What are the NABH (National Accreditation Board for Hospitals & Healthcare Providers) guidelines for antibiotic prophylaxis in postpartum women undergoing cesarean delivery, including recommended agents, dosing (cefazolin 2 g IV, 3 g if >100 kg), timing (15–60 minutes before incision), addition of azithromycin for emergency cesareans, alternatives for severe β‑lactam allergy, and indications for vaginal delivery?

NABH Antibiotic Prophylaxis Protocols for Post-Natal Patients

Cesarean Delivery Prophylaxis

All women undergoing cesarean delivery should receive cefazolin 2 g IV administered 15–60 minutes before skin incision as a single dose. 1, 2

Standard Dosing Protocol

• Cefazolin 2 g IV for women weighing <100 kg, given as a single dose 15–60 minutes pre-incision 1
• Cefazolin 3 g IV for women weighing ≥100 kg or with BMI >35 2, 3
• Timing is critical: Administration must occur within the 15–60 minute window before incision to achieve optimal tissue concentrations 1, 2
• No additional doses are routinely needed unless surgery exceeds 3 hours or blood loss exceeds 1500 mL, in which case redose after 3–4 hours 2

Enhanced Prophylaxis for Emergency Cesarean

For emergency cesarean deliveries, add azithromycin 500 mg IV to the standard cefazolin regimen to significantly reduce surgical site infections. 1, 4

• The combination of cefazolin plus azithromycin reduces SSI from 15% to 3% (P=0.03), endometritis from 8% to 2% (P=0.048), and febrile morbidity from 17% to 3% (P=0.001) 4
• This dual-agent approach is particularly cost-effective in tertiary care settings with high infection rates 4

Severe β-Lactam Allergy Alternatives

For women with history of anaphylaxis, angioedema, respiratory distress, or urticaria to penicillins or cephalosporins 5:

• Clindamycin 900 mg IV as a single dose (if duration >4 hours, give additional 600 mg) 1, 2
• Alternative: Clindamycin 900 mg IV + gentamicin 5 mg/kg IV as single doses 1
• Do NOT use cefazolin in high-risk allergy patients, as approximately 10% will cross-react 5

For women with low-risk penicillin allergy (no anaphylaxis history):

• Cefazolin remains the preferred agent at standard dosing 5, 2

Vaginal Delivery Prophylaxis

Routine antibiotic prophylaxis is NOT indicated for uncomplicated vaginal delivery. 2

Specific Indications for Vaginal Delivery

• Third or fourth degree perineal tears: Consider prophylactic antibiotics to reduce infectious morbidity 2
• Manual removal of placenta: Insufficient evidence to recommend routine prophylaxis 2
• Operative vaginal delivery (forceps/vacuum): No evidence supports routine prophylaxis 2

Group B Streptococcus (GBS) Prophylaxis

All women with positive GBS screening at 35–37 weeks or GBS bacteriuria during pregnancy must receive intrapartum IV antibiotic prophylaxis during labor, regardless of delivery mode. 1, 6

GBS Prophylaxis Regimens

First-line (no penicillin allergy):

• Penicillin G 5 million units IV initially, then 2.5–3.0 million units IV every 4 hours until delivery 1, 6
• Alternative: Ampicillin 2 g IV initially, then 1 g IV every 4 hours until delivery 1, 6

Penicillin allergy without high-risk features:

• Cefazolin 2 g IV initially, then 1 g IV every 8 hours until delivery 1, 5

High-risk penicillin allergy (anaphylaxis history):

• Clindamycin 900 mg IV every 8 hours IF isolate is susceptible to clindamycin and erythromycin 1, 6
• Vancomycin 1 g IV every 12 hours if susceptibility unknown or resistant 1, 6
• Susceptibility testing is mandatory for high-risk allergy patients 6

Critical GBS Scenarios

• GBS bacteriuria at ANY concentration during pregnancy: Requires both immediate UTI treatment AND intrapartum prophylaxis during labor 1, 6
• Previous infant with invasive GBS disease: Automatic indication for intrapartum prophylaxis 1
• Unknown GBS status with risk factors (delivery <37 weeks, membrane rupture ≥18 hours, fever ≥38.0°C): Give intrapartum prophylaxis 1

When GBS Prophylaxis is NOT Needed

Cesarean delivery before labor onset with intact membranes does NOT require GBS prophylaxis, regardless of GBS colonization status or gestational age. 1

• However, women should still undergo routine GBS screening at 35–37 weeks because labor or membrane rupture may occur before planned cesarean 1

Chorioamnionitis Management

When chorioamnionitis is suspected, broad-spectrum antibiotics active against GBS should replace routine GBS prophylaxis. 7

• Standard regimen: Ampicillin plus gentamicin with consideration for anaerobic coverage 7
• For penicillin allergy without anaphylaxis: Cefazolin-based regimen 7
• For severe penicillin allergy: Clindamycin or vancomycin with appropriate gram-negative coverage 7, 8
• Adding cefazolin to ampicillin-gentamicin regimens reduces postpartum infection risk (adjusted OR 0.49,95% CI 0.26–0.90) and surgical site infections (adjusted OR 0.11,95% CI 0.01–0.92) 8

Common Pitfalls to Avoid

• Never treat asymptomatic GBS vaginal colonization with oral antibiotics before labor—this is ineffective, promotes resistance, and does not prevent neonatal disease 1, 6
• Do not delay cefazolin administration beyond 60 minutes pre-incision, as tissue concentrations become suboptimal 1, 2
• Do not underdose obese patients—women with BMI >35 require doubled doses 2, 3
• Do not assume treating GBS bacteriuria eliminates the need for intrapartum prophylaxis—oral antibiotics do not eradicate genital tract colonization 6
• Do not use cefazolin in patients with documented high-risk penicillin allergy—cross-reactivity occurs in 10% of cases 5
• Do not give prophylactic antibiotics solely for endocarditis prevention in any obstetrical procedure 2

Institutional Protocol Development

Each institution should develop a patient safety bundle with standardized VTE and infection prophylaxis protocols for cesarean delivery. 1

• Mechanical prophylaxis (sequential compression devices) should be used for all cesarean deliveries until full ambulation 1
• Pharmacologic VTE prophylaxis decisions should be individualized based on validated risk stratification tools 1
• Women with prior VTE or inherited thrombophilia require pharmacologic VTE prophylaxis after cesarean delivery 1