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Cochrane Database of Systematic Reviews

Momento de administración de los antibióticos profilácticos intravenosos para la prevención de la morbilidad infecciosa posparto en pacientes sometidas a cesárea

Information

DOI:
https://doi.org/10.1002/14651858.CD009516.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 05 December 2014see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Pregnancy and Childbirth Group

Copyright:
  1. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • A. Dhanya Mackeen

    Correspondence to: Division of Maternal Fetal Medicine, Women's Health Service Line, Geisinger Health System, Danville, USA

    [email protected]

  • Roger E Packard

    Division of Maternal Fetal Medicine, Women's Health Service Line, Geisinger Health System, Danville, USA

  • Erika Ota

    Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan

  • Vincenzo Berghella

    Division of Maternal‐Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA

  • Jason K Baxter

    Division of Maternal‐Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA

Contributions of authors

A. Dhanya Mackeen, Roger Packard and Erika Ota abstracted data from the studies and entered data into RevMan. A. Dhanya Mackeen, Roger Packard, Vincenzo Berghella, and Erika Ota prepared the first draft. Erika Ota prepared the 'Summary of findings' tables. All authors approved the final version of the update for publication. A. Dhanya Mackeen is guarantor for the review.

Sources of support

Internal sources

  • UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.

    Erika Ota's work was financially supported by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization.

External sources

  • No sources of support supplied

Declarations of interest

None known.

Acknowledgements

Erika Ota's work was financially supported by the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), World Health Organization. The named authors alone are responsible for the views expressed in this publication.

The authors would like to thank Tanya Ohly and Samantha Weed for helping develop the protocol (Baxter 2011).

As part of the pre‐publication editorial process, this review has been commented on by two peers (an editor and referee who is external to the editorial team), a member of the Pregnancy and Childbirth Group's international panel of consumers and the Group's Statistical Adviser.

Version history

Published

Title

Stage

Authors

Version

2014 Dec 05

Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery

Review

A. Dhanya Mackeen, Roger E Packard, Erika Ota, Vincenzo Berghella, Jason K Baxter

https://doi.org/10.1002/14651858.CD009516.pub2

2011 Dec 07

Timing of prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery

Protocol

Jason K Baxter, Vincenzo Berghella, A Dhanya Mackeen, N. Tanya Ohly, Samantha Weed

https://doi.org/10.1002/14651858.CD009516

Differences between protocol and review

We have assessed the quality of the body of evidence using the GRADE approach (Schunemann 2009) ‐ this was not pre‐specified in our published protocol (Baxter 2011).

We added a subgroup analysis based on dose of cephalosporin (1 g versus 2 g).

We changed the definition of our primary outcome of composite morbidity to include sepsis (including septic shock), endomyometritis, wound infection, or death attributed to infection. We removed necrotizing fasciitis and bacteremia as these would have been included in infection and sepsis.

In addition, some sections of the methods have been updated in accordance with the Cochrane Pregnancy and Childbirth Group's standard methods text:

  • assessment of reporting biases;

  • subgroup analysis and investigation of heterogeneity.

We have also made minor edits to the list of planned outcomes:

Secondary maternal outcomes

  • 'Urinary tract infection' has been edited to 'Urinary tract infection, cystitis and pyelonephritis'

  • 'Upper respiratory infection (pneumonia) has been edited to 'Respiratory infection (e.g. pneumonia)'

  • 'Fever' has been changed to 'Febrile illness'

  • 'Sepsis' has been changed to 'Sepsis, including septic shock'

  • Clarified that the unit for hospital length of stay is in days

Secondary infant outcomes

  • 'Neonatal workup for infection' has been edited to 'Neonatal sepsis workup'

  • Length of ICU stay has been clarified as 'Length of ICU stay (days)'

  • 'Antibiotic treatment' has been edited to 'Neonatal antibiotic treatment'

  • Febrile illness has been added as a new secondary outcome

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

'Risk of bias. graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

'Risk of bias. graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Funnel plot of comparison: 1 Maternal postpartum infectious morbidity, outcome: 1.1 Composite morbidity (as defined by trials).
Figures and Tables -
Figure 4

Funnel plot of comparison: 1 Maternal postpartum infectious morbidity, outcome: 1.1 Composite morbidity (as defined by trials).

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 1 Composite morbidity (as defined by trials).
Figures and Tables -
Analysis 1.1

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 1 Composite morbidity (as defined by trials).

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 2 Endomyometritis.
Figures and Tables -
Analysis 1.2

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 2 Endomyometritis.

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 3 Wound infection.
Figures and Tables -
Analysis 1.3

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 3 Wound infection.

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 4 UTI/cystitis/pyelonephritis.
Figures and Tables -
Analysis 1.4

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 4 UTI/cystitis/pyelonephritis.

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 5 Pelvic abscess.
Figures and Tables -
Analysis 1.5

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 5 Pelvic abscess.

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 6 Respiratory infection (pneumonia).
Figures and Tables -
Analysis 1.6

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 6 Respiratory infection (pneumonia).

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 7 Hospital length of stay (days).
Figures and Tables -
Analysis 1.7

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 7 Hospital length of stay (days).

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 8 Febrile Illness.
Figures and Tables -
Analysis 1.8

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 8 Febrile Illness.

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 1 Sepsis.
Figures and Tables -
Analysis 2.1

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 1 Sepsis.

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 2 Neonatal sepsis work up.
Figures and Tables -
Analysis 2.2

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 2 Neonatal sepsis work up.

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 3 Infection with a resistant organism.
Figures and Tables -
Analysis 2.3

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 3 Infection with a resistant organism.

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 4 Infection (other).
Figures and Tables -
Analysis 2.4

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 4 Infection (other).

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 5 ICU admission.
Figures and Tables -
Analysis 2.5

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 5 ICU admission.

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 6 ICU length of stay (days).
Figures and Tables -
Analysis 2.6

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 6 ICU length of stay (days).

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 7 Neonatal antibiotic treatment.
Figures and Tables -
Analysis 2.7

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 7 Neonatal antibiotic treatment.

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 8 Fever.
Figures and Tables -
Analysis 2.8

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 8 Fever.

Summary of findings for the main comparison. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping

Prophylactic antibiotics for preventing postpartum infectious morbidity in women and infants after cesarean delivery

Population: women undergoing cesarean delivery.
Settings: eight trials were conducted in developed countries: seven from US, one from Austria. Five trials were conducted in developing countries: two trials from India, one trial each from Egypt, South Africa and Turkey.
Intervention: prophylactic intravenous antibiotic administration for cesarean birth administered prior to skin incision versus after neonatal umbilical cord clamping.

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Maternal and neonatal postpartum infectious morbidity

Maternal composite morbidity

Study population

RR 0.67
(0.54 to 0.82)

5041
(10 studies)

⊕⊕⊕⊕
high

85 per 1000

57 per 1000
(46 to 70)

Moderate

97 per 1000

65 per 1000
(52 to 80)

Maternal endomyometritis

Study population

RR 0.54
(0.36 to 0.79)

5041
(10 studies)

⊕⊕⊕⊕
high

28 per 1000

15 per 1000
(10 to 22)

Moderate

26 per 1000

14 per 1000
(9 to 21)

Maternal wound Infection

Study population

RR 0.59
(0.44 to 0.81)

5041
(10 studies)

⊕⊕⊕⊕
high

41 per 1000

24 per 1000
(17 to 33)

Moderate

51 per 1000

30 per 1000
(22 to 41)

Maternal UTI/cystitis/pyelonephritis

Study population

RR 1.02
(0.65 to 1.59)

4001
(8 studies)

⊕⊕⊕⊝
moderate1

18 per 1000

18 per 1000
(12 to 29)

Moderate

13 per 1000

13 per 1000
(8 to 21)

Maternal respiratory infection (pneumonia)

Study population

RR 2.3
(0.34 to 15.45)

1158
(2 studies)

⊕⊕⊝⊝
low2

2 per 1000

4 per 1000
(1 to 27)

Moderate

0 per 1000

0 per 1000
(0 to 0)

Neonatal sepsis

Study population

RR 0.76
(0.51 to 1.13)

2907
(5 studies)

⊕⊕⊕⊝
moderate1

37 per 1000

28 per 1000
(19 to 42)

Moderate

40 per 1000

30 per 1000
(20 to 45)

Neonatal ICU admission

Study population

RR 0.91
(0.74 to 1.13)

3708
(6 studies)

⊕⊕⊕⊕
high

86 per 1000

78 per 1000
(64 to 97)

Moderate

71 per 1000

65 per 1000
(53 to 80)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

1 Wide confidence interval crossing the line of no effect.
2 Wide confidence interval crossing the line of no effect, few events and small sample size.

Figures and Tables -
Summary of findings for the main comparison. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping
Comparison 1. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Composite morbidity (as defined by trials) Show forest plot

10

5041

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.45, 0.72]

1.1 Cephalosporin 1 g

5

2144

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.35, 0.86]

1.2 Cephalosporin 2 g

5

2897

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.43, 0.76]

2 Endomyometritis Show forest plot

10

5041

Risk Ratio (M‐H, Fixed, 95% CI)

0.54 [0.36, 0.79]

2.1 Cephalosporin 1 g

5

2144

Risk Ratio (M‐H, Fixed, 95% CI)

0.58 [0.30, 1.12]

2.2 Cephalosporin 2 g

5

2897

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.32, 0.83]

3 Wound infection Show forest plot

10

5041

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.44, 0.81]

3.1 Cephalosporin 1 g

5

2144

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.30, 1.01]

3.2 Cephalosporin 2 g

5

2897

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.43, 0.88]

4 UTI/cystitis/pyelonephritis Show forest plot

8

4001

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.65, 1.59]

5 Pelvic abscess Show forest plot

1

741

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.06, 15.97]

6 Respiratory infection (pneumonia) Show forest plot

4

1849

Risk Ratio (M‐H, Fixed, 95% CI)

2.30 [0.34, 15.45]

7 Hospital length of stay (days) Show forest plot

2

1342

Mean Difference (IV, Fixed, 95% CI)

‐0.17 [‐0.30, ‐0.04]

8 Febrile Illness Show forest plot

4

2650

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.63, 1.35]

Figures and Tables -
Comparison 1. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes)
Comparison 2. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Sepsis Show forest plot

5

2907

Risk Ratio (M‐H, Fixed, 95% CI)

0.76 [0.51, 1.13]

2 Neonatal sepsis work up Show forest plot

4

1170

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.69, 1.23]

3 Infection with a resistant organism Show forest plot

1

379

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.12, 4.14]

4 Infection (other) Show forest plot

1

302

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.52, 1.64]

5 ICU admission Show forest plot

6

3708

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.74, 1.13]

6 ICU length of stay (days) Show forest plot

3

1731

Mean Difference (IV, Random, 95% CI)

‐0.07 [‐2.60, 2.46]

7 Neonatal antibiotic treatment Show forest plot

1

90

Risk Ratio (M‐H, Fixed, 95% CI)

0.84 [0.12, 5.68]

8 Fever Show forest plot

1

953

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.28, 1.62]

Figures and Tables -
Comparison 2. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes)