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

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

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

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

5. 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 27 th, 2011

6. 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 27 th, 2011

7. 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

9. Methods 3 electronic databases Pubmed Cochrane Embase Period: 1966-2008 Keywords: antibiotics, antimicrobial cesarean prophylactic, prophylaxis

10. Flow chart Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011 201 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)

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

12. Maternal outcome

13. Neonatal outcome

14. Results before vs after cord clamping OutcomeOR [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 27 th, 2011

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

16. 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

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