What are the methods for preventing infection after a cesarean (C-section) section?

From the Guidelines

Infection prevention after cesarean delivery should prioritize the administration of intravenous antibiotics within 60 minutes before skin incision, with a first-generation cephalosporin recommended for all women, and the addition of azithromycin for women in labor or with ruptured membranes, as supported by high-level evidence 1.

Key Strategies for Infection Prevention

• Prophylactic antibiotics should be administered within 60 minutes before skin incision, with a first-generation cephalosporin being the preferred agent, as recommended by the Enhanced Recovery After Surgery Society 1.
• Chlorhexidine-alcohol is preferred to aqueous povidone-iodine solution for abdominal skin cleansing before cesarean delivery, due to its stronger recommendation grade despite a lower evidence level 1.
• Vaginal preparation with povidone-iodine solution should be considered for the reduction of postoperative infections, particularly in women with ruptured membranes, although the evidence level is moderate and the recommendation grade is weak 1.

Additional Measures to Reduce Infection Risk

• Hair removal, if necessary, should be done with clippers rather than razors to minimize skin irritation and reduce the risk of infection.
• The subcutaneous tissue should be closed if it's ≥2cm thick to prevent wound complications, as recommended by the Enhanced Recovery After Surgery Society 1.
• Skin closure with sutures rather than staples reduces wound complications and promotes faster healing.
• Maintaining normothermia and appropriate glucose control in diabetic patients further reduces infection risk and promotes overall recovery.

Evidence-Based Practices for Comprehensive Infection Prevention

• The combination of these evidence-based practices creates a comprehensive approach to infection prevention after cesarean delivery, significantly decreasing the risk of surgical site infections, endometritis, and other postoperative complications 1.
• By prioritizing these strategies, healthcare providers can reduce the risk of maternal morbidity, prolonged hospitalization, and increased healthcare costs associated with postoperative infections.

From the FDA Drug Label

To prevent postoperative infection in contaminated or potentially contaminated surgery, recommended doses are: 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery. For lengthy operative procedures (e.g., 2 hours or more), 500 mg to 1 gram IV or IM during surgery (administration modified depending on the duration of the operative procedure). 500 mg to 1 gram IV or IM every 6 to 8 hours for 24 hours postoperatively

The recommended dosage of cefazolin for infection prevention after cesarean section is:

• 1 gram IV or IM administered 1/2 hour to 1 hour prior to the start of surgery
• 500 mg to 1 gram IV or IM during surgery if the procedure is lengthy
• 500 mg to 1 gram IV or IM every 6 to 8 hours for 24 hours postoperatively 2

From the Research

Infection Prevention after Cesarean

• Surgical site infection (SSI) is a common complication of cesarean delivery, occurring in up to 12% of cases 3.
• Various interventions and techniques can be used to decrease the risk of SSI, including preoperative, intraoperative, and postoperative measures 3.
• A multifaceted SSI prevention bundle for cesarean delivery, which includes full-body preoperative wash with 4% CHG cloths, retraining on surgeon hand scrub, retraining for surgical prep, and patient education regarding wound care, has been shown to reduce SSI rates 4.
• The timing of preoperative antibiotic prophylaxis does not appear to have a significant impact on SSI risk, with no conclusive evidence of a difference in SSI risk after administration 60-30 minutes or 30-0 minutes before incision 5.
• Cefazolin is a commonly used preoperative antibiotic, and most patients with a penicillin allergy history may safely receive cefazolin, although additional care is warranted for patients with confirmed penicillin allergy 6.
• Different skin preparation methods, including chlorhexidine with alcohol, povidone-iodine with alcohol, and sequential combination of both, have been shown to have similar rates of surgical site infections 7.

Interventions for SSI Prevention

• Preoperative interventions:
  • Full-body preoperative wash with 4% CHG cloths 4
  • Patient education regarding wound care 4
• Intraoperative interventions:
  • Retraining on surgeon hand scrub 4
  • Retraining for surgical prep 4
• Postoperative interventions:
  • Patient education regarding wound care 4

Antibiotic Prophylaxis

• Cefazolin is the preoperative antibiotic of choice for cesarean delivery 6
• The timing of preoperative antibiotic prophylaxis does not appear to have a significant impact on SSI risk 5
• Most patients with a penicillin allergy history may safely receive cefazolin, although additional care is warranted for patients with confirmed penicillin allergy 6