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An Audit Into The Use Of Prophylactic Antibiotics During Caesarean Section at a Central Teaching Hospital - Are National Guidelines Being Followed?

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An Audit Into The Use of Prophylactic Antibiotics During Caesarean Section at a Central Teaching Hospital – Are National Guidelines Being Followed? 

 Dr. A. T. Sawati1, Dr J. Brennand2

1University of Glasgow, 2Southern General Hospital, Glasgow, UK 

1. Objectives

To determine if the use of antibiotics during caesarean section is in accordance with the latest national guidelines which state that:  

(1) Antibiotics should be administered before skin incision.                              

(2) Co-amoxiclav should not be used1


2. Background

Traditionally prophylactic antibiotics were administered after delivery and clamping of the umbilical cord due to concerns regarding sequelae of fetal antibiotic exposure with pre-incision administration. 

NICE guidelines (CG132) now recommend antibiotic administration before skin incision with studies suggesting a 50% reduction in post-caesarean maternal infection in  comparison to traditional methods2

The rising number of caesarean sections and the high health and economic burden associated with post-caesarean maternal infection means  effective antibiotic prophylaxis is essential.  

Co-amoxiclav is not recommended due to its association with necrotising  enterocolitis in the neonate3.

3. Methods

This was a prospective audit with data collected over a period of 4 weeks, from May to June 2012. Data was collected from anaesthetic proformas and the patient’s pregnancy notes. Time of knife to skin, time of antibiotic administration, name of antibiotic used and the type of caesarean section (elective or emergency)   were recorded onto  structured proformas. 

4. Results

• 65 patients were included in the audit with a mean age of 33.1 (range 18-44). 

• 38 patients (58.4%) had an elective procedure with the remaining 27 (41.6%) undergoing an emergency procedure..

All  65 patients were given prophylactic antibiotics after skin incision. 

Figure 1. Antibiotic treatment administered to the 65 patients. In 59 out of 65 patients (91 %) Co-amoxiclav only was used. Cefuroxime only was used in 3 cases (5 %) and Clindamycin only was used in 2 cases (3 %). In one case  Co-amoxiclav and  Metonidazole were used.  

Overall, the mean  time  of antibiotic administration was 12.5 minutes after skin incision. This was 13.6 minutes for elective procedures and 10.9 minutes for emergency procedures.

5. Discussion

In all cases antibiotics were administered after skin incision. This may reflect fears regarding fetal antibiotic exposure with pre-incision administration. 

Despite NICE guidelines, evidence regarding the safety of preincision prophylaxis, potential effect on neonatal infection and emergence of antimicrobial resistance  is lacking and further studies are required to address these concerns. 

If a there is a change in policy to pre-incison administration this will require a change in antibiotic. Studies suggest a narrow-spectrum first generation cephalosporin  as the most appropriate prophylactic agent.  

6. Conclusion

Prophylactic antibiotics are not being administered in accordance with the latest national guidelines. Review of the current antibiotic policy is required with close liason between the Obstetic and Anaesthetic teams.

7. References

1.NICE CG132 Caesarean Section. London: NICE; 2011, 2. Tita et al, Emerging Concepts in Antibiotic Prophylaxis for Caesarean Section A Systematic Review. Obstet Gynaecol 2009;113:675-681, 3. Kenyon S.L., Taylor D.J., Tarnow-Mordi W., Broad Spectrum Antibiotics for Preterm, prelabour Reupture of Fetal Membranes: the RACLE 1 Randomised Trial. The Lancet 2001:357;979-986    

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