Archives of Gynecology and Obstetrics

, Volume 285, Issue 5, pp 1219–1224

Timing of antibiotic administration and infectious morbidity following cesarean delivery: incorporating policy change into workflow

  • Brett C. Young
  • Michele R. Hacker
  • Laura E. Dodge
  • Toni H. Golen
Maternal-Fetal Medicine

Abstract

Purpose

To evaluate the success of a multidisciplinary approach to policy change regarding timing of antibiotic administration for the prevention of surgical-site infection after cesarean delivery.

Methods

After review of the evidence, our multidisciplinary Obstetrics Leadership Committee decided to change policy on the timing of antibiotic prophylaxis for cesarean delivery. Using a combination of meetings, email communications, and local champions, 100% compliance with the new policy was achieved in 5 weeks. The effect of this policy change was investigated through a prospective cohort study of consecutive patients undergoing cesarean delivery at one institution from January 2009 through May 2009. Approximately halfway through the study period our department implemented a practice change that required antibiotic administration before skin incision rather than after clamping the umbilical cord. We compared the incidence of surgical-site infection, including endometritis, cellulitis, and total infectious morbidity, among women who received antibiotics before skin incision to those who received antibiotics after umbilical cord clamp.

Results

There were 533 consecutive women who underwent cesarean delivery during the study period. Two hundred forty (45.0%) women received antibiotics after cord clamping, and 285 (53.5%) women received antibiotics before skin incision; timing could not be determined for 8 (1.5%) women. Within 5 weeks of the policy change, 100% of the women undergoing cesarean delivery received perioperative prophylactic antibiotics before skin incision. The incidence of infectious morbidity fell from 5.4 to 2.5% when antibiotics were given before skin incision. Compared to the administration of antibiotics before skin incision, receiving antibiotics after cord clamp yielded a crude relative risk (RR) of 2.21 (95% CI 0.89–5.44) for total infectious morbidity and 3.56 (95% CI 0.73–17.49) for endometritis. Although not statistically significant, there was an increased risk of cellulitis (RR 1.66; 95% CI 0.53–5.17) when antibiotics were administered after cord clamping.

Conclusions

A multidisciplinary approach was successful in achieving 100% adherence to our institution’s policy change regarding timing of prophylactic antibiotics. This approach was necessary in order to incorporate this type of change into the labor and delivery workflow and may serve as a paradigm for success in implementing labor and delivery quality improvement projects. In addition, administration of prophylactic antibiotics before skin incision resulted in fewer surgical-site infections following cesarean delivery. As the clinical and economic impact of surgical-site infections is considerable, the once common practice of administering antibiotics after cord clamping should be avoided.

Keywords

Antibiotic prophylaxis Cesarean Surgical-site infection Multidisciplinary 

Supplementary material

404_2011_2133_MOESM1_ESM.ppt (54 kb)
Supplementary material 1 (PPT 54 kb)

References

  1. 1.
    Smaill FM, Gyte GM (2010) Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev (1):CD007482Google Scholar
  2. 2.
    Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S et al (2009) Births: final data for 2006. Natl Vital Stat Rep 57(7):1–102Google Scholar
  3. 3.
    Cardo D, Horan T, Andrus M, Dembinski M, Edwards J, Peavy G et al (2004) National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 32(8):470–485CrossRefGoogle Scholar
  4. 4.
    Chelmow D, Hennesy M, Evantash EG (2004) Prophylactic antibiotics for non-laboring patients with intact membranes undergoing cesarean delivery: an economic analysis. Am J Obstet Gynecol 191(5):1661–1665PubMedCrossRefGoogle Scholar
  5. 5.
    American College of Obstetricians and Gynecologists (2009) Infectious Disease in Obstetrics and Gynecology: a systematic approach, pp 80–89Google Scholar
  6. 6.
    Bloom SL, Cox SM, Bawdon RE, Gilstrap LC (1996) Ampicillin for neonatal group B streptococcal prophylaxis: how rapidly can bactericidal concentrations be achieved? Am J Obstet Gynecol 175(4 Pt 1):974–976PubMedCrossRefGoogle Scholar
  7. 7.
    Fiore MT, Pearlman MD, Chapman RL, Bhatt-Mehta V, Faix RG (2001) Maternal and transplacental pharmacokinetics of cefazolin. Obstet Gynecol 98(6):1075–1079CrossRefGoogle Scholar
  8. 8.
    Terrone DA, Rinehart BK, Einstein MH, Britt LB, Martin JN Jr, Perry KG (1999) Neonatal sepsis and death caused by resistant Escherichia coli: possible consequences of extended maternal ampicillin administration. Am J Obstet Gynecol 180(6 Pt 1):1345–1348PubMedCrossRefGoogle Scholar
  9. 9.
    Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D (2007) Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol 196(5):455PubMedCrossRefGoogle Scholar
  10. 10.
    Costantine MM, Rahman M, Ghulmiyah L, Byers BD, Longo M, Wen T et al (2008) Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 199(3):301–306PubMedGoogle Scholar
  11. 11.
    Thigpen BD, Hood WA, Chauhan S, Bufkin L, Bofill J, Magann E et al (2005) Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. Am J Obstet Gynecol 192(6):1864–1868PubMedCrossRefGoogle Scholar
  12. 12.
    Wax JR, Hersey K, Philput C, Wright MS, Nichols KV, Eggleston MK et al (1997) Single dose cefazolin prophylaxis for postcesarean infections: before versus after cord clamping. J Matern Fetal Med 6(1):61–65PubMedCrossRefGoogle Scholar
  13. 13.
    Kaimal AJ, Zlatnik MG, Cheng YW, Thiet MP, Connatty E, Creedy P et al (2008) Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections. Am J Obstet Gynecol 199(3):310–315PubMedCrossRefGoogle Scholar
  14. 14.
    Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36(5):309–332PubMedCrossRefGoogle Scholar
  15. 15.
    Vadnais MA, Golen TH (2011) Documentation improvements following multidisciplinary educational program on electronic fetal heart rate tracings. J Matern Fetal Neonatal Med 24(5):741–744PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Brett C. Young
    • 1
    • 2
  • Michele R. Hacker
    • 1
    • 2
  • Laura E. Dodge
    • 1
  • Toni H. Golen
    • 1
    • 2
  1. 1.Department of Obstetrics and GynecologyBeth Israel Deaconess Medical CenterBostonUSA
  2. 2.Department of Obstetrics, Gynecology and Reproductive BiologyHarvard Medical SchoolBostonUSA

Personalised recommendations