剖宫产预防用药新观点
本帖最后由 海内知己 于 2010-9-26 14:41 编辑ACOG推荐在剖宫产前应用抗生素
Antibiotics Recommended Prior to Cesarean Incision, ACOG Says
By Kerri Wachter 2010-08-23
Elsevier Global Medical News
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Antimicrobial prophylaxis now should be administered within 60 minutes of the start of a cesarean delivery, rather than after cord clamping, which has been the preferred time for administration.
The recommended change in practice comes from a new opinion released Aug. 23 by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice as Committee Opinion No. 465, “Antimicrobial Prophylaxis for Cesarean Delivery: Timing of Administration” (Obstet. Gynecol. 2010;116:791-2).
“Based on the latest data, prophylactic antibiotics given to pregnant women before a cesarean significantly reduce maternal infections and do not appear to harm newborns,” Dr. William H. Barth Jr., chair of the committee, said in a statement.
“Anytime you have invasive surgery, you have an increased risk of developing an infection at the incision site,” he said in the statement. Infection is the most common complication of cesarean delivery and can occur in an estimated 10%-40% of women who undergo cesarean delivery, compared with 1%-3% of women who deliver vaginally, according to ACOG.
The committee recommends antimicrobial prophylaxis for all cesarean deliveries unless the patient is already receiving appropriate antibiotics. When it is not possible to begin administration within 60 minutes of the first incision – as with emergent delivery – prophylaxis should be administered as soon as possible.
Antimicrobial prophylaxis has been a common practice for cesarean deliveries. However, intraoperative antibiotics have been administered after umbilical clamping due to concerns about neonatal exposure to antibiotics. In particular, it has been theorized that antibiotics in neonatal serum could mask positive bacterial culture results in newborns and that fetal antibiotic exposure could lead to increased newborn colonization or infection with antibiotic-resistant organisms.
Older studies had suggested that when prophylactic antibiotics were given before the cesarean, pediatricians tended to do more invasive neonatal sepsis evaluations and costs were increased, Dr. Barth said in an interview. “This was based on the fear that the antibiotics given to the mother would cross rapidly to the fetus and then mask the signs of infection in the newborn child.” Pediatricians feared that the usual signs of sepsis might be masked by these antibiotics. Given this fear, tests such as blood draws and lumbar punctures that are useful in making a diagnosis of newborn sepsis tended to be used more frequently.
“However, based on recent randomized clinical trials and systematic reviews, giving the mother the antibiotics before the cesarean incision does not appear to increase problems in the newborn. None of the studies were large enough to say that definitively, but given the overall benefit to the mother, our committee – which included pediatricians – felt that this was the right thing to do,” said Dr. Barth, chief of maternal-fetal medicine at Massachusetts General Hospital, Boston.
In fact, preoperative antimicrobial prophylaxis “does not appear to have any deleterious effects on mother or neonate,” the committee wrote. Timing really does make a difference. In the studies reviewed, preoperative administration significantly reduced the rates of endometritis and total maternal infectious morbidity, compared with administration after cord clamping. Just as importantly, preoperative administration was not associated with an increase in neonatal infectious morbidity or the selection of antimicrobial-resistant bacteria causing neonatal sepsis.
The committee recommends that the infusion be timed so that a bactericidal serum level is reached by the time of skin incision. Therapeutic antibiotic levels should be maintained throughout the operation. Readministration is indicated at intervals of one or two times the half-life of the drug during longer procedures.
The committee recommends using narrow-spectrum drugs that are effective against gram-positive and gram-negative bacteria and against some anaerobic bacteria – such as first-generation cephalosporins. Notably, obese women may require doses larger than the recommended 1 gram intravenous cefazolin (with a therapeutic dose maintained for 3-4 hours). Clindamycin with gentamicin is an acceptable alternative for women with significant allergies to beta-lactam antibiotics.
Dr. Barth said he had conflicts of interest to disclose.
Copyright (c) 2010 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
8月23日，美国妇产科医师学会(ACOG)产科实践委员会发布第465号委员会意见“Antimicrobial Prophylaxis for Cesarean Delivery Timing of Administration” ，推荐在剖宫产开始60 min内(首选给药时间)应用预防性抗生素，而不应在脐带结扎之后才给药(Obstet. Gynecol. 2010;116:791-2)。
委员会主席兼波士顿马萨诸塞州综合医院的母-胎医学主任William H. Barth Jr.博士指出，最新资料表明，在剖宫产前应用预防性抗生素可显著减少孕产妇感染且似乎不会对新生儿产生任何不良影响。
感染是剖宫产的最常见并发症，剖宫产妇女的感染发生率为10%~40%，而阴道分娩妇女的感染发生率仅为1%~3%。
该委员会建议对所有剖宫产手术病例应用预防性抗生素，除非患者已正在使用合适的抗生素。在无法在剖宫产开始60 min内给药的情况下(如急诊分娩)，应尽可能快地应用预防性抗生素。
对剖宫产妇女预防性应用抗生素已经成为常规措施。然而，由于担心抗生素对新生儿产生危害，术中抗生素在脐带结扎后才给予。特别是有观点认为，新生儿血清中的抗生素可掩饰其阳性细菌培养结果，并且对新生儿应用抗生素可增加其发生抗生素耐药菌定植或感染的风险。
既往研究表明，在剖宫产前预防性应用抗生素的情况下，儿科医生往往会增加对侵袭性新生儿脓毒症的检查，而这也增加了医疗费用。检查增加的原因在于担心应用于孕产妇的抗生素会迅速到达胎儿，进而掩饰新生儿的感染征象。出于这种担心，抽血和腰穿等有助于诊断新生儿脓毒症的检查方法往往应用得较多。
然而，近期的随机临床研究和系统回顾显示，剖宫产前对孕产妇应用抗生素似乎不会增加新生儿感染风险。
该委员会指出，事实上，术前预防性应用抗生素“似乎不会对孕产妇和新生儿产生任何不良影响。” 给药时间实际上起着重要的作用。在所回顾的研究中，与脐带结扎后给药相比，术前给药能显著降低子宫内膜炎和孕产妇总体感染并发症的发生率。同样重要的是，术前给药并不与新生儿感染并发症增加相关，也不与导致新生儿脓毒症的耐药菌的选择相关。
该委员会建议，应对抗生素输注时间进行合理设定，以便能够在做皮肤切口的时候达到血清杀菌浓度。同时应在整个手术期间维持治疗性抗生素浓度。在长时间手术期间，应间隔1个或2个半衰期再次给药。
该委员会推荐应用能够有效抑制革兰阳性和阴性菌及某些厌氧菌的窄谱药物，如第一代头孢菌素类。需指出的是，在对肥胖妇女应用静脉头孢唑啉时，用药量可能需要大于1 g的推荐剂量（同时维持治疗剂量3~4 h）。 如患者对β-内酰胺类抗生素明显过敏，则使用克林霉素和庆大霉素是可以接受的。 本帖最后由 海内知己 于 2010-9-27 15:54 编辑
这个观点与我们国内现行规范是相左的，应该说这也是一种观点。我们建议，若要于术前开始使用的话，应严格规范选药种类，即这种用法仅限于规范所推荐的较为安全的品种。对于甲硝唑、克林霉素，以及万古霉素、氨基糖苷类或喹诺酮类等安全系数较低的药物，肯定要排除在外。 谢谢海内老师提供的资料，我们会在临床实践中进行实践和观察。 还是糊涂，理论和实践还是有矛盾。 不同的观点，应该有的，百家争鸣吗！有待实践检验。而且文中说了“委员会主席兼波士顿马萨诸塞州综合医院的母-胎医学主任William H. Barth Jr.博士指出，最新资料表明，在剖宫产前应用预防性抗生素可显著减少孕产妇感染且似乎不会对新生儿产生任何不良影响。”似乎两个字说明还没有证据表明没有影响，也没证据表明有影响。现实工作中要检验呀 “如患者对β-内酰胺类抗生素明显过敏，则使用克林霉素和庆大霉素是可以接受的。”--我院用的是庆大霉素 李英华 发表于 2012-6-22 11:15 static/image/common/back.gif
“如患者对β-内酰胺类抗生素明显过敏，则使用克林霉素和庆大霉素是可以接受的。”--我院用的是庆大霉素
我认为，使用庆大霉素作为剖宫产手术的预防用药，尤其是剖宫产术前用药的做法，应该慎重，值得商榷！
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