Is antibiotic prophylaxis recommended after cesarean section?

Antibiotic Prophylaxis After Cesarean Section

Antibiotic prophylaxis is strongly recommended for all women undergoing cesarean section, with administration ideally occurring 30-60 minutes before skin incision rather than after cord clamping. 1, 2

First-Line Prophylactic Regimen

• Cefazolin 2g IV as a single dose within 60 minutes before skin incision is the recommended first-line prophylactic antibiotic for cesarean section 1, 2
• For women in labor or with ruptured membranes, adding azithromycin to the regimen provides additional reduction in postoperative infections 1
• The timing of administration should be 30-60 minutes before skin incision, not after cord clamping, as this has been shown to reduce infection rates 1, 2

Alternative Options for Penicillin/Cephalosporin Allergies

• Clindamycin 900 mg IV slow infusion as a single dose is recommended for patients with penicillin/cephalosporin allergy 1
• Gentamicin 5 mg/kg/day as a single dose may be considered in allergic patients 1, 2

Duration of Prophylaxis

• A single preoperative dose is adequate for most cesarean sections lasting less than 4 hours 1
• If the cesarean procedure lasts longer than 4 hours, an additional dose of cefazolin (1g) may be considered 1
• Prophylaxis should generally not be extended beyond 24 hours 3

Special Considerations

• Vaginal preparation with povidone-iodine solution before cesarean delivery in women in labor or with rupture of membranes further reduces the risk of infectious complications 1
• For high-risk patients (e.g., prolonged rupture of membranes >6 hours), prophylaxis is particularly important as infection rates can be as high as 48% without antibiotics 4
• Cefoxitin is an FDA-approved alternative for prophylaxis in cesarean section, with clinical trials showing significant reduction in endometritis compared to placebo (5.2% vs 27.6%) 5, 6

Evidence Supporting Prophylaxis

• Multiple guidelines and studies consistently demonstrate that antibiotic prophylaxis significantly reduces postoperative infectious morbidity after cesarean section 2
• The American College of Obstetricians and Gynecologists recommends prophylactic antibiotics for all women undergoing cesarean delivery 1
• Studies show that narrow-spectrum cephalosporins (like cefazolin) are as effective as broader-spectrum antibiotics for prophylaxis 7

Common Pitfalls to Avoid

• Delaying antibiotic administration until after cord clamping reduces efficacy; antibiotics should be given before skin incision 1, 2
• Using broad-spectrum antibiotics when narrower options would be effective contributes to antimicrobial resistance 3
• Prolonging prophylaxis beyond 24 hours increases the risk of antimicrobial resistance without providing additional benefit 3

Monitoring After Prophylaxis

• Monitor for signs of infection including fever, wound erythema, purulent discharge, and uterine tenderness 8
• If infection develops despite prophylaxis, obtain appropriate cultures before initiating therapeutic antibiotics 8, 5

Antibiotic prophylaxis has become standard of care for cesarean section in most healthcare settings, with clear evidence showing reduction in infectious complications when properly administered 1, 7.