Reducing Infection Rates After C-section Deliveries

Although they’re often life-saving, all hospital operations come with the risk of surgical site infections; cesarean deliveries— or C-sections– are no different. In a recent medical trial, researchers have found a way to slash post-operative infection rates with the use of an extra antibiotic.

From 1996 to 2009, the rate of C-section births in the United States rose by 60%. According to the Centers for Disease Control and Prevention, while the rate of these deliveries has slightly dropped since 2009, more than 1.2 million babies are born each year by C-section delivery, making up nearly a third of all births in the United States. As with any surgical procedure, all C-sections come with the risk of surgical site infection, which occurs after surgery in the part of the body that had been operated on. While most of these infections are superficial and involve only the skin, some women can develop more serious infections involving skin tissue and organs. For women who’ve recently delivered via C-section, bacterial infections at the surgical incision site can cause fever along with pain, swelling, redness, and discharge in those areas. Endometritis, an infection of the lining of the uterus, can also occur.

In a recent study published in the New England Journal of Medicine, researchers conducted a trial aimed at reducing the rate of post-operative infections in women who’ve had C-section deliveries. The authors note, “Cesarean delivery is the most common major surgical procedure” done in the United States, “with a rate of surgical-site infection that is 5 to 10 times the rate for vaginal delivery.” Approximately 60% to 70% of C-sections are non-elective. The trial studied the effects of adding the antibiotic azithromycin to the standard preoperative antibiotic regimen of cefazolin. It was conducted in 14 US hospitals, and included 2,013 women undergoing non-elective C-section delivery with gestation of 24 weeks or more. All the participants received the standard cefazolin prophylaxis, and 1,019 women received the additional dose of intravenous azithromycin, while 994 women received a placebo. Most patients received the antibiotics before incision. The researchers chose azithromycin because it treats infections caused by ureaplasma organisms. These organisms are more commonly associated with infections that occur after C-section deliveries and have been associated with a reduced risk of wound infections and endometritis.

At postpartum follow-up within 6 weeks of delivery, the researchers were able to obtain information from 1,961 of the 2,013 women participating in the study. Looking for primary outcome rates that included endometritis, wound infection, or other infections, the study authors found that these occurred in 62 women, or 6.1%, who received azithromycin and in 119 women, or 12%, who received a placebo. Additional maternal outcomes, including rates of postpartum fever, treatment with antibiotics, and need for readmission or unscheduled visits (for any reason or specifically for infection), were significantly less common in the azithromycin group. The researchers noted one infant death in the placebo group as a result of extreme prematurity. In the study group, three infant deaths occurred due to fulminant herpes simplex infection, sudden infant death syndrome, and an unknown cause.

“In this large, multicenter, randomized trial, we found that the addition of azithromycin to standard antibiotic prophylaxis significantly reduced the frequency of infection after non-elective cesarean section,” write the study authors. “Our findings are consistent with those of previous studies supporting a lower risk of infection after cesarean section with the use of prophylactic extended-spectrum coverage than with standard antibiotic prophylaxis.”

Noting their awareness of the risk of infections from antibiotic-resistant bacteria, the authors add that it’s a concern that comes with azithromycin treatment. “However, it is unlikely that the single dose of antibiotic would significantly increase resistance,” they write. “Our findings from clinical maternal cultures are reassuring, but ongoing monitoring for changes in resistance profiles is needed.”

The World Health Organization notes that “the international healthcare community has considered the ideal rate for cesarean section section births to be between 10% to 15%,” well below the current US average of more than 32%. As with any surgery, C-sections are associated with short- and long-term risk, which can extend many years beyond the current delivery and affect the health of a woman, her child, and future pregnancies.