infection control & hospital epidemiology october 2015, vol. 36, no. 10 rese arch brie f


Survey of Cesarean Delivery Infection Prevention Practices Across US Academic Centers


Cesarean delivery infections occur in up to 7% of the 1.3 million cesarean deliveries performed annually in the United States.1,2 These infections can present as superficial and deep wound infections, intra-abdominal abscesses, and endometritis. The bacterial flora of these infections is polymicrobial.3 There are no specific guidelines for the prevention of cesarean delivery infections, but multiple recommendations have been made for general prevention of surgical site infections. Cesarean deliveries are unique in many aspects and general surgical guidelines may not be applicable to this specific population. Timing of anti- biotics to prevent infections and protect newborns from unne- cessary antibiotic exposure has been a controversial area until recently,4–6 and appropriate weight-based dosing for pregnant women without validated body mass index measurements is not entirely clear.7 There are few data on the best antibiotic for surgical prophylaxis.8 A recent review suggests that only 29% of 77 interventions evaluated for prevention of cesarean delivery infections have strong evidence to support their use.9We sought to assess cesarean delivery infection prevention practices in academic medical centers across the continental United States. A literature review for best evidence-based practices for


the prevention of cesarean delivery infections was performed and a short survey was developed, focusing on antibiotic prophylaxis and antisepsis practices (Online Appendix A). All US residency programs for obstetrics and gynecology were identified through the Association of Professors in Obstetrics and Gynecology website (https://www.apgo.org/component/ residencydirectory). Programs outside the continental United States were excluded and multiple residency programs within the same main hospital were consolidated. The charge nurse, clinical specialist, nurse educator, or nurse manager of each labor and delivery unit for the primary hospital in each residency program agreed to participate and was interviewed by telephone between August and December 2014. Data were collected on an electronic spreadsheet (Excel; Microsoft) and analyzed. This survey project was approved by Johns Hopkins University Institutional Review Board. Two hundred nineteen residency programs were identified


and 198 hospitals met the inclusion criteria; of these, 197 participated in the telephone interview. Of the 197 hospitals, 193 (98.0%) used antibiotics prior to


skin incision for cesarean deliveries. One hospital dosed antibiotics after cord clamping and 3 hospitals did not uni- versally use antibiotic prophylaxis. One hundred seventy-nine hospitals (90.9%) used first-generation cephalosporins, and


5 hospitals used combination therapy with azithromycin (4 hospitals) or metronidazole (1 hospital). Five hospitals prophylactically administered second-generation cephalos- porins, 2 hospitals used ampicillin, and 2 used clindamycin. Only 109 hospitals (55.3%) consistently used higher doses of antibiotics for obese patients. Three interviewees did not know if dosing was modified for obesity and 2 hospitals sometimes adjusted the dose for obese patients. One hundred fifty-two hospitals (77.2%) used some form of chlorhexidine-based preoperative skin antisepsis prior to Caesarean delivery. Twelve hospitals used either chlorhexidine skin antisepsis or a povidone-iodine–based skin preparation, depending on physician preference, and 3 interviewees were not sure of the type of skin antisepsis used. Twenty-five hospitals (12.7%) consistently used vaginal preoperative antisepsis prior to cesarean delivery surgery and 6 additional hospitals sometimes used vaginal preoperative antisepsis, depending on physician preference (Table 1). Although not specifically asked, all hospitals that used vaginal antisepsis used povidone-iodine. Cesarean delivery infections cause significant morbidity to


mothers with new babies. There are no consolidated guidelines specifically for the prevention of surgical site infections in women undergoing cesarean delivery. The 2013 guidelines for surgical prophylaxis10 and the 2011 American College of Obstetrics and Gynecology Practice Bulletin5 recommend cefazolin before skin incision for cesarean delivery surgery and weight-based dosing for obesity, acknowledging that there is limited evidence for these recommendations. Our study found that some interventions are widely accep-


ted and consistently used and others are inconsistently implemented or not used. We found the most consistency in the use of preoperative antibiotics prior to skin incision, with some variability in the type of antibiotic used and significant variability in dosing for obesity. Several other adjunctive interventions have been investigated


to reduce the incidence of post–cesarean delivery infections. Washing with chlorhexidine prior to surgery has been shown to reduce infections in orthopedic patients and in coronary artery bypass surgery patients but not in general surgery.11 There is some evidence that chlorhexidine-alcohol antisepsis, compared with povidone-iodine with alcohol, reduced surgical site infec- tions in clean surgery and that alcohol-based antiseptics are more effective than aqueous antiseptics.12 There are not enough data to recommend the use of chlorhexidine antisepsis in pre- venting infection outcomes specifically in cesarean delivery patients.13Most of the hospitals we surveyed used some formof chlorhexidine-based skin antisepsis prior to surgery. Multiple studies have shown that vaginal antisepsis with


povidone-iodine in women undergoing cesarean delivery, par- ticularly in women with ruptured membranes prior to surgery, reduced by 50% the incidence of postoperative endometritis.14


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