Meta-Analysis: Does Adjunctive Prophylaxis Further Reduce Cesarean Surgical Site Infections?
BACKGROUND AND PURPOSE:
ACOG states that adjunctive azithromycin to prevent surgical site infections following cesarean may be considered
Markwei et al. (AJOG, 2021) examined the effectiveness of pre-incision cefazolin with or without adjunctive prophylaxis (macrolides or metronidazole) to decrease post-Cesarean surgical site infections
Systematic review and meta-analysis
RCTs | Prospective observational studies
Studies in women undergoing cesarean delivery that compared
Pre-incision cefazolin alone
Pre-incision cefazolin plus adjunctive therapy (500 mg, oral or intravenous) azithromycin, metronidazole, or clarithromycin
Synthesis and appraisal were done using GRADE criteria and ACOG guidelines
Treatment effects were evaluated using meta-analysis and pooled relative risks
Infections of the skin, subcutaneous fascia, deep tissue, organs, or organ space within 30 days post-surgery
Surgical site infection: Composite of endometritis, wound infection, or other infection
Febrile morbidity | Duration of hospital stay
3 RCTs and 1 prospective observational study | 2613 women
Cefazolin plus adjunctive prophylaxis was associated with significant reductions in
Surgical site infections
RR 0.46 (95% CI, 0.3 to 0.63; 3 RCTs; High certainty evidence)
Same findings for macrolides alone (azithromycin or clarithromycin)
Duration of hospital stay
Weighted mean difference –1.46 days (95% CI, –2.21 to –0.71) | 2 RCTs
There was no significant difference in maternal febrile morbidity
RR 0.38 (95% CI, 0.11 to 1.25) | 2 RCTs
Adding adjunctive prophylaxis to cefazolin at the time of cesarean was associated with significant reductions in surgical site infections and length of hospital stay
Data lends support to use of clarithromycin during azithromycin shortage
The authors state
Our findings provide evidence for the use of pre-incision adjunctive extended-spectrum prophylaxis with cefazolin, over cefazolin alone
Future investigations are required to establish the relative efficacies of different adjunctive antibiotic options, and look at other risk factors such as BMI and type of surgery (elective versus non-elective) that may influence SSIs
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