最近一项关于预防性使用抗生素预防手术阴道分娩后感染的随机对照试验表明,接受预防性静脉注射阿莫西林和克拉维酸的妇女在手术阴道分娩后6周内发生确诊或疑似感染的风险显着降低(风险比[RR],0.58;95%置信区间[CI],0.49-0.69;P<.001)。随后更新了一些国际和国家指南,以包括手术阴道分娩后的预防性抗生素。然而,在会阴切开率较低的情况下(试验中89%的女性进行了会阴切开术),试验结果的普遍性可能受到限制.此外,尽管预防性使用抗生素,但预防性抗生素组的感染负担仍然很高.确定手术阴道分娩后感染的可改变的危险因素至关重要。包括抗生素给药的时间。
本研究旨在评估预防性抗生素在减少确诊或疑似感染方面的有效性是否独立于会阴创伤,确定手术阴道分娩后感染的危险因素,并研究疗效随抗生素给药时间的变化。
本研究是对3225名妇女的二次分析,主要结果数据来自预防性抗生素预防手术阴道分娩后感染的随机对照试验。根据经历的会阴创伤(会阴切开术和/或会阴撕裂)将妇女分为亚组。使用对数二项回归和似然比检验评估预防性抗生素在预防亚组感染中的一致性。多变量对数二项回归用于研究与感染相关的因素。随后将多变量危险因素模型拟合到接受阿莫西林和克拉维酸的女性组以研究抗生素给药的时机。
在二次分析中纳入的3225名女性中,2144(66.5%)仅进行了会阴切开术,726(22.5%)进行了会阴切开术和撕裂,277(8.6%)仅有眼泪,78例(2.4%)既无会阴切开术也无撕裂。在经历会阴创伤的女性中,与安慰剂组相比,阿莫西林和克拉维酸在所有亚组中均对感染有保护作用,亚组与试验分配之间无显著交互作用(P=.17).此外,2925名女性纳入多变量危险因素分析。以下与调整后的感染风险比相关:会阴切开术,2.94(95%置信区间,1.62-5.31);镊子,1.37(95%置信区间,1.12-1.69)与真空提取相比;基本奇偶校验,1.34(95%置信区间,1.05-1.70);阿莫西林和克拉维酸给药,0.60(95%置信区间,0.51-0.72);体重指数为25.0至29.9kg/m2,1.21(95%置信区间,1.00-1.47),体重指数≥30kg/m2,1.22(95%置信区间,0.98-1.52),而体重指数<25kg/m2。出生和使用抗生素之间每增加15分钟,感染风险就会增加3%(调整后的风险比,1.03;95%置信区间,1.01-1.06)。
术后阴道分娩的所有妇女应及时使用预防性抗生素,无论会阴创伤的类型。会阴切开术的使用,产钳,原语奇偶校验,和超重与手术阴道分娩后确诊或疑似感染的风险增加相关.
A recent randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth showed that women allocated prophylactic intravenous amoxicillin and clavulanic acid had a significantly lower risk of developing confirmed or suspected infection within 6 weeks after operative vaginal birth (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.49-0.69; P < .001). Some international and national guidelines have subsequently been updated to include prophylactic antibiotics after operative vaginal birth. However, the generalizability of the trial results may be limited in settings where the episiotomy rate is lower (89% of women in the
trial had an episiotomy). In addition, there was a high burden of infection in the prophylactic antibiotics group despite the administration of prophylactic antibiotics. It is essential to identify modifiable risk factors for infection after operative vaginal birth, including the timing of antibiotic administration.
This
study aimed to evaluate if the effectiveness of the prophylactic antibiotic in reducing confirmed or suspected infection was independent of perineal trauma, identify risk factors for infection after operative vaginal birth, and investigate variation in efficacy with the timing of antibiotic administration.
This
study was a secondary analysis of 3225 women with primary outcome data from the prophylactic antibiotics for the prevention of infection following operative vaginal birth randomized controlled trial. Women were divided into subgroups according to the perineal trauma experienced (episiotomy and/or perineal tear). The consistency of the prophylactic antibiotics in preventing infection across the subgroups was assessed using log-binomial regression and the likelihood ratio test. Multivariable log-binomial regression was used to investigate factors associated with infection. The multivariable risk factor model was subsequently fitted to the group of women who received amoxicillin and clavulanic acid to investigate the timing of antibiotic administration.
Of the 3225 women included in the secondary analysis, 2144 (66.5%) had an episiotomy alone, 726 (22.5%) had an episiotomy and a tear, 277 (8.6%) had a tear alone, and 78 (2.4%) had neither episiotomy nor tear. Among women who experienced perineal trauma, amoxicillin and clavulanic acid administration was protective against infection in all subgroups compared with placebo with no significant interaction between subgroup and trial allocation (P=.17). Moreover, 2925 women were included in the multivariable risk factor analysis. The following were associated with adjusted risk ratios of infection: episiotomy, 2.94 (95% confidence interval, 1.62-5.31);
forceps, 1.37 (95% confidence interval, 1.12-1.69) compared to vacuum extraction; primiparity, 1.34 (95% confidence interval, 1.05-1.70); amoxicillin and clavulanic acid administration, 0.60 (95% confidence interval, 0.51-0.72); body mass index of 25.0 to 29.9 kg/m2, 1.21 (95% confidence interval, 1.00-1.47), and body mass index of ≥30 kg/m2, 1.22 (95% confidence interval, 0.98-1.52) compared to body mass index of <25 kg/m2. Each 15-minute increment between birth and antibiotic administration was associated with a 3% higher risk of infection (adjusted risk ratio, 1.03; 95% confidence interval, 1.01-1.06).
Timely prophylactic antibiotics should be administered to all women after operative vaginal birth, irrespective of the type of perineal trauma. The use of episiotomy,
forceps birth, primiparity, and overweight were associated with an increased risk of confirmed or suspected infection after operative vaginal birth.