Comparing different types of antibiotics given routinely to women at caesarean section to prevent infections

Alfirevic Z, Gyte GML, Dou L

Published Online:

October 6, 2010

Women undergoing caesarean section have an increased likelihood of getting an infection compared with women who give birth vaginally. These infections can be in the surgical incision or in the urine. The infection can also be in the organs within the pelvis, such as the lining of the womb (endometritis). The infections can become serious, causing, for example, an abscess in the pelvis or infection in the blood, and very occasionally can lead to the mother's death. For the prevention of surgical infections, it is generally considered that sound surgical technique is important along with skin antiseptics and the use of antibiotics. However, antibiotics can cause adverse effects such as nausea, vomiting, skin rash and rarely allergic reactions in the mother, and the risk of thrush (candida) for the mother and the baby. Antibiotics, given to women around the time of giving birth, can also change the baby's gut flora which contribute to the baby's developing immune system. Thus antibiotics given at this time may interfere with the baby's developing immune system. This review looked at which types of antibiotics might work best. We found 25 randomised studies, involving 6367 women, which compared cephalosporins with penicillins. Cephalosporins and penicillins had similar effects in reducing infections after caesareans and similar adverse effects. However, none of the included studies assessed infections that arise after the woman is discharged home. The effects were similar whether the caesarean section was an elective or emergency caesarean. None of the studies looked at outcomes on the babies, so it is unclear if one class of antibiotic might be better than another in this respect. Consideration also needs to be given to antibiotics compatible with breastfeeding. Tetracyclines can cause discolouration of teeth in children and are best avoided. We were unable to assess what impact, if any, the use of different types of antibiotics might have on bacterial resistance, and this is a crucial issue when considering which antibiotic might be used.

Abstract (click to read)

Background:

Caesarean section increases the risk of postpartum infection for women and prophylactic antibiotics have been shown to reduce the incidence; however, there are adverse effects. It is important to identify the most effective class of antibiotics to use and those with the least adverse effects.

Objectives:

To determine, from the best available evidence, the balance of benefits and harms between different classes of antibiotic given prophylactically to women undergoing caesarean section.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2010) and reference lists of retrieved papers.

Selection criteria:

We included randomised controlled trials comparing different classes of prophylactic antibiotics given to women undergoing caesarean section. We excluded trials that compared drugs with placebo or drugs within a specific class; these are assessed in other Cochrane Reviews.

Data collection and analysis:

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

Main results:

We included 29 studies of which 25 provided data on 6367 women. There was a lack of good quality data and important outcomes often included only small numbers of women. This meant we could only conclude that the current evidence shows no overall difference between the different classes of antibiotics in terms of reducing maternal infections after caesarean sections. However, none of the studies looked at outcomes on the baby, nor did they report infections diagnosed after the initial postoperative hospital stay. We were unable to assess what impact, if any, the use of different classes of antibiotics might have on bacterial resistance.

Authors' conclusions:

Based on the best currently available evidence, cephalosporins and penicillins have similar efficacy at caesarean section when considering immediate postoperative infections. We have no data for outcomes on the baby, nor on late infections (up to 30 days) in the mother. Clinicians need to consider bacterial resistance and women's individual circumstances.

This record should be cited as:

Alfirevic Z, Gyte GML, Dou L. Different classes of antibiotics given to women routinely for preventing infection at caesarean section. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD008726. DOI: 10.1002/14651858.CD008726

Assessed as up to date:

August 16, 2010

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Primary Review Group:

Pregnancy and Childbirth Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are the different classes of antibiotics given as prophylaxis for infection prior to caesarean section (CS)?

Bottom line:

Both cephalosporins and penicillins represent good choices for prophylaxis for maternal infections following CS, although the impact on post-discharge infections and on the infant are unknown, as is the impact on bacterial resistance. The effects were similar, whether the CS was an elective or emergency procedure. Both classes of antibiotic had similar adverse effects (allergic reactions, nausea, vomiting, diarrhoea, skin rashes). More costly extended-spectrum penicillins, second or third generation cephalosporins and combination regimens were not demonstrated to be more effective, but there were few data upon which to make a clear judgement.

Caveat:

There was a lack of good quality data, and important outcomes often included only small numbers of women. Many of the studies were conducted in the 1980s and 1990s. None of the studies assessed infections that arose when the women were discharged home, and none looked at outcomes in the babies. No consideration was given to antibiotics compatible with breastfeeding, and the review was unable to assess what impact, if any, the use of different types of antibiotics might have had on bacterial resistance.

Context:

CS increases the risk of post-partum infection (infections of the wound or abdominal fascia, the urinary tract or pelvic organs, as well as thrombophlebitis and, rarely, septicaemia), and prophylactic antibiotics have been shown to reduce the incidence of this.

Cochrane Systematic Review:

Alfirevic Z, Gyte GML, Dou L et. Different classes of antibiotics given to women routinely for preventing infection at caesarean section. Cochrane Reviews, 2010, Issue 10. Article No. CD008726. DOI: 10.1002/14651858.CD008726. This review contains 25 studies involving 6367 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Pregnancy & childbirth > Caesarian section > Other interventions

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Comparing different types of antibiotics given routinely to women at caesarean section to prevent infections

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