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Febrile morbidity following cefamandole nafate intrauterine irrigation during cesarean section
Febrile morbidity following cefamandole nafate intrauterine irrigation during cesarean section EUGENE
G. RUDD,
WILLIAM
H.
MICHAEL
B. DILLON,
Ho?~olul~,
M.D.
LONG,
M.D. M.D.
Hawaii
The effectiveness of intrauterine irrigation during cesarean section with a solution of cefamandole nafate in reducing febrile morbidity was studied in a prospective double-blind fashion. Ninety patients who were undergoing cesarean section at Tripler Army Medical Center were randomized into three groups: (1) intrauterine irrigation with cefamandole nafate solution, (2) intrauterine irrigation with normal saline solution, and (3) no irrigation. Febrile morbidity was evaluated by means of a fever index. There was a statistically significant reduction in the fever index in the group that received in!rauterine irrigation with cefamandole nafate. The incidences of clinically diagnosed endomyometritis in the three groups were O%, 26.7%, and 23.3%, respectively. Prophylactic intrauterine irrigation with cefamandole nafate during cesarean section markedly reduces febrile morbidity, primarily by reducing the incidence of endomyometritis. (AM. J. OBS~ET. GYNECOL. 141:12, 1961.)
FEBRILE morbidity subsequent to cesarean section is one of the major problems confronting the obstetrician. With the dramatic increase in cesarean delivery, many more patients are subject to the morbidity of puerperal infection. ‘3 2 Despite a growing use of parenteral prophylactic antibiotics, the incidence of febrile morbidity remains high.3-x Recently, antibiotic irrigation has been reported to markedly reduce the incidence of endomyometritis subsequent to cesarean section.g Since the diagnosis of endomyometritis is based on a fairly subjective evaluation, a more objective parameter is needed to gauge the effectiveness of this new technique of antibiotic irrigation by using the objective parameter of postoperative
From the Department of Obstetrics Tripler Army Medical Center.
and Gynecology,
The lriews expressed herein are those of the authors and do not necessarily r$ect the views of the United States Army or the Depurtment of Defense. Received for publication KPrllsed February Accepted March
September
23, 1980.
18, 1981. 4, 1981.
Reprint requests: CPT Eugene C. Rudd, MC, Department of Obstetrics and Gynecology, Ireland Army Hospital, Fort knox, Kentucky 40121.
12
fever, specifically, the fever index. The fever index has been established as an aid in the evaluation of effectiveness when comparing therapeutic regimens for febrile illnesses.“’
Study design During a ?Jmo period, patients undergoing cesarean section were offered entrance into the study. Those patients with a history of penicillin or cephalosporin allergy, those who were taking antibiotics, and those with a known infectious process were excluded from the study. After the attending physician had obtained informed consent, the hospital pharmacy personnel used a table of randomized numbers to assign each patient into one of three groups. The patients and physicians were blinded to the group assignments until after the study had been completed. The three groups, each containing 30 patients, were as follows: cfjkhmandolr irrigation group, irrigation with 2 gm of cefamandole nafate in 800 ml of normal saline solution; irrigation rontro/group, irrigation with X00 ml of normal saline solution: Izonirrlgulio?z (.(~&ol gro@, no irrigation. A vitamin solution (Solu-B-Forte, .i drops) was added to both irrigation solutions to make them visually identical. During operation, after delivery of the infant. placenta. and membranes, irrigation was performed if the
Volume Number
I41 I
patient was in the cefamandole irrigation or irrigation control group. If the patient was in the nonirrigation control group, no intrauterine irrigation was performed and the operation proceeded in a usual fashion. For the irrigation, a bulb syringe was used to create ajetlike effect. Care was taken to ensure that the margins of the uterine incision received a direct application of irrigant. The fluid was suctioned from the operative site simultaneously. Repair of the uterine incision was then performed in a routine fashion, with additional irrigant applied to the uterine incision prior to the closure of the bladder flap. With the patient in reverse Trendelenburg position, the abdominal gutters were irrigated and suctioned free of clot and debris. Closure of- the abdominal incision was performed in a fashion chosen by the surgeon, with any remaining irrigant apphed to the abdominal incision. All procedures were performed by the resident and staff physicians on call at the time of the operation. Postoperative examinations and evaluations were performed by those physicians usually assigned to that service. Patients who were considered to have the clinical diagnosis of endomyometritis were those who demonstrated (1) a febrile course (persistent temperature > 100.4” F beyond 24 hr postoperatively), (2) unusual uterine and parametrial tenderness, and (3) no evidence for another source of infection (urinary, pulmonary, etc.). Each of these patients was subsequently treated with parenteral antibiotics. Postoperative temperatures were recorded at least every 4 hr. A fever index was calculated after the manner of Ledger and Kriewall.” This fever index is the area between the curve formed by adjacent temperature readings and a line extending horizontally at 99” F.
Results There were no significant differences in age, parity, weight, and socioeconomic background in the three groups. Table I shows that the indications for cesarean section were similar between the groups. Table I also demonstrates that patients in the cefamandole irrigation group were subject to more proved risk factors’2-“’ for developing endomyometritis than were the control groups. Endomyometritis was clinically diagnosed, and then treated with parenteral antibiotics in eight patients of the irrigation control group (26.7%) and in seven patients of the nonirrigation control group (23.3%). No patients in the cefamandole ihigation group had endomyometritis. This difference was statistically significant (P < 0.01, T = -4.03). The fever index for each patient is presented in Fig.
Febrile
morbidity
z z
--
220
.-
200
--
180
--
160
--
140
--
120
--
100
--
intrauterine
cefamandole
13
.
260 I 240
following
I
.
I g x & =! 0” 2
. I
80
--
60
--
40
--
. . .
.
.
20 --
I
.
.I
CEFAMANDOLE IRRIGATION GROUP
T. . . . : .* .. x 5 IRRIGATION CONTROL GROUP
. . .‘. 2 . :. : $ NONIRRIGATION CONTROL GROUP
Fig. 1. Scattergram of fever index for each patient.m Indicates patients with a diagnosis of endomyometritis. Bar indicates mean fever index for group.
1. The mean fever indices for the three groups were as follows: cefamandole irrigation group, 19.6 febrile-, degree hr; irrigation control group, 5 1.4 febrile-degree hr; nonirrigation control group, 37.3 febrile-degree hrs. The febrile course for those patients in the antibiotic irrigation group was significantly less than that of the patients in the control groups (P < 0.05, T = 3.14). Fig. 1 also shows that the clinical diagnosis of endomyometritis correlates well with a higher than mean
14
Rudd,
Long,
September
and Dillon
1, 1981
Am. .I. Obcter. Gynccol.
14 -
12 -
2-
1
3
2 POSTOPERATIVE
4
DAY
Fig. 2. Daily postoperative fever index. Table
I. Incidence
of endometritis
Subgroup
Each study group Failure to progress Repeat cesarean section Other indicationst Ruptured membranes >6 hr Active labor Internal fetal monitoring
vs. indication
for cesarean
section and certain
risk factors
Irrigation
Cefamandole irrigation group
contntl
0% (o/so)* 0 (O/10) 0 (O/11) 0 (O/9) 0 (O/11) 0 (O/21) 0 (O/12)
group
26.7% (S/SO) 45.5 (5/l 1) 7.7 (l/13) 33.3 (216) 50 (418) 42.1 (8119) 55.5 (5/9)
Nonirrigotion cmtrol
group
23.3% (7&O) 42.8 (317) 0 (O/12) 36.4 (4/ 11) 71.4 (517) 36.8 (7/19) 55.5 (5/9)
*Percentage (No. with endometritis/No. in subgroup). t Breech malpresentation, twins, compound presentation. fever index. Patients with endomyometritis had fever indices above 48 febrile-degree hr. Two patients in the cefamandole irrigation group had fever indices above this level. One had a febrile transfusion reaction, and the other had a fever attributed to pulmonary atelectasis. A plot of the daily postoperative fever indices for the three study groups demonstrates some interesting findings (Fig. 2). The difference between the curves can be explained, in large part, by the fever index of those patients in whom the clinical diagnosis was endomyometritis. The decline in the fever curve after the second postoperative day of the control groups corresponds to the institution of parenteral antibiotics to treat those patients with clinical infection. When this graph was converted to a square root or log scale to allow for skewed distribution, the differences remained significant. Patients irrigated with the antibiotic had an average postoperative course of 4.53 2 1.04 days. Only two of 30 patients treated with antibiotic required hospitalization longer than 5 days postoperatively. Patients in the
control groups stayed in the hospital an average of 5.37 ‘- 2.53 days. Eighteen of 60 control patients required hospitalization beyond 5 days postoperatively. The cost-benefit analysis of this type of preventive medicine should be favorable.
Cofn~nt There is a marked difference between the incidence of infectious morbidity in those patients who undergo delivery by cesarean section and the incidence in those who undergo vaginal delivery.z The difference is attributed to the uterine incision and trauma associated with the operation. In patients in labor whose membranes are ruptured for longer than 6 hr, the amniotic fluid is contaminated with bacteria in all cases.‘” This contamination is due to ascending vaginal flora. Patients who undergo elective repeat cesarean section have not had this process occur and are at low risk for febrile morbidity. If an incision is made into the uterine cavity after the membranes have been ruptured and contamination has occurred, a bacterial inoculum is introduced into the myometrium, bladder flap, and pel-
Febrile morbidity following intrauterine cefamandole
vie cavity. Areas around this uterine incision are not open to drainage as is the endometrial cavity, and with the surgical procedure leaving devitalized tissue in that site, host defense mechanisms are rendered less effective. Because of these factors, patients who undergo cesarean section are at greater than normal risk for developing postoperative infection. This increased risk for infection meets accepted criteria for procedures suitable for prophylactic antibiotics.‘j Many studies have reported on the use of parenteral prophylactic antibiotics in cesarean section.“-8 Appropriate timing for administration of the antibiotics remains controversial. If these are given parenteraily preoperatively, fetal exposure occurs, possibly masking neonatal sepsis. If they are given after clamping the cord, there are two disadvantages: (1) bacterial contarnination of the tissues has already occurred, and (2) hemostatic suturing, along with decreased perfusion of the contracting uterus, may prevent adequate access of the antibiotics to the contaminated incision. Despite these disadvantages, parenteral antibiotic prophylaxis has reduced the incidence of postoperative febrile morbidity. However, the resulting incidence remains unacceptably high, especially in those patients at high risk for infection. Irrigation with antibiotics during operation has been well studied. In routine sterile abdominal procedures, antibiotic irrigation has not been shown to significantly
15
reduce postoperative infection. In well-vascularized areas, such as the abdominal cavity, antibiotic irrigation has not been found to be superior to parenteral antibiotics.16 However, in contaminated surgical sites in which normal blood flow is compromised, antibiotic irrigation is effective in reducing infection.‘7-2” Cesarean section results in just such a surgical site. Cefamandole nafate was chosen for irrigation because of its demonstrated broad-spectrum activity against organisms which commonly cause puerperal infection.21 Cephalosporins have been widely used in local irrigation, with no adverse effects.16. ” Cefamandole nafate has a high tissue affinity with a relatively long half-life. 23 It is our opinion that the technique of antibiotic irrigation should be stressed, and that the choice of antibiotic should be made on the basis of the pathogenic bacteria common to a particular institution. The zero rate of endomyometritis would not be expected to continue. Indeed, in the evaluation of over 200 patients treated with antibiotic irrigation, the incidence of puerperal infection appears to be 1% to 2%. In conclusion, prophylactic antibiotic intrauterine irrigation at the time of cesarean section markedly reduces febrile morbidity postoperatively. We wish to express our appreciation to the staff of the Department of Obstetrics and Gynecology, Tripler Army Medical Center.
REFERENCES
1. Bottoms, S. F., Rosen, M. G., and Sokol, R. J.: The increase in cesarean birth rate, N. Engl. J. Med. 302:559, 1980. 2. Evrard, J. R., Gold, E. M., and Cahill, T. F.: Cesarean section, a contemporary assessment, J. Reprod. Med. 24: 147, 1980. 3. Gibbs, R. S., DeCherney, A. H., and Schwartz, R. H.: Prophylactic antibiotics ‘in cesarean section: A doubleblind studv. AM. 1. OBSTET. GYNECOL. 114:1048. 1972. 4. Gibbs, R. i. Hun< J. E., and Schwartz, R. H.: A follow-up study on prophylactic antibiotics in cesarean section, A?dn. J. OBSTET. GYNECOL. 117:419, 1973. 5. Moro, M., and Andrews, M.: Prophylactic antibiotics rn cesarean section, Obstet. Gynecol. 44:688, 1974. 6. Hilliard, G. D., and Harris, R. E.: Utilization of antibiotics for prevention of symptomatic postpartum infection, Obstet. Gynecol. 50:285, 1977. 7. Morrison, J. C., Coxwell, W. L., Kennedy, B. S., et al.: The use of prophylactic antibiotics in patients undergoing cesarean section, Surg. Gynecol. Obstet. 136:425, 1973. 8. Weissberg, S. M., Edwards, N. L., and O’Leary, J. A.: Prophylactic antibiotics in cesarean section, Obstet. Gynecol. 38:290, 1971. 9. Long, W. I-I., Rudd. E. G., and Dillon, M. B.: Intrauterine irrigation with cefamandole nafate solution at cesarean section: A preliminary report, AM. J. OBSTET. GYNECOL. 13th7.55, 1980.
10. dizerega, G., Yonekura, L., Roy, S., et al.: A comparison of clindamycin-gentamycin and penicillin-gentamycin in the treatment of postcesarean section endometritis, AM. 1. OBSTET.
GYNEC~L.
134:238,
1979.
11. Ledger. W. I.. and Kriewall. T. I.: The fever index: A quaititative Oindirect measure of hospital acquired infections in obstetrics and gynecology, AM. J. OBSTET. GYNECOL.
115:514,
1973.
12. Cunningham, F. G., Hauth, J. D., Strong, J. D., and Kappus, S. S.: Infectious morbidity following cesarean seciion, Obstet. Gynecol. 52:656, i978. 13. Gibbs, R. S.. Listwa, H. M., and Read, J. A.: The effect of internal fetal monitoring on maternal infection following cesarean section, Obstet. Gynecol. 48:653, 1976. 14. Gilstrap, L. C., and Cunningham, F. G.: The bacterial pathogenesis of infection following cesarean section, Obstet. Gynecol. 53:545, 1979. prophy15. Hirschmann, J. V., and Inui, T. S.: Antimicrobial laxis: A critique of recent trials, Rev. Infect. Dis. 2: 1, 1980. of the peritoneal cavity with 16. Tambo, W. M.: Irrigation ceohalothin. Am. 1. Sure. 123:192. 1972. 17. HAlasz, N. k.: W&d ynfection and topical antibiotics, Arch. Surg. 112: 1240, 1977. 18. Belzer, F. 0.. Salvatierra, O., Schweizer, R. T., et al.: Prevention of wound infection by topical antibiotics in high risk patients, Am. J. Surg. 126:180, 1973.
16 Rudd, Long, and Dillon
19. DiGiglia, J. W., Leonard, G. L., and Ochsner, J. L.: Local irrigation with an antibiotic solution in the prevention of infection in vascular prosthesis, Surgery 67:836, 1970. 20. Polluck, A. V., and Evans, M.: Surgical-wound sepsis and methods of hemostasis, N. Engl. J, Med. 302:970, 1980. 21. Sanders, C. V., and Bourge, R. C.: When and how to use the new cephalosporins, Contemp. Obstet. Gynecol. 14:67, 1979.
22. Waterman, pi. G., Howell, R. S., and Babich. M.: I‘hc effect of prophylactic topical antibiotic (cephalothin) on the incidence of wound infection, Arch. Surg. 97:365. 1968. 23. Eli Lilly 8c Company, Indianapolis, Indiana: Product information.
G. RUDD,
WILLIAM
H.
MICHAEL
B. DILLON,
Ho?~olul~,
M.D.
LONG,
M.D. M.D.
Hawaii
The effectiveness of intrauterine irrigation during cesarean section with a solution of cefamandole nafate in reducing febrile morbidity was studied in a prospective double-blind fashion. Ninety patients who were undergoing cesarean section at Tripler Army Medical Center were randomized into three groups: (1) intrauterine irrigation with cefamandole nafate solution, (2) intrauterine irrigation with normal saline solution, and (3) no irrigation. Febrile morbidity was evaluated by means of a fever index. There was a statistically significant reduction in the fever index in the group that received in!rauterine irrigation with cefamandole nafate. The incidences of clinically diagnosed endomyometritis in the three groups were O%, 26.7%, and 23.3%, respectively. Prophylactic intrauterine irrigation with cefamandole nafate during cesarean section markedly reduces febrile morbidity, primarily by reducing the incidence of endomyometritis. (AM. J. OBS~ET. GYNECOL. 141:12, 1961.)
FEBRILE morbidity subsequent to cesarean section is one of the major problems confronting the obstetrician. With the dramatic increase in cesarean delivery, many more patients are subject to the morbidity of puerperal infection. ‘3 2 Despite a growing use of parenteral prophylactic antibiotics, the incidence of febrile morbidity remains high.3-x Recently, antibiotic irrigation has been reported to markedly reduce the incidence of endomyometritis subsequent to cesarean section.g Since the diagnosis of endomyometritis is based on a fairly subjective evaluation, a more objective parameter is needed to gauge the effectiveness of this new technique of antibiotic irrigation by using the objective parameter of postoperative
From the Department of Obstetrics Tripler Army Medical Center.
and Gynecology,
The lriews expressed herein are those of the authors and do not necessarily r$ect the views of the United States Army or the Depurtment of Defense. Received for publication KPrllsed February Accepted March
September
23, 1980.
18, 1981. 4, 1981.
Reprint requests: CPT Eugene C. Rudd, MC, Department of Obstetrics and Gynecology, Ireland Army Hospital, Fort knox, Kentucky 40121.
12
fever, specifically, the fever index. The fever index has been established as an aid in the evaluation of effectiveness when comparing therapeutic regimens for febrile illnesses.“’
Study design During a ?Jmo period, patients undergoing cesarean section were offered entrance into the study. Those patients with a history of penicillin or cephalosporin allergy, those who were taking antibiotics, and those with a known infectious process were excluded from the study. After the attending physician had obtained informed consent, the hospital pharmacy personnel used a table of randomized numbers to assign each patient into one of three groups. The patients and physicians were blinded to the group assignments until after the study had been completed. The three groups, each containing 30 patients, were as follows: cfjkhmandolr irrigation group, irrigation with 2 gm of cefamandole nafate in 800 ml of normal saline solution; irrigation rontro/group, irrigation with X00 ml of normal saline solution: Izonirrlgulio?z (.(~&ol gro@, no irrigation. A vitamin solution (Solu-B-Forte, .i drops) was added to both irrigation solutions to make them visually identical. During operation, after delivery of the infant. placenta. and membranes, irrigation was performed if the
Volume Number
I41 I
patient was in the cefamandole irrigation or irrigation control group. If the patient was in the nonirrigation control group, no intrauterine irrigation was performed and the operation proceeded in a usual fashion. For the irrigation, a bulb syringe was used to create ajetlike effect. Care was taken to ensure that the margins of the uterine incision received a direct application of irrigant. The fluid was suctioned from the operative site simultaneously. Repair of the uterine incision was then performed in a routine fashion, with additional irrigant applied to the uterine incision prior to the closure of the bladder flap. With the patient in reverse Trendelenburg position, the abdominal gutters were irrigated and suctioned free of clot and debris. Closure of- the abdominal incision was performed in a fashion chosen by the surgeon, with any remaining irrigant apphed to the abdominal incision. All procedures were performed by the resident and staff physicians on call at the time of the operation. Postoperative examinations and evaluations were performed by those physicians usually assigned to that service. Patients who were considered to have the clinical diagnosis of endomyometritis were those who demonstrated (1) a febrile course (persistent temperature > 100.4” F beyond 24 hr postoperatively), (2) unusual uterine and parametrial tenderness, and (3) no evidence for another source of infection (urinary, pulmonary, etc.). Each of these patients was subsequently treated with parenteral antibiotics. Postoperative temperatures were recorded at least every 4 hr. A fever index was calculated after the manner of Ledger and Kriewall.” This fever index is the area between the curve formed by adjacent temperature readings and a line extending horizontally at 99” F.
Results There were no significant differences in age, parity, weight, and socioeconomic background in the three groups. Table I shows that the indications for cesarean section were similar between the groups. Table I also demonstrates that patients in the cefamandole irrigation group were subject to more proved risk factors’2-“’ for developing endomyometritis than were the control groups. Endomyometritis was clinically diagnosed, and then treated with parenteral antibiotics in eight patients of the irrigation control group (26.7%) and in seven patients of the nonirrigation control group (23.3%). No patients in the cefamandole ihigation group had endomyometritis. This difference was statistically significant (P < 0.01, T = -4.03). The fever index for each patient is presented in Fig.
Febrile
morbidity
z z
--
220
.-
200
--
180
--
160
--
140
--
120
--
100
--
intrauterine
cefamandole
13
.
260 I 240
following
I
.
I g x & =! 0” 2
. I
80
--
60
--
40
--
. . .
.
.
20 --
I
.
.I
CEFAMANDOLE IRRIGATION GROUP
T. . . . : .* .. x 5 IRRIGATION CONTROL GROUP
. . .‘. 2 . :. : $ NONIRRIGATION CONTROL GROUP
Fig. 1. Scattergram of fever index for each patient.m Indicates patients with a diagnosis of endomyometritis. Bar indicates mean fever index for group.
1. The mean fever indices for the three groups were as follows: cefamandole irrigation group, 19.6 febrile-, degree hr; irrigation control group, 5 1.4 febrile-degree hr; nonirrigation control group, 37.3 febrile-degree hrs. The febrile course for those patients in the antibiotic irrigation group was significantly less than that of the patients in the control groups (P < 0.05, T = 3.14). Fig. 1 also shows that the clinical diagnosis of endomyometritis correlates well with a higher than mean
14
Rudd,
Long,
September
and Dillon
1, 1981
Am. .I. Obcter. Gynccol.
14 -
12 -
2-
1
3
2 POSTOPERATIVE
4
DAY
Fig. 2. Daily postoperative fever index. Table
I. Incidence
of endometritis
Subgroup
Each study group Failure to progress Repeat cesarean section Other indicationst Ruptured membranes >6 hr Active labor Internal fetal monitoring
vs. indication
for cesarean
section and certain
risk factors
Irrigation
Cefamandole irrigation group
contntl
0% (o/so)* 0 (O/10) 0 (O/11) 0 (O/9) 0 (O/11) 0 (O/21) 0 (O/12)
group
26.7% (S/SO) 45.5 (5/l 1) 7.7 (l/13) 33.3 (216) 50 (418) 42.1 (8119) 55.5 (5/9)
Nonirrigotion cmtrol
group
23.3% (7&O) 42.8 (317) 0 (O/12) 36.4 (4/ 11) 71.4 (517) 36.8 (7/19) 55.5 (5/9)
*Percentage (No. with endometritis/No. in subgroup). t Breech malpresentation, twins, compound presentation. fever index. Patients with endomyometritis had fever indices above 48 febrile-degree hr. Two patients in the cefamandole irrigation group had fever indices above this level. One had a febrile transfusion reaction, and the other had a fever attributed to pulmonary atelectasis. A plot of the daily postoperative fever indices for the three study groups demonstrates some interesting findings (Fig. 2). The difference between the curves can be explained, in large part, by the fever index of those patients in whom the clinical diagnosis was endomyometritis. The decline in the fever curve after the second postoperative day of the control groups corresponds to the institution of parenteral antibiotics to treat those patients with clinical infection. When this graph was converted to a square root or log scale to allow for skewed distribution, the differences remained significant. Patients irrigated with the antibiotic had an average postoperative course of 4.53 2 1.04 days. Only two of 30 patients treated with antibiotic required hospitalization longer than 5 days postoperatively. Patients in the
control groups stayed in the hospital an average of 5.37 ‘- 2.53 days. Eighteen of 60 control patients required hospitalization beyond 5 days postoperatively. The cost-benefit analysis of this type of preventive medicine should be favorable.
Cofn~nt There is a marked difference between the incidence of infectious morbidity in those patients who undergo delivery by cesarean section and the incidence in those who undergo vaginal delivery.z The difference is attributed to the uterine incision and trauma associated with the operation. In patients in labor whose membranes are ruptured for longer than 6 hr, the amniotic fluid is contaminated with bacteria in all cases.‘” This contamination is due to ascending vaginal flora. Patients who undergo elective repeat cesarean section have not had this process occur and are at low risk for febrile morbidity. If an incision is made into the uterine cavity after the membranes have been ruptured and contamination has occurred, a bacterial inoculum is introduced into the myometrium, bladder flap, and pel-
Febrile morbidity following intrauterine cefamandole
vie cavity. Areas around this uterine incision are not open to drainage as is the endometrial cavity, and with the surgical procedure leaving devitalized tissue in that site, host defense mechanisms are rendered less effective. Because of these factors, patients who undergo cesarean section are at greater than normal risk for developing postoperative infection. This increased risk for infection meets accepted criteria for procedures suitable for prophylactic antibiotics.‘j Many studies have reported on the use of parenteral prophylactic antibiotics in cesarean section.“-8 Appropriate timing for administration of the antibiotics remains controversial. If these are given parenteraily preoperatively, fetal exposure occurs, possibly masking neonatal sepsis. If they are given after clamping the cord, there are two disadvantages: (1) bacterial contarnination of the tissues has already occurred, and (2) hemostatic suturing, along with decreased perfusion of the contracting uterus, may prevent adequate access of the antibiotics to the contaminated incision. Despite these disadvantages, parenteral antibiotic prophylaxis has reduced the incidence of postoperative febrile morbidity. However, the resulting incidence remains unacceptably high, especially in those patients at high risk for infection. Irrigation with antibiotics during operation has been well studied. In routine sterile abdominal procedures, antibiotic irrigation has not been shown to significantly
15
reduce postoperative infection. In well-vascularized areas, such as the abdominal cavity, antibiotic irrigation has not been found to be superior to parenteral antibiotics.16 However, in contaminated surgical sites in which normal blood flow is compromised, antibiotic irrigation is effective in reducing infection.‘7-2” Cesarean section results in just such a surgical site. Cefamandole nafate was chosen for irrigation because of its demonstrated broad-spectrum activity against organisms which commonly cause puerperal infection.21 Cephalosporins have been widely used in local irrigation, with no adverse effects.16. ” Cefamandole nafate has a high tissue affinity with a relatively long half-life. 23 It is our opinion that the technique of antibiotic irrigation should be stressed, and that the choice of antibiotic should be made on the basis of the pathogenic bacteria common to a particular institution. The zero rate of endomyometritis would not be expected to continue. Indeed, in the evaluation of over 200 patients treated with antibiotic irrigation, the incidence of puerperal infection appears to be 1% to 2%. In conclusion, prophylactic antibiotic intrauterine irrigation at the time of cesarean section markedly reduces febrile morbidity postoperatively. We wish to express our appreciation to the staff of the Department of Obstetrics and Gynecology, Tripler Army Medical Center.
REFERENCES
1. Bottoms, S. F., Rosen, M. G., and Sokol, R. J.: The increase in cesarean birth rate, N. Engl. J. Med. 302:559, 1980. 2. Evrard, J. R., Gold, E. M., and Cahill, T. F.: Cesarean section, a contemporary assessment, J. Reprod. Med. 24: 147, 1980. 3. Gibbs, R. S., DeCherney, A. H., and Schwartz, R. H.: Prophylactic antibiotics ‘in cesarean section: A doubleblind studv. AM. 1. OBSTET. GYNECOL. 114:1048. 1972. 4. Gibbs, R. i. Hun< J. E., and Schwartz, R. H.: A follow-up study on prophylactic antibiotics in cesarean section, A?dn. J. OBSTET. GYNECOL. 117:419, 1973. 5. Moro, M., and Andrews, M.: Prophylactic antibiotics rn cesarean section, Obstet. Gynecol. 44:688, 1974. 6. Hilliard, G. D., and Harris, R. E.: Utilization of antibiotics for prevention of symptomatic postpartum infection, Obstet. Gynecol. 50:285, 1977. 7. Morrison, J. C., Coxwell, W. L., Kennedy, B. S., et al.: The use of prophylactic antibiotics in patients undergoing cesarean section, Surg. Gynecol. Obstet. 136:425, 1973. 8. Weissberg, S. M., Edwards, N. L., and O’Leary, J. A.: Prophylactic antibiotics in cesarean section, Obstet. Gynecol. 38:290, 1971. 9. Long, W. I-I., Rudd. E. G., and Dillon, M. B.: Intrauterine irrigation with cefamandole nafate solution at cesarean section: A preliminary report, AM. J. OBSTET. GYNECOL. 13th7.55, 1980.
10. dizerega, G., Yonekura, L., Roy, S., et al.: A comparison of clindamycin-gentamycin and penicillin-gentamycin in the treatment of postcesarean section endometritis, AM. 1. OBSTET.
GYNEC~L.
134:238,
1979.
11. Ledger. W. I.. and Kriewall. T. I.: The fever index: A quaititative Oindirect measure of hospital acquired infections in obstetrics and gynecology, AM. J. OBSTET. GYNECOL.
115:514,
1973.
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