial registrationClinicalTrials.gov Identifier: NCT03009110.

Dataset Information

Choice of Prophylactic Antibiotics and Surgical Site Infections After Cesarean Delivery.

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Choice of Prophylactic Antibiotics and Surgical Site Infections After Cesarean Delivery.

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