the american college of obstetricians and gynecologists

women s health care physicians

P R AC T I C E
BUL L E T I N
clinical management guidelines for obstetrician gynecologists

Number 120, June 2011

(Replaces Committee Opinion Number 445, November 2009 and

Committee Opinion Number 421, November 2008)

Use of Prophylactic Antibiotics in Labor

and Delivery
The use of antibiotics to prevent infections during the antepartum, intrapartum, and postpartum periods is distinctly
different from the use of antibiotics to treat established infections. For many years, the use of prophylactic antibiotics was thought to have few adverse consequences. Concerns about the emergence of resistant strains of common
bacteria, in addition to the emergence of strains with increased virulence, have resulted in increased scrutiny of the
use of antibiotics, particularly in the hospital setting. In labor and delivery, awareness of the potential adverse effects
of resistant bacterial infections on neonates has been growing. Finally, cost is an element to consider in the use and
choice of prophylactic agents. The purpose of this Practice Bulletin is to present a review of clinical situations in
which prophylactic antibiotics are frequently prescribed and to weigh the evidence supporting the use of antibiotics
in these scenarios.

Background
Effective prophylactic antibiotic agents are active against
most but not all potential pathogens, which usually are
endogenous flora. The goal of antibiotic prophylaxis
is to prevent infection, not to cure or treat disease. In
contrast to the therapeutic use of antibiotics, prophylaxis
must be administered before the potential exposure, and
usually for a short duration (less than 24 hours). The
goal of prophylactic antibiotic use is to have therapeutic
tissue levels in place at the time microbial contamination might occur. Delaying administration by even a few
hours reduces or eliminates the benefit of prophylaxis.
Ideally, the agent of choice should be long acting, narrowly focused on the likely bacteria, inexpensive, and
have a low incidence of adverse effects.

Resistance Risks of Prophylactic

Antibiotics
Although the risks of inappropriate antibiotic use may
be difficult to recognize in any individual patient, the
broader effect of the increasing use of antibiotics can
be seen in the hospital setting. Antimicrobial prophylaxis has been shown to result in marked changes in an
individuals skin flora, with increases in resistant flora
seen postoperatively (1). This appears to be the result of
selection of resistant endogenous flora by prophylactic
antibiotics, as well as the nosocomial acquisition of
resistant micro-organisms.
In labor and delivery, awareness of the potential
adverse effects of resistant bacterial infections on neonates has been increasing. A comparison of very low
birth weight neonates (less than 1,500 g) born between

Committee on Practice BulletinsObstetrics. This Practice Bulletin was developed by the Committee on Practice BulletinsObstetrics with the assistance of Amy Murtha, MD, and Neil Silverman, MD. The information is designed to aid practitioners in making decisions about appropriate obstetric and
gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

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1998 and 2000 with those born between 1991 and 1993
found an important reduction in early-onset neonatal
sepsis from group B streptococci (GBS), but an increase
in sepsis caused by Escherichia coli (2).
Changes have been reported in resistance patterns of
isolated strains of E coli in newborns, particularly after
maternal antibiotic administration (38). The increases
in E coli sepsis and the increasing resistance to ampicillin are primarily confined to the preterm population and
low birth weight population although an effect on term
infants has been suggested as well (910). Sepsis in
very low birth weight neonates with ampicillin-resistant
E coli is more likely to be fatal than infection with susceptible strains (7). In addition to resistant E coli, some
studies show that up to 30% of GBS isolates are resistant
to erythromycin and clindamycin. These results have led
to significant changes in intrapartum protocols designed
to prevent invasive neonatal GBS disease (1114).
In the past, resistance has been countered by the
development of new classes of drugs or modifications of
older drugs. However, it seems increasingly unlikely that
the pharmaceutical industry will be able to keep pace
with the rapid emergence of resistant organisms (15). In
the past two decades, for example, increasing difficulties
have been encountered in treating multidrug-resistant
tuberculosis as well as increasingly resistant strains of
Staphylococcus aureus, enterococci, and Streptococcus
pneumoniae (16).
The potential for the development of resistant
organisms is also a financial consideration when planning prophylactic antibiotic strategies. The cost implications of methicillin-resistant S aureus (MRSA) infection
treatment among obstetric patients have been estimated
to be more than $8 million annually in the United States
alone (17).

after administration for GBS prophylaxis has been

reported, and there are reports of exfoliative dermatitis
and severe immune hemolytic anemia associated with
cephalosporin therapy (2022). Although these instances are uncommon, antibiotic use should be limited to the
specific indications as outlined.

Pharmacokinetics of Antibiotics

Other risks of antibiotic administration include allergic

reactions or anaphylaxis, although the true incidences
of these risks are unclear. Approximately 25% of all
patients requiring antimicrobial therapy in the hospital
report an allergy to at least one antibiotic, typically
penicillin, although only 4% of those patients have documentation as to the specific type of allergic reaction (18).
Anaphylaxis to penicillin is estimated to occur in 1 in
2,50025,000 patients, with less severe reactions occurring in approximately 10% of patients (9). It has been
estimated that approximately 5% of patients receiving an
antibiotic in the hospital will have a significant adverse
reaction (19). Skin reactions (urticaria, rash, pruritus)
to cephalosporins occur in 13% of patients; however,
the risk of anaphylaxis is thought to be much lower
(0.0010.1%) (20). A case of anaphylaxis to penicillin

It has long been assumed that the pharmacokinetics of

antibiotics differ between pregnant and nonpregnant
patients. As a result of the increase in the glomerular
filtration rate that begins early in the first trimester during pregnancy, those medications that are excreted by
renal filtration may be expected to have shorter half-lives
and may be expected to reach lower peak serum levels in
pregnant women. Because of the increased plasma volume in pregnancy, the volume of distribution is greater
and the concentration of plasma proteins is lower than in
the nonpregnant state, which potentially leads to lower
plasma and serum levels of antibiotics. Hormone-mediated
increases in binding proteins also may result in changes in
the distribution of drugs, whereas decreases in gastric
emptying time and changes in gastric acidity may change
the oral absorption of drugs. Overall, these considerations
are believed to result in a reduction in the amount of the
drug available to the woman and, potentially, a need for
increased antibiotic dosages during pregnancy.
When therapeutic levels of antibiotics in the amniotic cavity are desired, agents known to have efficient
transplacental transfer should be used. Examples of
such clinical situations include prophylaxis for preterm
premature rupture of membranes (PROM) to prolong
the latency period as well as maternal intrapartum prophylaxis for GBS. Antibiotics that are known to reach
fetal concentrations of 3090% of maternal serum in the
second trimester and beyond include ampicillin, cephalothin, clindamycin, and the aminoglycosides (23, 24).
Antibiotics that do not appear to cross the placenta well
include erythromycin and azithromycin. (2325).
High doses of prophylactic antibiotics also may be
indicated in the context of an obese patient (body mass
index [BMI] greater than 30). Although this issue has
not been studied extensively in pregnant patients, in
patients undergoing bariatric surgery, for example, a single preoperative 2-g dose of cefazolin resulted in intraoperative serum and tissue levels comparable with those
seen in nonobese patients given a 1-g dose (26, 27).
Comparably, increases in both volume of distribution
and drug clearance for cephalosporins have been demonstrated in obese patients (2729). Therefore, adjustment
of single-dose preoperative antibiotic prophylaxis in the
context of maternal obesity seems reasonable based on
currently available pharmacokinetic data (26, 30).

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Use of Prophylactic Antibiotics in Labor and Delivery 1473

Antibiotic Allergy and Anaphylaxis Risks

Practice Bulletin

Clinical Considerations and

Recommendations
Is antibiotic prophylaxis appropriate for
patients undergoing cesarean delivery?
The single most important risk factor for infection in
the postpartum period is cesarean delivery, with rates of
postoperative infection significantly higher than would
be predicted compared with rates from other surgical
procedures (3133). As with other elective, noninfected
surgical cases, antimicrobial prophylaxis is recommended for all cesarean deliveries unless the patient is
already receiving an antibiotic regimen with appropriate
coverage (eg, for chorioamnionitis), and such prophylaxis should be administered within 60 minutes before
the start of the cesarean delivery (34). When this is not
possible (eg, need for emergent delivery), prophylaxis
should be administered as soon as possible after the incision is made.
A recent Cochrane review included 86 studies with
more than 13,000 participants enrolled in randomized
clinical trials to evaluate the effect of prophylactic antibiotics in both emergent and nonemergent cesarean deliveries. This review found significant reductions in overall
febrile morbidity, wound complications, and endometritis
with the use of prophylactic antibiotics. In this analysis,
the risk of endometritis after elective cesarean delivery,
for example, was reduced by 76% (relative risk [RR]
0.24; 95% confidence interval [CI], 0.250.35). All risk
reductions remained significant regardless of the type of
cesarean delivery (emergent or elective) (35). In addition,
a recent review of more than 9,000 U.S. women undergoing a term prelabor cesarean delivery showed significant
reductions in both postpartum endometritis and wound
complications when antibiotic prophylaxis was received.
This study, conducted through the Eunice Kennedy
Shriver National Institute of Child Health and Human
Development-sponsored MaternalFetal Medicine Units
Network, demonstrated significant reductions in morbid-
ity outcomes in the face of very low baseline rates for
these complications after nonlabor cesarean deliveries
(2.6% for endometritis and 1% for wound infections).
These risk reductions remained significant when the
analysis was controlled for patients who had rupture of
membranes, but not labor, before their surgery (36).

Timing and Choice of Antibiotic Regimen

Antibiotics that are effective against gram-positive
bacteria, gram-negative bacteria, and some anaerobic
bacteria, are mainly used for prophylaxis for cesarean
delivery. A variety of antibiotics have been shown to

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be efficacious for prophylaxis, including cefazolin,

cefotetan, cefuroxime, ampicillin, piperacillin, cefoxitin, and ampicillinsulbactam. One retrospective study
of 2,280 nonelective cesarean deliveries reported that
cefazolin, a first-generation cephalosporin, and cefoxitin, a second-generation cephalosporin, were equally
efficacious in preventing endometritis, with cefazolin
costing 80% less than cefoxitin (37). Similarly, a metaanalysis of 51 antibiotic trials confirmed that ampicillin
and first-generation cephalosporins had comparable
efficacy when compared with second-generation and
third-generation cephalosporins for cesarean delivery
prophylaxis (38). Ampicillin, however, would be a less
appropriate choice for surgical prophylaxis compared
with cefazolin because of its much shorter half-life. This
same review demonstrated no differences in efficacy
when first-generation cephalosporins were compared
with broader-spectrum second-generation cephalosporins or third-generation cephalosporins for the purpose
of surgical prophylaxis in general.
Single-dose therapy has been shown to be as efficacious as multidose therapy in most studies (3942).
Single-dose therapy also reduces costs, potential toxicity, and the risk of colonization with resistant organisms.
Therefore, a single dose of a targeted antibiotic, such as
a first-generation cephalosporin, is the first-line anti-
biotic of choice, unless significant drug allergies are
present. For women with a history of a significant
penicillin or cephalosporin allergy (anaphylaxis, angioedema, respiratory distress, or urticaria), a single-dose
combination of clindamycin with an aminoglycoside is a
reasonable alternative for cesarean delivery prophylaxis.
Extended-spectrum antibiotics, such as azithromycin, have been suggested by some investigators as alternatives or adjuncts to first-generation cephalosporins
for cesarean delivery prophylaxis, administered either
before or after umbilical cord clamping. In one review,
the benefit of postincision administration of azithromycin appeared to be comparable to preincisional cefazolin
(43). At present, the advantage of this strategy remains
unproved and further systematic study is necessary
before its routine adoption.
After a single 1-g intravenous dose of cefazolin, a
therapeutic level is maintained for approximately 34
hours. A higher dose may be indicated if a woman is
obese. Although no specific dose has been studied in
obese pregnant patients, as previously mentioned, consideration should be given to using a higher dose of preoperative antibiotics for surgical prophylaxis for women
with a BMI greater than 30 or an absolute weight more
than 100 kg (27). Further study is needed to determine
whether additionally augmented dosages are warranted
in patients at or above definitions of extremely morbid

Use of Prophylactic Antibiotics in Labor and Delivery

OBSTETRICS & GYNECOLOGY

or World Health Organization class III, obesity (BMI

greater than 4045).
The most appropriate timing for administration of
prophylactic antibiotics also has been increasingly studied. A recent meta-analysis of three randomized trials
(4446), with a combined sample size of 749 participants,
supported the use of antibiotic prophylaxis for cesarean delivery administered up to 60 minutes before skin
incision rather than after umbilical cord clamping (47).
Antibiotic prophylaxis before skin incision was found in
this study and a later systematic review to decrease the
incidence of postpartum endometritis and total infectious
morbidities without affecting neonatal outcomes (47, 43).
Two subsequent retrospective cohort studies from large
centers evaluated the effect of policy change at these
institutions from administering antibiotics after umbilical cord clamping to administering preincisional cesarean prophylaxis to all patients. These two studies, with a
combined sample size of 10,326 women, reinforced the
findings of low rates of both surgical site infections and
overall maternal infectious morbidities with presurgical
prophylaxis. No differences in rates of neonatal intensive
care unit admission, neonatal sepsis, or suspected sepsis
were reported between the treatment groups, although,
as with other studies, power calculations were not based
on evaluation of these secondary neonatal outcomes (48,
49). In addition, a retrospective casecontrol study of
1,600 patients who underwent cesarean delivery showed
that antibiotic prophylaxis administered more than 1 hour
before incision was associated with double the rate of
surgical site infections compared with timing within 1
hour of incision (RR, 2.1; CI, 1.23.8) (50). As for surgical prophylaxis in general, patients with lengthy surgical
procedures or those who experience excessive blood loss
should receive an additional intraoperative dose of the
antibiotic used for preincision prophylaxis (51).

Does colonization with methicillin-resistant

S aureus affect antibiotic prophylaxis for
cesarean delivery?
The epidemiology of MRSA infections has changed
from primarily hospital-acquired infection among ill or
immunocompromised patients to infections related to the
emergence of more virulent MRSA strains over the past
10 years, which constitutes a major public health problem no longer confined to intensive care units or health
care institutions in general (5255). In one recent survey,
MRSA isolation among patients with culture-confirmed
surgical site infection increased from 16% to 21% over
a 5-year study period (56). Methicillin-resistant S aureus
has been associated with serious postpartum infections,
particularly after cesarean delivery (57, 58), and surveil-

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Practice Bulletin

lance studies have detected MRSA colonization rates

of up to 10% in rectovaginal swab specimens and up to
2% of nasal swab specimens in asymptomatic pregnant
women at term (59, 60). Despite these increasing concerns, there are currently insufficient data in pregnant
patients to warrant or recommend screening all women
preoperatively for MRSA colonization status, particularly because most colonized patients will not develop
invasive disease.
Although intranasal or topical (skin wash) antimicrobial decolonization protocols have been studied for
the prevention of recurrent skin and soft tissue infections
among MRSA carriers, the overall efficacy, optimal dosage and duration for these regimens remains uncertain
(61). In the context of skin and soft tissue infections
alone, nasal mupirocin has been shown to decrease the
prevalence of nasal MRSA colonization, but not to reduce
the incidence of first-time skin and soft tissue infections
(62). In addition, concerns about high levels of mupirocin
resistance have been raised by analysis of MRSA isolates
in some community settings (63). Although a preoperative
skin preparation using chlorhexidine alcohol was shown
to reduce rates of surgical infections compared with povidone iodine (64), chlorhexidine skin wipes used alone had
no effect on lowering skin and soft tissue infections rates
among MRSA carriers (65). Finally, a Cochrane review
found no benefit from oral antibiotics for eradication of
MRSA colonization among patients in the health care setting (66), and oral antibiotics are not currently routinely
recommended for the purpose of MRSA decolonization
(61).
In addition, any potential benefit of preoperative
decolonization protocols for MRSA carriers may be
limited in obstetric populations to women who have a
planned cesarean delivery and who are known before the
delivery to be MRSA colonized (defined as those with
a history of MRSA infection or positive culture in the
past). Routine screening of obstetric patients for MRSA
colonization is not recommended. However, in obstetric
patients known to be MRSA colonized, consideration
may be given to adding a single dose of vancomycin
to the recommended antibiotic prophylaxis regimen
for women undergoing cesarean delivery (cefazolin
or an alternative for patients with b-lactam allergies).
Vancomycin alone does not provide sufficient coverage
for surgical prophylaxis in general.

Is antibiotic prophylaxis appropriate for

patients with preterm premature rupture of
membranes?
For patients with PROM at less than 37 weeks of gestation, antibiotic prophylaxis is indicated to prolong the

Use of Prophylactic Antibiotics in Labor and Delivery 1475

latency period between membrane rupture and delivery

(13, 67) (see Box 1). Numerous trials have evaluated the
prophylactic use of intravenous and oral antibiotics to
prolong latency and to improve maternal and neonatal
outcomes after preterm PROM (6873). Regardless
of the antibiotic prescribed or the duration of treatment, most trials described a statistically significant
prolongation of the latency period but generally did not
show an improvement in neonatal outcome. However,
a MaternalFetal Medicine Units Network multicenter
trial did demonstrate a reduction in neonatal morbidity and mortality with antibiotic prophylaxis, including
reductions in respiratory distress syndrome, necrotizing
enterocolitis, intraventricular hemorrhage, and earlyonset sepsis (72). In this study, neonates of GBS-positive
women did not receive the same benefit, and none of the
patients received antenatal corticosteroids.
Several meta-analyses have concluded that antibiotic prophylaxis after preterm PROM is effective in
prolonging pregnancy, reducing maternal infectious com-
plications, and reducing neonatal infectious morbidity
(7375). However, a large multicenter trial from the
United Kingdom reported that pregnancy was prolonged
by the use of erythromycin, amoxicillinclavulanic acid,
or both, but that only the use of erythromycin resulted
in reduced neonatal morbidity (76). A review of the
current literature does not reveal a consistent pattern of
increased risk with broader-spectrum antibiotic therapy,

Box 1. Recommendations for Use of Antibiotics

in Women With Preterm Premature Rupture of
Membranes or Preterm Labor
For patients with preterm labor with intact membranes
Use intrapartum antibiotics to prevent group B streptococcal perinatal infection.
Do not use antibiotics to prolong pregnancy.
For patients with acute infections requiring antibiotic
treatment during pregnancy
Erythromycin, or amoxicillinclavulanate, or both
may be given if appropriate based on known or
anticipated bacterial sensitivities to these agents.
For patients with preterm premature rupture of
membranes
Use antibiotics to prevent group B streptococcal
perinatal infection.
Use broad-spectrum antibiotics during conservative
management to prolong pregnancy and decrease
short-term neonatal complications for preterm
premature rupture of membranes.

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Practice Bulletin

and one recent retrospective review of the use of amoxicillinclavulanic acid did not demonstrate an association
with necrotizing enterocolitis (77).
The Eunice Kennedy Shriver National Institute of
Child Health and Human Development-sponsored
MaternalFetal Medicine Units Network Trial, as well
as the Society of Obstetricians and Gynaecologists of
Canada have recommended the use of prophylactic
antibiotics for preterm PROM when fetal lung maturity is not documented and delivery is not imminent,
with options including a regimen of both amoxicillin
and erythromycin for a total of 7 days (78). Several
recent studies have attempted to determine whether a
shorter duration of 7 days of antibiotic therapy could
be adequate after preterm PROM, but they have been
of inadequate size and power to demonstrate equivalent
effectiveness in reducing infant morbidity (79, 80).
Recently revised guidelines from the Centers for
Disease Control and Prevention recommend that women
with preterm PROM who are not in labor should
receive a regimen that will include adequate intravenous GBS coverage for at least the first 48 hours of
preterm PROM latency prophylaxis, pending the GBS
test results obtained on admission. However, GBS test
results should not affect the overall duration of antibiotic
therapy. If the patient completes the full 7-day course of
antibiotic prophylaxis and remains without evidence of
infection or labor, intrapartum GBS prophylaxis should
then be managed by the results of the baseline GBS
test at the time of preterm PROM unless 5 weeks have
passed (a negative GBS test result is considered valid for
5 weeks) (13, 14).

Is antibiotic prophylaxis appropriate for

preterm labor?
Antibiotic use intended only for pregnancy prolongation
in women with preterm labor with intact membranes
does not have short-term neonatal benefits and may be
associated with long-term harm. Thus, antibiotic prophylaxis should not be used for pregnancy prolongation
in women with preterm labor and intact membranes (72,
73, 76). This recommendation is distinct from recommendations for antibiotic use for preterm PROM and
GBS carrier status (7, 13, 81).
In cases of preterm labor with intact membranes,
intravenous GBS prophylaxis should be administered
until GBS test results are available unless the patient
has had a negative GBS test result within the preceding 5 weeks. If the GBS test result obtained at the time
the patient was admitted is positive but true labor does
not ensue, the GBS prophylaxis should be stopped and
restarted at the onset of true labor (13).

Use of Prophylactic Antibiotics in Labor and Delivery

OBSTETRICS & GYNECOLOGY

A recent multicenter, randomized clinical trial provided a 7-year follow-up of a large group of patients
receiving antibiotics (placebo versus oral erythromycin,
amoxicillinclavulanate, or both) for preterm labor with
intact membranes. From this trial, 3,196 children (71%
of those enrolled) had outcome information available
(82). Despite being comparable in acute morbidities and
mortality, the study groups were significantly different
in terms of long-term follow-up data. Infants exposed
prenatally to erythromycin, had more functional impairment (42.3% versus 38.3%) and mild functional impairment (23.9% versus 21.3%) compared with those who
had not received erythromycin. These data reinforce the
lack of benefit and potential harm in using antibiotic
prophylaxis for preterm labor with intact membranes, in
contrast to its use with preterm PROM.

Is antibiotic prophylaxis appropriate for

prevention of bacterial endocarditis at the
time of delivery?

Box 2. Cardiac Conditions With High Risk of

Endocarditis in the Presence of Bacteremia
Prophylaxis against infective endocarditis is reasonable
for the following patients at highest risk of adverse outcomes from infective endocarditis who undergo dental
procedures that involve manipulation of either gingival
tissue or the periapical region of teeth or
perforation of the oral mucosa*:
Patients with prosthetic cardiac valve or prosthetic
material used for cardiac valve repair
Patients with previous infective endocarditis
Patients with CHD
Unrepaired cyanotic CHD, including palliative shunts
and conduits
Completely repaired congenital heart defect repaired
with prosthetic material or device, whether placed by
surgery or by catheter intervention, during the first
6 months after the procedure.
Repaired CHD with residual defects at the site or
adjacent to the site of a prosthetic patch or prosthetic
device (both of which inhibit endothelialization)
Cardiac transplant recipients with valve regurgitation
due to a structurally abnormal valve.

Infective endocarditis prophylaxis is not recommended

for either vaginal delivery or cesarean delivery in the
absence of infection, except possibly for the small subset
of patients at highest potential risk for adverse cardiac
outcomes who are undergoing vaginal delivery (83, 84).
Joint statements from the American Heart Association
and the American College of Cardiology recommend
this approach for three main reasons: 1) most cases of
endocarditis are not attributable to an invasive procedure
(whether dental, gastrointestinal, or genitourinary), but
rather are the result of randomly occurring bacteremia
from routine daily activities; 2) prophylaxis may only
prevent a small number of cases of infective endocarditis
in women undergoing genitourinary procedures; and 3)
the risk of antibiotic-associated adverse events exceeds
the benefit, if any, from prophylactic antibiotic therapy
(83, 85). Mitral valve prolapse is not considered a lesion
that ever needs infective endocarditis prophylaxis.
Only cardiac conditions associated with the highest
risk of adverse outcomes from endocarditis are appropriate for infective endocarditis prophylaxis, and this is
primarily for patients undergoing dental procedures that
involve manipulation of gingival tissue or the periapical
region of teeth, or perforation of the oral mucosa (see
Box 2). However, because of the potential for significant
morbidity and mortality, based on expert opinion and a
limited retrospective study of women with congenital
heart disease (86), the American Heart Association and
the American College of Cardiology recommend that
the use of prophylactic antibiotic therapy be considered
for vaginal delivery in patients with the highest risk of
adverse outcomes from endocarditis. Those at highest

risk are women with cyanotic cardiac disease, or prosthetic valves, or both (84). For those not already receiving intrapartum antibiotic therapy for another indication
that would also provide coverage against endocarditis,
antibiotic regimens for endocarditis prophylaxis can be
administered as close to 3060 minutes before anticipated time of delivery as is feasible.
In patients with one of these high-risk conditions
and who have an established infection that could result
in bacteremia, such as chorioamnionitis or pyelonephritis, the underlying infection should be treated to prevent
infection or sepsis, but specific additional endocarditis
prophylaxis is not recommended (83). In such cases,
the regimen being used to treat the established infection will almost uniformly already contain an agent that
is recommended as a single-dose for prophylaxis with

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Practice Bulletin

Abbreviation: CHD, congenital heart disease.

*Prophylaxis against infective endocarditis is not recommended for
nondental procedures in the absence of active infection.
Data from Nishimura RA, Carabello BA, Faxon DP, et al. ACC/
AHA 2008 guideline update on valvular heart disease: focused
update on infective endocarditis. A report of the American
College of Cardiology/American Heart Association Task Force on
Practice Guidelines: endorsed by the Society of Cardiovascular
Anesthesiologists, Society of Cardiovascular Angiography, and
Society of Thoracic Surgeons. Circulation 2008;118:88796.

dental procedures (ampicillin or amoxicillin, cefazolin or ceftriaxone, clindamycin, or azithromycin) (see

Table 1). Multiple-dose combination regimens are no
longer indicated or recommended for prophylaxis even
in the context of invasive dental procedures.

Is antibiotic prophylaxis appropriate for

patients undergoing repair of third-degree
lacerations or fourth-degree lacerations?
The use of prophylactic antibiotics in the setting of significant perineal trauma has not been extensively studied.
A single randomized trial suggests that a single dose of a
second-generation cephalosporin (cefotetan or cefoxitin),
or of clindamycin if the patient was penicillin allergic,
was protective against perineal wound complications
(8.2% in the treatment group at 2 weeks, compared with
24.1% in the control group; P=0.04, RR 0.34; 95% CI,
0.120.96). However, this study had a follow-up loss rate
of 27%, and its findings have not been replicated (87).
In a recent meta-analysis, additional data regarding the
use of prophylactic antibiotics in this setting were felt
to be necessary before recommendations could be made
(88).

Is antibiotic prophylaxis appropriate for

patients undergoing cervical cerclage?
Evidence is insufficient to recommend perioperative antibiotic prophylaxis at the time of prophylactic or emergency cervical cerclage. Few studies have specifically
evaluated the use of prophylactic antibiotics during the
performance of a prophylactic cervical cerclage. Because
the rate of complications (including infectious complications) after prophylactic cerclage (when performed
before any evidence of cervical dilation or shortening) is
low (15%), a study with a sufficiently large sample size
to determine whether prophylactic antibiotic therapy is of
benefit would be extremely difficult to implement (89).

Cerclage performed later in pregnancy, and when

cervical dilation and effacement are present, has a high
rate of complications, including chorioamnionitis and
rupture of membranes (89, 90). In addition, the risk of
pre-existing, often subclinical, chorioamnionitis as a
cause of the cervical insufficiency is significant, averaging approximately 33% (89, 91). Randomized trials
of cerclage in both high-risk individuals and low-risk
individuals with cervical shortening have not uniformly
included antibiotic prophylaxis as part of their protocols
and, therefore, the current evidence is insufficient to
recommend antibiotic prophylaxis for either prophylactic
or emergency cerclage (92, 93). If prophylaxis is used
in such a situation, it should be guided by the general
principles previously outlined, particularly a focusedcoverage spectrum and short duration.
Similarly, consistent data are lacking regarding the
use of antibiotic prophylaxis for abdominal cerclage.
When performed via laparotomy, however, routine prophylaxis would not be indicated, in accordance with recommendations for other gynecologic surgical procedures
that do not involve the vagina. Similarly, in cases where
this procedure is performed laparoscopically, antibiotic
prophylaxis, as for other laparoscopic procedures, is not
indicated (51).

Is antibiotic prophylaxis appropriate for

patients undergoing manual removal of the
placenta?
Several studies document the increased risk of postpartum
endometritis after manual removal of the placenta during cesarean delivery, even in the presence of antibiotic
prophylaxis (94 96). Although it is common practice to
administer prophylactic antibiotics to patients who give
birth vaginally and in whom a manual removal of the
placenta has been performed, no data exist to support this
practice.

Table 1. Antibiotic Prophylaxis Appropriate for Infective Endocarditis

Treatment
Antibiotic
Intravenous therapy

Regimen (Preferable Treatment

of Antibiotic 3060 Minutes
Before Procedure)

Ampicillin
or
Cefazolin or ceftriaxone*

2 g intravenously

Allergic to penicillin or ampicillin

Cefazolin or ceftriaxone*
or
Clindamycin

1 g intravenously*

Oral

Amoxicillin

2g

1 g intravenously

600 mg intravenously*

*This regimen does not cover enterococcus. Vancomycin can be used if enterococcus is of concern.

1478

Cephalosporins should not be used in patients with a significant sensitivity to penicillins.

Practice Bulletin

Use of Prophylactic Antibiotics in Labor and Delivery

OBSTETRICS & GYNECOLOGY

Summary of
Recommendations and
Conclusions
The following recommendations are based on
good and consistent scientific evidence (Level A):
Antimicrobial prophylaxis is recommended for all
cesarean deliveries unless the patient is already
receiving appropriate antibiotics (eg, for chorioamnionitis) and that prophylaxis should be administered within 60 minutes before the start of the
cesarean delivery.

For cesarean delivery prophylaxis, a single dose of

a targeted antibiotic, such as a first-generation cephalosporin, is the first-line antibiotic of choice, unless
significant drug allergies are present.

Antibiotic prophylaxis is indicated for patients with

preterm PROM to prolong the latency period
between membrane rupture and delivery.

Antibiotic prophylaxis should not be used for pregnancy prolongation in women with preterm labor
and intact membranes. This recommendation is distinct from recommendations for antibiotic use for
preterm PROM and GBS carrier status.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):
For women with a history of a significant penicillin
or cephalosporin allergy (anaphylaxis, angioedema,
respiratory distress, or urticaria), a single-dose combination of clindamycin with an aminoglycoside is a
reasonable alternative choice for cesarean delivery
prophylaxis.

Infective endocarditis prophylaxis is no longer recommended for either vaginal or cesarean delivery in
the absence of infection except possibly for the
small subset of patients at highest potential risk of
adverse cardiac outcomes who are undergoing vaginal delivery.

The following recommendations are based primarily on consensus and expert opinion (Level C):
Evidence is insufficient to recommend antibiotic
prophylaxis for either prophylactic or emergency
cerclage.

VOL. 117, NO. 6, JUNE 2011

Practice Bulletin

In obese patients (BMI greater than 30) undergoing

cesarean delivery, consideration should be given to
using a higher dose of preoperative antibiotics for
surgical prophylaxis.

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The MEDLINE database, the Cochrane Library, and the

American College of Obstetricians and Gynecologists
own internal resources and documents were used to con
duct a literature search to locate relevant articles published
between January 1990January 2011. The search was
restricted to articles published in the English language.
Priority was given to articles reporting results of original
research, although review articles and commentaries also
were consulted. Abstracts of research presented at sympo
sia and scientific conferences were not considered adequate
for inclusion in this document. Guidelines published by
organizations or institutions such as the National Institutes
of Health and the American College of Obstetricians and
Gynecologists were reviewed, and additional studies were
located by reviewing bibliographies of identified articles.
When reliable research was not available, expert opinions
from obstetriciangynecologists were used.
Studies were reviewed and evaluated for quality according
to the method outlined by the U.S. Preventive Services
Task Force:
I
Evidence obtained from at least one properly
designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncon
trolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and con
sistent scientific evidence.
Level BRecommendations are based on limited or incon
sistent scientific evidence.
Level CRecommendations are based primarily on con
sensus and expert opinion.
Copyright June 2011 by the American College of Obstet-
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Requests for authorization to make photocopies should be
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The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920
Use of prophylactic antibiotics in labor and delivery. Practice Bulletin
No. 120. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2011;117:147283.

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