Correspondence

Case 33-2009: A Woman with Fever after Cesarean Section

N Engl J Med 2010; 362:273-274January 21, 2010

Article

To the Editor:

In the Case Record, de Moya and colleagues (Oct. 22 issue)1 describe a patient who received cefazolin after clamping of the umbilical cord, and a discussant states “the patient received appropriate prophylactic antibiotic coverage.” Historically, prophylactic antibiotics during cesarean delivery have been administered after cord clamping, out of concern for fetal exposure. Studies in the past few years suggest that antibiotic coverage during cesarean delivery should be consistent with general surgical antimicrobial prophylaxis (i.e., administered before skin incision).2-4 There is no increase in neonatal workups, sepsis, or other consequences after administration of prophylactic antibiotics before skin incision.2-4 Cesarean delivery is associated with a higher incidence of surgical-site infections than comparable surgeries, with potential catastrophic consequences, as described in the case reported on by de Moya et al. Multiple investigations have shown that prophylactic antibiotic coverage within 60 minutes before skin incision reduces the incidence of fever and infection by up to 50% without adverse consequences for the neonate.2-4 Antimicrobial prophylaxis for cesarean delivery should be administered before skin incision, under the same guidelines as surgical antibiotic coverage.5

Rayna Clay, M.D.
William Camann, M.D.
Brigham and Women's Hospital, Boston, MA
wcamann@partners.org

No potential conflict of interest relevant to this letter was reported.

5 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 33-2009). N Engl J Med 2009;361:1689-1697
   Full Text | Web of Science | Medline

2. 2

   Owens SM, Brozanski BS, Meyn LA, Wiesenfeld HC. Antimicrobial prophylaxis for cesarean delivery before skin incision. Obstet Gynecol 2009;114:573-579
   CrossRef | Web of Science | Medline

3. 3

   Tita ATN, Rouse DJ, Blackwell S, Saade GR, Spong CY, Andrews WW. Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstet Gynecol 2009;113:675-682
   Web of Science | Medline

4. 4

   Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized controlled trial. Am J Obstet Gynecol 2007;196(5);455.e1-455.e5. [Erratum, Am J Obstet Gynecol 2007;197:333.]
   

5. 5

   Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999: Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97-132
   CrossRef | Web of Science | Medline

Author/Editor Response

We thank Clay and Camann for their comments regarding the timing of antibiotic prophylaxis for surgical delivery. Our statement that “the patient received appropriate prophylactic antibiotic coverage” was meant to indicate that the choice of antibiotic — cefazolin — was appropriate, and we did not specifically address the timing of antibiotic prophylaxis. Although in the past, the administration of antibiotics was delayed until after cord clamping to avoid interference with neonatal cultures,1 we agree that antibiotic therapy before incision should be the standard for all surgical procedures, including delivery by cesarean section. Randomized trials that have compared the administration of antibiotics before incision with administration after cord clamping have shown that delivery of antibiotics before incision is more effective in preventing infectious complications (relative risk, 0.50; 95% confidence interval, 0.33 to 0.78).2-5

Marcela G. del Carmen, M.D., M.P.H.
Marc A. de Moya, M.D.
Massachusetts General Hospital, Boston, MA

Since publication of their article, the authors report no further potential conflict of interest.

5 References

1. 1

   Cunningham FG, Leveno KJ, DePalma RT, Roark M, Rosenfeld CR. Perioperative antimicrobials for cesarean delivery: before or after cord clamping? Obstet Gynecol 1983;62:151-154
   Web of Science | Medline

2. 2

   Thigpen BD, Hood WA, Chauhan S, et al. Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. Am J Obstet Gynecol 2005;192:1864-1868
   CrossRef | Web of Science | Medline

3. 3

   Wax JR, Hersey K, Philput C, et al. Single dose cefazolin prophylaxis for postcesarean infections: before vs. after cord clamping. J Matern Fetal Med 1997;6:61-65
   CrossRef | Medline

4. 4

   Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized controlled trial. Am J Obstet Gynecol 2007;196(5);455.e1-455.e5. [Erratum, Am J Obstet Gynecol 2007;197:333.]
   

5. 5

   Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008;199(3):301.e1-301.e6.
   

Citing Articles (2)

Citing Articles

1. 1

   Horng-Jyh Tsai. (2011) Antibiotic prophylaxis for cesarean delivery: Before skin incision or after umbilical cord clamping?. Taiwanese Journal of Obstetrics and Gynecology 50:1, 129-130
   CrossRef

2. 2

   W. Camann, R. Tuomala. (2011) Antibiotic prophylaxis for cesarean delivery: always before skin incision!. International Journal of Obstetric Anesthesia 20:1, 1-2
   CrossRef