What is the recommended routine antibiotic for cesarean delivery, Cefazolin (cephalosporin) or Clindamycin?

Cefazolin is the Recommended Routine Antibiotic for Cesarean Delivery

For routine antibiotic prophylaxis in cesarean delivery, cefazolin is strongly recommended as the first-line agent over clindamycin due to superior efficacy and safety profile. 1

First-Line Antibiotic Recommendation

• Cefazolin is the antibiotic of choice for prophylaxis in cesarean delivery according to multiple high-quality guidelines 1
• The recommended dosing is 2g IV initial dose, then 1g IV every 8 hours until delivery 1, 2
• Administration should occur 30-60 minutes before skin incision to maximize effectiveness in preventing surgical site infections 1, 3

Evidence Supporting Cefazolin

• The American Society of Health-Systems Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, and Society for Healthcare Epidemiology of America all recommend cefazolin as the first-choice antibiotic for surgical prophylaxis in most procedures, including cesarean delivery 1
• The Society of Obstetricians and Gynecologists of Canada specifically recommends a single dose first-generation cephalosporin (such as cefazolin) for all women undergoing cesarean section 1
• Research demonstrates that cefazolin provides serum concentrations above minimum inhibitory concentrations for susceptible pathogens in most women undergoing scheduled cesarean delivery 2
• A meta-analysis showed that prophylactic use of cefazolin before skin incision significantly reduced the risk of surgical site infection compared to administration after umbilical cord clamping (OR 0.48,95% CI 0.29-0.82) 3

Alternative for Penicillin-Allergic Patients

• For patients with non-severe penicillin allergy (no history of anaphylaxis, angioedema, respiratory distress, or urticaria), cefazolin remains the preferred agent 1, 4
• For patients with severe penicillin allergy (high risk for anaphylaxis), clindamycin 900 mg IV every 8 hours is recommended 1, 4
• If GBS isolates are resistant to clindamycin or susceptibility is unknown, vancomycin 1g IV every 12 hours should be used 1

Dosing Considerations

• For women weighing <80 kg, 1g of cefazolin is appropriate 2
• For women weighing ≥80 kg, 2g of cefazolin is recommended to achieve adequate tissue concentrations 2
• Single-dose prophylaxis is generally sufficient for elective cesarean deliveries with low infection risk 5
• For emergency cesarean sections, which carry higher infection risk, antibiotic prophylaxis significantly reduces post-operative febrile morbidity (11% vs 30.6%, p=0.001) and wound infections 5

Clinical Pearls and Pitfalls

• Cefazolin is superior to clindamycin for surgical prophylaxis due to its narrow spectrum of activity and ability to achieve high intraamniotic concentrations 1
• Routine use of vancomycin is not recommended for standard prophylaxis and should be reserved for specific situations such as known MRSA colonization or severe penicillin allergy 1
• Antibiotic prophylaxis is not recommended for cesarean deliveries performed before labor onset on women with intact amniotic membranes, regardless of GBS colonization status 1
• Broader spectrum agents might be necessary for treatment of chorioamnionitis rather than simple prophylaxis 1

By following these evidence-based recommendations, clinicians can significantly reduce the risk of post-cesarean infectious complications and improve maternal outcomes.