Antibiotics are prescribed in pregnancy but only few reports provide information about the actual practice of prophylactic antibiotics usage in various obstetrical conditions amongst obstetricians. The present study evaluates the practice of obstetricians of Delhi regarding prescription of antibiotics in vaginal deliveries and caesarean sections. The open-ended predesigned questionnaire study incorporated details of the obstetricians working in different hospitals of Delhi and their practice of prescribing antibiotics in vaginal deliveries, episiotomies and caesarean sections was filled by obstetricians. The data was analysed using Student's ‘t’ test and Chi-square test. The mean age of obstetricians was 35.5 years; 90% were females and 48.9% were postgraduate students with 70% less than 5 years experience and 77.8% were working in a government hospital. In episiotomy, 18.9% obstetricians did not use antibiotics while 33.3%, 27.8% and 20% obstetricians used ampicillin, amoxicillin and cephalexin orally for 5 days respectively. Injection cefazolin was used intravenously, 1 g 12 hourly for 3 days by 34.4% and 33.3% obstetricians in elective and emergency caesarean sections respectively, while it was used for 5 days by 35.5% and 41.1% obstetricians respectively. A combination of ampicillin, gentamicin and metronidazole for 5 days was used by 30% and 25.5% obstetricians for elective and emergency caesarean sections respectively.
In spite of clear evidence from Cochrane Database of Clinical Reviews that use of penicillin or first generation cephalosporins in single dose therapy is effective; the actual practice is contrary with use of multiagent antibiotics for long periods, being very rampant in actual clinical practice.
[J Indian Med Assoc 2008; 106: 147-9]
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Key words : Caesarean section, episiotomy, prophylactic antibiotics.
Antibiotic prophylaxis refers to the administration of
antibiotics to prevent infection by eradicating or retarding the growth of endogenous micro-organisms. It has been in vogue in peri-operative period since the introduction of antibiotics in the 1950s in an attempt to reduce the rate of postoperative infection1. The prophylaxis differs from treatment by short courses and frequently a single dose is administered shortly before or at the time of bacterial contamination2. Prophylactic antibiotics exert their effect by decreasing the size of inoculum at the operative site, altering the biophysical characteristics of the serosanguinous fluid collecting at the base of the pelvic cavity, by penetrating the cells lining the mucosal surfaces of the genital tract, decreasing adherence to mucous membranes, by penetrating polymorphonuclear leucocytes and enhancing phagocytosis3.
The idea prophylactic antibiotic should be inexpensive, easy to administer, broad-spectrum, free of serious side-effects, has a long half-life and should not be generally the first line drug for treatment of overt infection3. In caesarean section, most studies4-6 advise use of single agent penicillin or first generation cephalosporin after tying of umbilical cord. Single dose therapy with one or two agents has been proven to be superior to multiagent therapy of long-term therapy7-10. In spite of this knowledge, many obstetricians continue to use multiagent therapy or long-term antibiotic prophylaxis in caesarean section.
Material and Method
An open-ended questionnaire was designed incorporating details of the obstetricians regarding their qualification, experience, post and their choice of dosage, route and duration of prophylactic antibiotics in their clinical practice for elective and emergency caesarean section. The obstetricians from various hospitals of Delhi were requested to fill the predesigned questionnaire and information as follows :
(1) Qualification : MBBS / postgraduate student/DGO/MD/any other
(2) Private/government
(3) Junior resident/senior resident/consultant
(4) Years of qualification
(5) What is your practice of antibiotic use in obstetric procedures?
Name of antibiotics / dose and route / duration
in : Elective caesaran section
Emergency caesarean section
Vaginal delivery with episiotomy
Independent variables were type of antibiotics, dose, route and duration of use. Data was entered and analysed using SPSS version 10.0 and calculations were made.
Observations
A total of 100 obstetricians filled the questionnaires; 10 were excluded from evaluation as they were incompletely filled. Hence, questionnaires from 90 respondents were evaluated for analysis. The characteristics of the obstetricians are depicted in Table 1. Thus, majority of respondents were women (90%), and almost half (48.9%) were postgraduate students and the majority (77.8%) were working in government hospitals. Table 2 shows the practice of use of antibiotics in episiotomies. No antibiotics were used by 18.9% obstetricians. Oral amplicillin, amoxicillin and cephalexin for 5 days duration were used by 33.3%, 27.8% and 20% respondents respectively. Table 3 shows the practice of respondents in elective and emergency caesarean section. Injection cefazolin (first generation cephalosporin) was the most commonly used antibiotic. It was used in a dose of 1 g 12 hourly for 3 days by 34.4% and 33.3% respondents in elective and emergency caesarean section respectively. It was used for longer duration (5 days) by 35.5% and 41.1% respondents in elective and emergency caesarean section respectively. Combination of parenteral ampicillin, gentamicin and metronidazole for 5 days was used by 30% respondents in elective caesarean section and 25.5% respondents in emergency caesarean section respectively.
Discussion
The goal of prophylactic antibiotics in obstetric practice is to attain therapeutic levels of antibiotic agents in tissues at the time of microbial contamination with the agent which should be long acting, inexpensive and have a low incidence of side-effects1-3. While the international studies and Cochrane database clearly had shown that antibiotics are of no use and should not be used for vaginal deliveries with episiotomies, it is seen that in the present study, only 18.9% obstetricians followed this practice. Majority of other obstetricians used oral ampicillin, amoxicillin and cephalexin for 5 days. Prophylactic antibiotics should be prescribed routinely in fourth degree perineal tear only as the drawbacks of antibiotics include potential drug allergy, development of antibiotic resistant bacteria and promotion of opportunistic infections. Use of prophylactic antibiotics reduces the incidence of endometritis following elective and emergency caesarean section by two-thirds to three quarters and the incidence of wound infection by three quarters2-4. Prophylactic antibiotics also lower the incidence of febrile morbidity and urinary tract infection after caesarean section2-10. Also, fewer serious complications occur after prophylactic antibiotics2. A meta-analysis of 51 randomised controlled trials (RCTs) indicates that both ampicillin and first generation cephalosporins have similar efficacy in the reduction of maternal infectious morbidity when compared to second and third generation cephalosporins for caesarean delivery prophylaxis2. There is no evidence from this meta-analysis to recommend multiple doses of antibiotics as superior to a single dose regimen. There is insufficient data upon which to offer a recommendation.concerning timing of administration of prophylactic antibiotics for caesarean section (pre-operative versus cord clamping) as most published trials since 1978 have administered the antimicrobial agent immediately after the cord is clamped to avoid the passage of drug to the foetus. The Cochrane database authors have recommended that both ampicillin and first generation cephalosporins in 1 to 2 doses represent good choices for prophylaxis in women undergoing caesarean section. More costly extended spectrum penicillin, second or third generation cephalosporin on combination regimes has not been found to be more effective. There is also no evidence to suggest that a multiple dose regimen is of greater benefit to the woman than a single dose regimen2-9. The practice of obstetricians in the present study show that cephalosporin was used for 3 days in 34.4% and 33.3% cases; for 5 days in 35.5% and 41.1% cases in elective and emergency caesarean section respectively. A total of 30% and 25.5% obstetricians still used parenteral ampicillin, gentamicin and metronidazle for 5 days in elective and emergency caesarean section much against the recommendation of Cochrane Database of Systematic Reviews2. These different results are probably due to deep seated myths in the minds of obstetricians that Indian women have lower resistance, are more often anaemic and malnourished thus prone to infections and they just feel more comfortable giving them combination regimens for longer duration as per the practice of their seniors. Also, amplicillin, gentamicin and metronidazole are routinely available free of cost in most government hospitals while cephalosporins have to be bought by the patient. This may also be the reason for prescribing the combination for better compliance.
There is frank misuse of prophylactic antibiotics in India as is clear from the present study. Antibiotic prophylaxis can cause marked changes in an individual’s skin flora with an increase in the resistant flora postoperatively11. There is a high rate of postoperative colonisation with resistant staphylococci with prophylactic antibiotics11. There are potential adverse effects of prophylactic antibiotics on neonates in the form in increased sepsis with ampicillin resistant E coli and other Gram-negative organisms12-14. Use of prophylactic antibiotics after clamping of cord can reduce many but not all these risks. The questionnaire clearly shows that the obstetricians continue to use their own traditional multiagent, long-term regimens in obstetrical practice against the recommendations of evidence based medicine like Cochrane reviews. This may have harmful implications due to higher cost and risk of emergence of resistant micro-organisms. This study was done by obstetricians of Delhi who have more access to scientific journals. The practice of multiple antibiotics is bound to be more rampant in peripheral and smaller hospitals in India. Surveys have been used to get important information about patient care in vaginal delivery and caesarean section15,16.
In spite of clear evidence from Cochrane Database of Clinical Reviews that use of penicillin or first generation cephalosporins in single dose therapy is effective; the actual practice is contrary with use of multiagent antibiotics for long periods, being very rampant in actual clinical practice.
References
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11 Archer GL — Alteration of cutaneous staphylococcal flora as a consequence of antimicrobial prophylaxis. Rev Infect Dis 1991; 13: S805-9.
12 Towers CV, Carr MH, Padilla G, Asrat T — Potential consequences of widespread antepartal use of ampicillin. Am J Obstet Gynecol 1998; 179: 879-83.
13 Levine EM, Ghai V, Barton JJ, Strom CM — Intrapertum antibiotic prophylaxis increases the incidence of Gram-negative neonatal sepsis. Infect Dis Obstet Gynecol 1999; 7: 210-3.
14 Baltimore RS, Huie SM, Meek JI, Schuchat A, O’Brien KL — Early-onset neonatal sepsis in the era of group B streptococcal prevention. Pediatrics 2001; 108: 1094-8.
15 Sharma JB, Malhotra M, Joshi D, Arora R — Survey of the patients' views on awareness, information, choices and care during labor in a teaching hospital. J Obstet Gynaecol India 2003; 53: 252-6.
16 Sharma JB, Sharma K, Sarin U — A study of maternal awareness and perticipation during caesarean section. J Obstet Gynaecol India 2001; 51: 37-9.
Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi 110029
*MD, MRCOG, Assistant Professor
**MD, Senior Resident
***MBBS, Junior Resident, Lok Nayak Jai Prakash Hospital, New Delhi 110002
****MD, FAMS, FRCOG, Professor and Head of the Department
Accepted January 25, 2008
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