Antimicrobial prophylaxis for Cesarean delivery: before or after cord clamping? Dr Emmanuel Boselli Anesthesiology and Intensive Care Department Édouard Herriot Hospital, HCL Lyon, France Swiss Association of Obstetric Anesthesia (SAOA) Fall meeting / SSAR 2011 Interlaken, October 27 th, 2011

Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011 Cesaeran section Risk factor for : –post-partum infection –maternal morbidity –  length of stay

Post-partum infection No antimicrobial prophylaxis Polymicrobial : – Gram + cocci – Gram - bacilli – Anaerobes Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Prevention of infection Rigorous surgical technique Skin disinfection Antimicrobial prophylaxis Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Antimicrobial prophylaxis  infectious complications –endometritis –wound infection –bacteremia or severe infection  length of stay Smaill F et al. Cochrane Database Syst Rev 2002;CD Fall meeting / SSAR 2011, Interlaken, October 27 th, 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;CD Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Surgery = before skin incision Cesarean = after cord clamping –modification of neonatal flora? –risk of neonatal necrotic enterocolitis? Recent data : better before? Optimal timing? 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 27 th, 2011

Methods 3 electronic databases Pubmed Cochrane Embase Period: Keywords: antibiotics, antimicrobial cesarean prophylactic, prophylaxis

Flow chart Fall meeting / SSAR 2011, Interlaken, October 27 th, potential trials 191 RCTs concerning prophylaxis 166 RCTs concerning IV prophylaxis 5 RCTs comparing timing (n = 1108) 10 exclusions (Non RCTs) 25 exclusions (Non IV prophylaxis) 161 exclusions (Efficacy studies)

Results Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Maternal outcome

Neonatal outcome

Results before vs after cord clamping OutcomeOR [95% CI] Maternal Endometritis Wound infection Total infectious morbidity 0.59 [ ] 0.58 [ ] 0.51 [ ] Neonatal Infection Suspected sepsis Documented sepsis Admission in ICU 1.06 [ ] 1.02 [ ] 0.93 [ ] 0.97 [ ] Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Conclusion Fall meeting / SSAR 2011, Interlaken, October 27 th, 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 27 th, 2011

Antimicrobial prophylaxis for Cesarean section before cord clamping: To be recommended?