Antibiotic regimens for management of intra‐amniotic infection

Evelina Chapman; Ludovic Reveiz; Eduardo Illanes; Xavier Bonfill Cosp

doi:10.1002/14651858.CD010976.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Analysis 3.1

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 1 Treatment failure (endometritis).

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Analysis 3.2

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 2 Initial successful response to antibiotics.

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Analysis 3.3

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 3 Maximum maternal temperature.

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Analysis 3.4

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 4 Postpartum hemorrhage.

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Analysis 3.5

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 5 Blood transfusion.

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Analysis 3.6

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 6 Maternal postpartum hospital stay (days).

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Analysis 3.7

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 7 Histologic chorioamnionitis.

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Analysis 3.8

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 8 Neonatal sepsis.

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Analysis 3.9

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 9 Respiratory distress syndrome.

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Analysis 3.10

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 10 Neonatal antibiotic (days).

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Analysis 3.11

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 11 Treatment failure.

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Analysis 3.12

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 12 Maternal death.

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Analysis 3.13

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 13 Postpartum endometritis (double vs triple therapy).

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Analysis 3.14

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 14 Postpartum endometritis vaginal delivery (double vs triple therapy).

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Analysis 3.15

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 15 Postpartum endometritis cesarean section (double vs triple therapy).

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Analysis 3.16

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 16 Neonatal sepsis (blood culture).

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Analysis 3.17

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 17 Neonatal deaths.

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Analysis 3.18

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 18 Intraventricular hemorrhage.

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Analysis 3.19

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 19 Respiratory distress syndrome.

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Analysis 3.20

Comparison 3 Antibiotics versus antibiotics during labor, Outcome 20 Neonatal seizures.

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Analysis 4.1

Comparison 4 Antibiotics versus no treatment during postpartum period, Outcome 1 Postpartum endometritis.

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Analysis 4.2

Comparison 4 Antibiotics versus no treatment during postpartum period, Outcome 2 Wound infection.

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Analysis 4.3

Comparison 4 Antibiotics versus no treatment during postpartum period, Outcome 3 Neonatal sepsis.

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Analysis 4.4

Comparison 4 Antibiotics versus no treatment during postpartum period, Outcome 4 Neonatal death.

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Analysis 4.5

Comparison 4 Antibiotics versus no treatment during postpartum period, Outcome 5 Trasient tachypnea.

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Analysis 5.1

Comparison 5 Antibiotics versus placebo during postpartum period, Outcome 1 Treatment failure.

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Analysis 5.2

Comparison 5 Antibiotics versus placebo during postpartum period, Outcome 2 Endomyometritis.

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Analysis 5.3

Comparison 5 Antibiotics versus placebo during postpartum period, Outcome 3 Wound infection.

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Analysis 5.4

Comparison 5 Antibiotics versus placebo during postpartum period, Outcome 4 Maternal sepsis.

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Analysis 5.5

Comparison 5 Antibiotics versus placebo during postpartum period, Outcome 5 Readmission to hospital.

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Analysis 6.1

Comparison 6 Antibiotic versus antibiotics during postpartum period, Outcome 1 Treatment failure.

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Analysis 6.2

Comparison 6 Antibiotic versus antibiotics during postpartum period, Outcome 2 Nephrotoxicity.

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Analysis 6.3

Comparison 6 Antibiotic versus antibiotics during postpartum period, Outcome 3 Length of treatment (days).

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Analysis 7.1

Comparison 7 Antibiotics (short duration) versus antibiotics (long duration) in postpartum, Outcome 1 Duration of hospital stay (days).

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Analysis 7.2

Comparison 7 Antibiotics (short duration) versus antibiotics (long duration) in postpartum, Outcome 2 Treatment failure (vaginal and cesarean delivery).

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Analysis 7.3

Comparison 7 Antibiotics (short duration) versus antibiotics (long duration) in postpartum, Outcome 3 Treatment failure (cesarean delivery).

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Analysis 7.4

Comparison 7 Antibiotics (short duration) versus antibiotics (long duration) in postpartum, Outcome 4 Treatment failure (vaginal delivery).

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Analysis 7.5

Comparison 7 Antibiotics (short duration) versus antibiotics (long duration) in postpartum, Outcome 5 Wound infection.

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Analysis 7.6

Comparison 7 Antibiotics (short duration) versus antibiotics (long duration) in postpartum, Outcome 6 Pelvic abscess.

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Analysis 8.1

Comparison 8 Intrapartum versus postpartum treatment, Outcome 1 Maximum maternal temperature postpartum.

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Analysis 8.2

Comparison 8 Intrapartum versus postpartum treatment, Outcome 2 Maternal postpartum hospital stay (days).

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Analysis 8.3

Comparison 8 Intrapartum versus postpartum treatment, Outcome 3 Maternal febrile days.

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Analysis 8.4

Comparison 8 Intrapartum versus postpartum treatment, Outcome 4 Maternal bacteremia.

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Analysis 8.5

Comparison 8 Intrapartum versus postpartum treatment, Outcome 5 Early neonatal sepsis.

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Analysis 8.6

Comparison 8 Intrapartum versus postpartum treatment, Outcome 6 Neonatal pneumonia or sepsis.

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Analysis 8.7

Comparison 8 Intrapartum versus postpartum treatment, Outcome 7 Neonatal hospital stay.

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Summary of findings for the main comparison. Antibiotics versus antibiotics in labor for management of intra‐amniotic infection

Antibiotics versus antibiotics in labor for management of intra‐amniotic infection
Population: women in labor with management of intra‐amniotic infection Settings: hospitals in the USA Intervention: antibiotics vs antibiotics in labor
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Antibiotics versus antibiotics
Maternal death	See comment	See comment	Not estimable	38 (1 study)	See comment	Comparing daily gentamicin versus 8‐hour gentamicin. Outcome was reported with no events.
Neonatal deaths	Study population		RR 1.39 (0.24 to 8.06)	133 (1 study)	⊕⊝⊝⊝ Very low^a,b	Comparing dual‐agent therapy versus triple‐agent therapy.
	31 per 1000	43 per 1000 (7 to 252)
	Moderate
	31 per 1000	43 per 1000 (7 to 250)
Neonatal sepsis	Study population		RR 1.07 (0.4 to 2.86)	163 (2 studies)	⊕⊕⊝⊝ Low^a	Comparing daily gentamicin versus 8‐hour gentamicin.
	84 per 1000	90 per 1000 (34 to 241)
	Moderate
	141 per 1000	151 per 1000 (56 to 403)
Respiratory distress syndrome	Study population		RR 1.69 (0.42 to 6.78)	125 (1 study)	⊕⊕⊝⊝ Low^a	Comparing daily gentamicin versus 8‐hour gentamicin.
	48 per 1000	80 per 1000 (20 to 323)
	Moderate
	48 per 1000	81 per 1000 (20 to 325)
Maternal postpartum hospital stay (days)		Mean maternal postpartum hospital stay (days) in the intervention groups was 0 higher (0.43 lower to 0.43 higher)		125 (1 study)	⊕⊕⊝⊝ Low^c	Comparing daily gentamicin versus 8‐hour gentamicin.
Postpartum readmission for endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Treatment failure (endometritis)	Study population		RR 0.86 (0.27 to 2.7)	163 (2 studies)	⊕⊕⊝⊝ Low^a	Comparing daily gentamicin versus 8‐hour gentamicin.
	72 per 1000	62 per 1000 (20 to 195)
	Moderate
	65 per 1000	56 per 1000 (18 to 176)
The basis for the assumed risk* (eg, 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.
^aWide confidence interval crossing the line of no effect, few events, and small sample size. ^bOne study with design limitations. ^cWide confidence interval crossing the line of no effect and small sample size.

Summary of findings for the main comparison. Antibiotics versus antibiotics in labor for management of intra‐amniotic infection

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Summary of findings 2. Antibiotics versus no treatment during postpartum period for management of intra‐amniotic infection

Antibiotics versus no treatment during postpartum period for management of intra‐amniotic infection
Population: women with management of intra‐amniotic infection Settings: 2 hospitals in USA Intervention: antibiotics vs no treatment during postpartum period
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Antibiotics versus no treatment during postpartum period
Neonatal death	Study population		RR 3.32 (0.14 to 79.88)	116 (1 study)	⊕⊝⊝⊝ Very low^a,b
	Not estimable
	Moderate
	Not estimable
Neonatal sepsis	Study population		RR 1.11 (0.23 to 5.27)	55 (1 study)	⊕⊝⊝⊝ Very low^a,b
	148 per 1000	55 per 1000 (11 to 259)
	Moderate
	148 per 1000	54 per 1000 (11 to 258)
Postpartum endometritis	Study population		RR 1.48 (0.68 to 3.24)	116 (1 study)	⊕⊝⊝⊝ Very low^a,b
	148 per 1000	218 per 1000 (100 to 478)
	Moderate
	148 per 1000	219 per 1000 (101 to 480)
Duration of maternal and neonatal hospital stay	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Need for additional antibiotic therapy	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Postpartum readmission for endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Failure of treatment	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

The basis for the assumed risk* (eg, 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.
^aOne study with design limitations. ^bWide confidence interval crossing the line of no effect, few events, and small sample size.

Summary of findings 2. Antibiotics versus no treatment during postpartum period for management of intra‐amniotic infection

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Summary of findings 3. Antibiotics versus placebo during postpartum period for management of intra‐amniotic infection

Antibiotics versus placebo during postpartum period for management of intra‐amniotic infection
Population: women with management of intra‐amniotic infection Settings: hospitals in USA Intervention: antibiotics vs placebo during postpartum period
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Antibiotics versus placebo during postpartum period
Maternal and neonatal mortality	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Maternal and neonatal severe infection	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Duration of maternal and neonatal hospital stay	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Endomyometritis	See comment	See comment	Not estimable	288 (2 studies)	See comment	This outcome was reported with no events.
Need for additional antibiotic therapy	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Postpartum readmission for endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Treatment failure	Study population		RR 0.97 (0.14 to 6.77)	288 (2 studies)	⊕⊝⊝⊝ Very low^a,b	The outcome was reported with no events in one study.
	14 per 1000	14 per 1000 (2 to 97)
	Moderate
	8 per 1000	8 per 1000 (1 to 54)
The basis for the assumed risk* (eg, 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.
^aOne study with serious design limitations. ^bWide confidence interval crossing the line of no effect and small sample size.

Summary of findings 3. Antibiotics versus placebo during postpartum period for management of intra‐amniotic infection

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Summary of findings 4. Antibiotic versus antibiotics during postpartum period for management of intra‐amniotic infection

Antibiotic versus antibiotics during postpartum period for management of intra‐amniotic infection
Population: women with management of intra‐amniotic infection Settings: obstetric service in North Carolina Intervention: antibiotic vs antibiotics during postpartum period
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Antibiotic versus antibiotics during postpartum period
Maternal and neonatal mortality	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Maternal and neonatal severe infection	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Length of treatment (days)		Mean length of treatment (days) in the intervention groups was 0.3 lower (0.9 lower to 0.3 higher)		131 (1 study)	⊕⊝⊝⊝ Very low^a,b	Once daily versus thrice daily.
Endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Postpartum readmission for endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Treatment failure	Study population		RR 1.02 (0.27 to 3.89)	131 (1 study)	⊕⊝⊝⊝ Very low^a,b	Once daily versus thrice daily.
	61 per 1000	62 per 1000 (16 to 236)
	Moderate
	61 per 1000	62 per 1000 (16 to 237)
The basis for the assumed risk* (eg, 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.
^aOne study with design limitations. ^bWide confidence interval crossing the line of no effect and small sample size.

Summary of findings 4. Antibiotic versus antibiotics during postpartum period for management of intra‐amniotic infection

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Summary of findings 5. Antibiotics (short duration) compared with antibiotics (long duration) postpartum for management of intra‐amniotic infection

Antibiotics (short duration) compared with antibiotics (long duration) postpartum for management of intra‐amniotic infection
Population: women with management of intra‐amniotic infection Settings: Delivery Unit at Shands Hospital at the University of Florida Intervention: antibiotics (short duration) Comparison: antibiotics (long duration) in postpartum
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Antibiotics (long duration) postpartum	Antibiotics (short duration)
Maternal and neonatal mortality	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Wound infection	Study population		RR 1.87 (0.17 to 20.37)	292 (1 study)	⊕⊕⊝⊝ Low^a
	7 per 1000	13 per 1000 (1 to 144)
	Moderate
	7 per 1000	13 per 1000 (1 to 143)
Duration of hospital stay (days)		Mean duration of hospital stay (days) in the intervention groups was 0.9 lower (1.64 to 0.16 lower)		292 (1 study)	⊕⊕⊕⊝ Moderate^b
Need for additional antibiotic therapy	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Postpartum readmission for endometritis	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Treatment failure (vaginal and cesarean delivery)	Study population		RR 1.31 (0.42 to 4.02)	292 (1 study)	⊕⊕⊝⊝ Low^a
	35 per 1000	46 per 1000 (15 to 143)
	Moderate

The basis for the assumed risk* (eg, 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.
^aWide confidence interval crossing the line of no effect and small sample size. ^bEstimate based on small sample size.

Summary of findings 5. Antibiotics (short duration) compared with antibiotics (long duration) postpartum for management of intra‐amniotic infection

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Summary of findings 6. Intrapartum compared with postpartum treatment

Intrapartum compared with postpartum treatment
Population: women with management of intra‐amniotic infection Settings: a tertiary care facility Intervention: intrapartum Comparison: postpartum
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
		Intrapartum
Maternal and neonatal mortality	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

Maternal bacteremia	Study population		RR 2.19 (0.25 to 19.48)	45 (1 study)	⊕⊝⊝⊝ Very low^a,b
	53 per 1000	115 per 1000 (13 to 1000)
	Moderate
	53 per 1000	116 per 1000 (13 to 1000)
Early neonatal sepsis	Study population		RR 0.08 (0 to 1.44)	45 (1 study)	⊕⊝⊝⊝ Very low^a,b
	211 per 1000	17 per 1000 (0 to 303)
	Moderate
	211 per 1000	17 per 1000 (0 to 304)
Neonatal pneumonia or sepsis	Study population		RR 0.06 (0 to 0.95)	45 (1 study)	⊕⊝⊝⊝ Very low^a,c
	316 per 1000	19 per 1000 (0 to 300)
	Moderate
	316 per 1000	19 per 1000 (0 to 300)
Maternal postpartum hospital stay (days)		Mean maternal postpartum hospital stay (days) in the intervention groups was 1 lower (1.94 to 0.06 lower)		45 (1 study)	⊕⊝⊝⊝ Very low^a,b
Neonatal hospital stay		Mean neonatal hospital stay in the intervention groups was 1.9 lower (3.31 to 0.49 lower)		45 (1 study)	⊕⊝⊝⊝ Very low^a,d
Endometritis/Failure treatment	Study population		Not estimable	0 (0)	See comment	This outcome was not reported in any of the included studies.
	See comment	See comment
	Moderate

The basis for the assumed risk* (eg, 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.
^aOne study with serious design limitations. ^bWide confidence interval crossing the line of no effect and small sample size. ^cWide confidence interval. ^dSmall sample size.

Summary of findings 6. Intrapartum compared with postpartum treatment

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Comparison 3. Antibiotics versus antibiotics during labor

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Treatment failure (endometritis) Show forest plot	2	163	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.27, 2.70]

2 Initial successful response to antibiotics Show forest plot	1	125	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.94, 1.17]

3 Maximum maternal temperature Show forest plot	1	125	Mean Difference (IV, Fixed, 95% CI)	0.40 [‐0.45, 1.25]

4 Postpartum hemorrhage Show forest plot	2	163	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.76, 2.56]

5 Blood transfusion Show forest plot	1	125	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.18, 3.27]

6 Maternal postpartum hospital stay (days) Show forest plot	1	125	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.43, 0.43]

7 Histologic chorioamnionitis Show forest plot	1	125	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.63, 1.33]

8 Neonatal sepsis Show forest plot	2	163	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.40, 2.86]

9 Respiratory distress syndrome Show forest plot	1	125	Risk Ratio (M‐H, Fixed, 95% CI)	1.69 [0.42, 6.78]

10 Neonatal antibiotic (days) Show forest plot	1	125	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.37, 0.77]

11 Treatment failure Show forest plot	1	19	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

12 Maternal death Show forest plot	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

13 Postpartum endometritis (double vs triple therapy) Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.86 [0.67, 5.14]

14 Postpartum endometritis vaginal delivery (double vs triple therapy) Show forest plot	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	9.63 [0.55, 167.95]

15 Postpartum endometritis cesarean section (double vs triple therapy) Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.32, 3.10]

16 Neonatal sepsis (blood culture) Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.06, 14.52]

17 Neonatal deaths Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.24, 8.06]

18 Intraventricular hemorrhage Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	4.64 [0.23, 94.90]

19 Respiratory distress syndrome Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.36, 3.47]

20 Neonatal seizures Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.06, 14.52]

Comparison 3. Antibiotics versus antibiotics during labor

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Comparison 4. Antibiotics versus no treatment during postpartum period

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Postpartum endometritis Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	1.48 [0.68, 3.24]

2 Wound infection Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	0.37 [0.04, 3.45]

3 Neonatal sepsis Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.23, 5.27]

4 Neonatal death Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	3.32 [0.14, 79.88]

5 Trasient tachypnea Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.19, 3.55]

Comparison 4. Antibiotics versus no treatment during postpartum period

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Comparison 5. Antibiotics versus placebo during postpartum period

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Treatment failure Show forest plot	2	288	Risk Ratio (M‐H, Fixed, 95% CI)	0.97 [0.14, 6.77]

2 Endomyometritis Show forest plot	2	288	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

3 Wound infection Show forest plot	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Maternal sepsis Show forest plot	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

5 Readmission to hospital Show forest plot	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Antibiotics versus placebo during postpartum period

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Comparison 6. Antibiotic versus antibiotics during postpartum period

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Treatment failure Show forest plot	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	1.02 [0.27, 3.89]

2 Nephrotoxicity Show forest plot	1	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

3 Length of treatment (days) Show forest plot	1	131	Mean Difference (IV, Fixed, 95% CI)	‐0.30 [‐0.90, 0.30]

Comparison 6. Antibiotic versus antibiotics during postpartum period

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Comparison 7. Antibiotics (short duration) versus antibiotics (long duration) in postpartum

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Duration of hospital stay (days) Show forest plot	1	292	Mean Difference (IV, Fixed, 95% CI)	‐0.90 [‐1.64, ‐0.16]

2 Treatment failure (vaginal and cesarean delivery) Show forest plot	1	292	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.42, 4.02]

3 Treatment failure (cesarean delivery) Show forest plot	1	117	Risk Ratio (M‐H, Fixed, 95% CI)	3.31 [0.38, 28.75]

4 Treatment failure (vaginal delivery) Show forest plot	2	284	Risk Ratio (M‐H, Random, 95% CI)	1.46 [0.39, 5.51]

5 Wound infection Show forest plot	1	292	Risk Ratio (M‐H, Fixed, 95% CI)	1.87 [0.17, 20.37]

6 Pelvic abscess Show forest plot	1	292	Risk Ratio (M‐H, Fixed, 95% CI)	2.80 [0.12, 68.24]

Comparison 7. Antibiotics (short duration) versus antibiotics (long duration) in postpartum

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Comparison 8. Intrapartum versus postpartum treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maximum maternal temperature postpartum Show forest plot	1	45	Mean Difference (IV, Fixed, 95% CI)	‐0.5 [‐1.08, 0.08]

2 Maternal postpartum hospital stay (days) Show forest plot	1	45	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐1.94, ‐0.06]

3 Maternal febrile days Show forest plot	1	45	Mean Difference (IV, Fixed, 95% CI)	‐1.06 [‐2.04, ‐0.08]

4 Maternal bacteremia Show forest plot	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	2.19 [0.25, 19.48]

5 Early neonatal sepsis Show forest plot	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	0.08 [0.00, 1.44]

6 Neonatal pneumonia or sepsis Show forest plot	1	45	Risk Ratio (M‐H, Fixed, 95% CI)	0.06 [0.00, 0.95]

7 Neonatal hospital stay Show forest plot	1	45	Mean Difference (IV, Fixed, 95% CI)	‐1.90 [‐3.31, ‐0.49]

Comparison 8. Intrapartum versus postpartum treatment

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