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Grand Rounds

Can Clarithromycin Be Used as Antibiotic Prophylaxis for Cesarean When Azithromycin is Unavailable?

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BACKGROUND AND PURPOSE:

  • There have been reported shortages of azithromycin due to the COVID-19 pandemic | Azithromycin can be considered for adjunct use in women undergoing cesarean section in addition to standard prophylaxis (usually cefazolin)
  • Martingano et al (PLoS ONE, 2020) evaluated safety and effectiveness of clarithromycin as an adjunct prophylactic alternative for patients undergoing non-elective cesarean delivery

METHODS:

  • Multi-center, prospective observational cohort study
  • Participants
    • Women undergoing non-elective cesarean deliveries
  • Exposures
    • Clarithromycin for adjunct surgical prophylaxis
    • No macrolide antibiotic
  • Primary outcome
    • Development of postpartum endometritis
  • Secondary outcomes
    • Meconium-stained amniotic fluid at time of cesarean delivery
    • Neonatal sepsis
    • NICU admission
    • Neonatal acute respiratory distress syndrome

RESULTS:

  • 240 patients
    • Clarithromycin: 133 patients
    • No macrolide prophylaxis: 107 patients
  • Patients who received clarithromycin had significantly lower rates of postpartum endometritis (P=0.025)
    • Clarithromycin: 4.5%
    • No macrolide prophylaxis: 11.2%
  • In unadjusted analysis, there was a significantly lower risk for developing endometritis in the clarithromycin group (P=0.040)
    • 66% decreased risk (95% CI, 0.12 to 0.95)
  • Adjusted analysis:  Risk for endometritis in the clarithromycin group was still significantly lower (P=0.034)
    • 67% decreased risk (95% CI, 0.11 to 0.97)
  • In stratified analysis, there was a significantly decreased risk of endometritis with clarithromycin in
    • Black women
      • Crude: 87% decreased risk (95% CI, 0.08 to 0.83; P=0.032)
      • Adjusted: 91% decreased risk (95% CI, 0.06 to 0.79; P=0.026)
    • Women 18 to 29 years
      • Crude: 79% decreased risk (95% CI, 0.06 to 0.80; P=0.014)
      • Adjusted model: 75% decreased risk (95% CI, 0.06 to 0.94; P=0.028)
  • All other stratified analyses did not demonstrate significant differences in endometritis risk

CONCLUSION:

  • Clarithromycin for antibiotic adjunct prophylaxis for cesarean delivery may be an acceptable substitute for azithromycin if it is unavailable
  • Authors recognize limitations, including lack of randomization
    • Study did adjust for hospital site and indication for surgery but “not a substitute for randomized-controlled study design”
  • Decreased risk for endometritis with adjunctive use of clarithromycin was especially noted in Black women and women ages 18 to 29

Learn More – Primary Sources:

Clarithromycin use for adjunct surgical prophylaxis before non-elective cesarean deliveries to adapt to azithromycin shortages in COVID-19 pandemic

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Related ObG Topics:

ACOG Guidance: Antibiotic Prophylaxis during Labor and Delivery
What is the Best Practices Prevention Bundle for Post Cesarean Infection?
Does Azithromycin Cut Infection-associated Costs Following Cesarean Section?
Prospective Trial Results (France): Hydroxychloroquine and Azithromycin Provide No Clinical Benefit for COVID-19
Azithromycin Prophylaxis to Reduce Infection Risk Post C-Section

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