What are the recommended antibiotics post cesarean section?

Recommended Antibiotics for Post-Cesarean Section Prophylaxis

For all women undergoing cesarean section, a first-generation cephalosporin (cefazolin) is the recommended antibiotic for prophylaxis, with the addition of azithromycin for women in labor or with ruptured membranes. 1

Primary Antibiotic Recommendations

• Cefazolin 2g IV should be administered as a single dose within 60 minutes before skin incision 1
• For women with BMI >30 kg/m², consider increasing cefazolin dose to 3g IV 2, 3
• For women in labor or with ruptured membranes, add azithromycin to the regimen for additional reduction in postoperative infections 1, 4

For Patients with Penicillin/Cephalosporin Allergy

• Clindamycin 900 mg IV slow infusion as a single dose 1, 2
• Consider adding gentamicin 5 mg/kg/day as a single dose in allergic patients 1

Timing of Administration

• Antibiotics should be administered 30-60 minutes before skin incision, not after cord clamping 1
• This timing has been shown to significantly reduce surgical site infections compared to administration after cord clamping 4, 5
• No additional doses are needed if the procedure duration is less than 4 hours 1, 2

Additional Considerations

• If the cesarean procedure lasts longer than 4 hours, consider an additional dose of cefazolin (1g) 1, 2
• For cefuroxime or cefamandole (alternative second-generation cephalosporins), re-dose if procedure lasts longer than 2 hours 1
• Vaginal preparation with povidone-iodine solution before cesarean delivery in women in labor or with rupture of membranes reduces the risk of infectious complications 1

Evidence Quality and Rationale

• The recommendation for cefazolin as first-line prophylaxis is supported by high-quality evidence with strong recommendation grade 1
• The addition of azithromycin for women in labor or with ruptured membranes is based on studies showing significant reduction in surgical site infections 1, 4
• The timing of antibiotic administration (before skin incision rather than after cord clamping) is supported by multiple studies showing reduced infection rates without increased neonatal complications 4, 5

Common Pitfalls to Avoid

• Delaying antibiotic administration until after cord clamping is no longer recommended as it results in higher rates of postoperative infections 1, 4
• Failing to adjust antibiotic dosing for patients with obesity (BMI >30) may result in subtherapeutic levels and increased infection risk 2, 3
• Extending prophylactic antibiotics beyond a single dose does not provide additional benefit and may contribute to antibiotic resistance 1, 2