Antibiotic Prophylaxis Helps Reduce Post-Cesarean Endometritis

Laurie Barclay, MD

June 27, 2003

June 27, 2003 — Antibiotic prophylaxis helps reduce endometritis after cesarean delivery, according to the results of a randomized, double-blind trial published in the June issue of Obstetrics and Gynecology. A combination of azithromycin with doxycycline, in addition to a single dose of intravenous cefotetan, reduced rates of endometritis after cesarean delivery compared to placebo with cefotetan. Furthermore, length of stay was shorter even in those who did develop endometritis.

"Post–cesarean delivery endometritis is the most common complication of cesarean delivery and is generally believed to have a polymicrobial etiology resulting from ascension of bacteria from the lower to the upper genital tract," write William W. Andrews, MD, and colleagues from the University of Alabama at Birmingham. "Earlier reports implicated Ureaplasma urealyticum as having a potential role in the pathophysiology of endometritis."

Of 597 women enrolled in this study, 56% were black and 43% were nulliparous. Mean age was 25.5 ± 6.2 years. After cord clamping at cesarean delivery, all women received prophylaxis with cefotetan, and they were then randomized to receive doxycyline plus azithromycin or placebo. Both groups were similar for black race, parity, maternal age, and most risk factors for post-cesarean delivery endometritis.

Post-cesarean delivery endometritis, defined clinically as fever from a nonpelvic source of at least 100.4° F and one or more supporting clinical signs, occurred in 16.9% of the doxycycline/azithromycin group and in 24.7% of the placebo group ( P = .020). The former group also fared better in wound infections (0.8% vs. 3.6%; P = .030), and in a combination of these two outcomes (19.0% vs. 27.8%; P = .019).

Although the doxycycline/azithromycin and placebo groups were significantly different for maternal leukocytosis (24.9% vs. 12.5%; P = .042) and frequency of classic uterine incision (7.6% vs. 12.5%; P = .048), adjusting for these factors did not change the risk ratio for post-cesarean delivery endometritis. Relative risk for the doxycycline/azithromycin vs. placebo-treated group was 0.65 (95% confidence interval, 0.43 - 0.98).

Compared with women receiving doxycycline/azithromycin, length of stay was longer in the placebo group overall (104 ± 56 vs. 95 ± 32 hours; P = .016) and among women with endometritis (146 ± 52 vs. 127 ± 46 hours; P = .047).

"Extended spectrum prophylactic antibiotic treatment (with presumed efficacy against U. urealyticum) given to women undergoing cesarean delivery at term shortens hospital stay and reduces the frequency of post-cesarean delivery endometritis and wound infections," the authors write. "The use of extended spectrum antibiotic prophylaxis should be strongly considered, especially in obstetric populations at high risk for post-cesarean delivery infection related morbidity such as those managed in tertiary care centers."

Pfizer provided azithromycin and placebo capsules.

Obstet Gynecol. 2003;101:1183-1189

Reviewed by Gary D. Vogin, MD


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