Swiss Association of Obstetric Anesthesia SAOA Fall meeting

Swiss Association of Obstetric Anesthesia (SAOA) Fall meeting / SSAR 2011 Interlaken, October 27 th, 2011 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

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

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 000933 Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Antimicrobial agent Single-dose cefazolin (1 GC) – as efficient as larger-spectrum agents – as efficient as multiple-doses Allergy : clindamycin Hopkins L et al. Cochrane Database Syst Rev 2000; CD 001136 Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Optimal timing? Surgery = before skin incision Cesarean = after cord clamping – modification of neonatal flora? – risk of neonatal necrotic enterocolitis? Recent data : better before? Thigpen BD et al. Am J Obstet Gynecol 2005; 192: 1864– 71 Sullivan SA et al. Am J Obstet Gynecol 2007; 196: 455[e 1–e 5] Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Methods 3 electronic databases • Pubmed • Cochrane • Embase Period: 1966 -2008 Keywords: • antibiotics, antimicrobial • cesarean • prophylactic, prophylaxis Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

Flow chart 201 potential trials 10 exclusions (Non RCTs) 191 RCTs concerning prophylaxis 25 exclusions (Non IV prophylaxis) 166 RCTs concerning IV prophylaxis 161 exclusions (Efficacy studies) 5 RCTs comparing timing (n = 1108) Fall meeting / SSAR 2011, Interlaken, October 27 th, 2011

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

Maternal outcome

Neonatal outcome

Results before vs after cord clamping Outcome Maternal Endometritis Wound infection Total infectious morbidity Neonatal Infection Suspected sepsis Documented sepsis Admission in ICU OR [95% CI] 0. 59 [0. 39 -0. 98] 0. 58 [0. 29 -1. 16] 0. 51 [0. 32 -0. 82] 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

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