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CMECNE

ACOG Responds to ANODE Trial and Antibiotic Use for Operative Vaginal Delivery

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Describe the key highlights from the ANODE Trial
2. Discuss the ACOG recommendations for use of antibiotics during operative vaginal delivery and the reasoning behind the guidelines

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 12/01/2022 through 12/01/2024, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

ACOG has published a Practice Bulletin (April 2020) that provides guidance on the use of antibiotics in the setting of operative vaginal delivery. The recommendations follow the publication of the ANODE RCT that demonstrated antibiotic prophylaxis reduces the risk of maternal infection following operative vaginal birth. The authors of this trial concluded that “this trial shows clear benefit of a single dose of prophylactic antibiotic after operative vaginal birth, and guidance should be changed to reflect this finding”

Summary of the ANODE Trial

Background and Purpose

Knight et al. (Lancet, 2019) investigated whether antibiotic prophylaxis was effective at preventing maternal infection following operative vaginal birth

Methods

Blinded, randomized controlled trial (RCT)
- 27 UK obstetric units
Participants
- ≥16 years who had undergone operative vaginal birth at ≥36 weeks
Exposure
- Single dose IV: 1 g amoxicillin and 200 mg clavulanic acid
- Administered as soon as possible and no more than 6 h after giving birth
Primary outcome
- Confirmed or suspected maternal infection within 6 weeks of delivery

Results

3,420 women
- 1,715 in antibiotic group | 1,705 in placebo group
Significantly fewer women in the amoxicillin and clavulanic acid group had confirmed or suspected infection
- 11% of amoxicillin and clavulanic acid group
- 19% of placebo group
- Risk ratio (RR) 0.58, (95% CI, 0.49–0.69; p<0.0001)
Intervention benefit was also seen at 6 weeks post-delivery with significantly lower proportion of women affected with secondary adverse outcomes such as wound breakdown, perineal infection and pain
Forceps and vacuum separately (post-hoc analysis)
- In both forceps and vacuum, number of women with infection was reduced by approximately 50%

KEY POINTS:

ACOG Response

Limitations of the ANODE trial
- 89% of women received an episiotomy | Assumption that most are mediolateral based on UK setting
- Therefore, results not necessarily generalizable due to different practice patterns in the US currently vs UK at the time the study was undertaken
- ACOG states that the

…use of routine prophylactic antibiotics before delivery would not be recommended. Because wound infections and complications are more common in the setting of a third- or fourth-degree laceration, it may be more judicious to consider antibiotics if a third- or fourth-degree laceration occurs”

Learn More – Primary Sources:

ACOG Practice Bulletin 219: Operative Vaginal Birth

Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial

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ACOG Responds to ANODE Trial and Antibiotic Use for Operative Vaginal Delivery