Guidelines
Caesarean Delivery

Caesarean Delivery

Key Points

Successful antibiotic surgical prophylaxis necessitates that the antimicrobial agent achieve serum and tissue concentrations above the MIC for probable organisms at the time of incision, as well as for the duration of the procedure

Administer all antibiotics for prophylaxis within 60 min prior to cut time*

*Exception: Vancomycin (See below)

Antibiotic Surgical prophylaxis should be administered regardless of whether patient is receiving GBS prophylaxis, since the spectrum of activity needed for surgical prophylaxis is different, and to ensure adequate tissue levels at time of surgery

First Line Antibiotic

Elective Procedures

Consider 3 g if patient weighs > 120 kg

Non- Elective Procedures

Consider 3 g if patient weighs > 120 kg

plus

Non Severe Penicillin Allergy

  • Most patients with non-severe penicillin allergy can safely receive cefazolin for surgical prophylaxis

  • Non-severe includes rash and other non-allergic reactions, such as GI intolerance

Consider 3 g if patient weighs > 120 kg

Cefazolin or Severe Penicillin Allergy

Severe penicillin allergy:

  • Includes Ig-E mediated reactions (anaphylaxis, urticarial, bronchospasm, angioedema) and exfoliative dermatitis (Stevens-Johnson syndrome, toxic epidermal necrolysis)

  • These patients should not receive a beta-lactam for surgical prophylaxis

  • See below for alternative antibiotic combinations to cefazolin for all procedures (and in addition to azithromycin for non-elective procedures)

OR

PLUS

Clinical Considerations

  • If practical, we recommend vancomycin as first-line alternative agent to improve gram positive coverage and minimize the adverse effects of clindamycin

  • Vancomycin requires a longer infusion time and should be given 60-120 minutes within incision time

Weight < 80 kg

  • 1g IV over 60 minutes preoperatively
  • Start 90 minutes before incision time

Weight 80 - 99.9 kg

  • 1.25 g IV over 90 minutes preoperatively
  • Start within 120 min of incision time

Weight 100 - 119.9  kg

  • 1.5 g IV over 90 minutes
  • Start within 120 min of incision time

Weight ≥ 120 kg

  • 1.75 g IV over 120 minutes
  • Start within 120 minutes of incision time
  • Can be used when it is not practical to give vancomycin

  • Clindamycin has considerably reduced susceptibility for Staphylococcus and grp B strep species compared to vancomycin, which remains at 100% susceptible (as per SAH antibiogram)

Weight Dose
Less than 60 kg 240 mg
60.9 - 79.9 kg 320 mg
80 - 99.9 kg 400 mg
100 - 119.9 kg 480 mg
≥ 120 kg 500 mg

In patients with renal failure (CrCl < 30 ml/min) decrease dose to 2- 3 mg/kg; consult pharmacist for dosing

Some evidence exists showing that the addition of azithromycin in non-elective C-Section procedures was more effective than placebo in reducing postoperative infections (regardless of BMI).

Common Targeted Pathogens and Antibiogram

Additional Information

  1. Dale W. Bratzler, E. Patchen Dellinger,et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery; Am J Health-Syst Pharm. 2013; 70:195-283.
  2. Alan T.N. Tita, M.D., Ph.D., et al. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery; N Engl J Med 2016; 375:1231-1241 ; Sept 2016 DOI:10.1056/NEJMoa1602044