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Cesareandeliveryprocedures,1,Content,BackgroundOrganismsEfficacyChoiceofagentTimingDurationRecommendation,2,Background,Approximately1.2millioninfantsarebornbycesareandeliveryintheUnitedStatesannually.Theinfectionrateaftercesareandeliveryhasbeenreportedtobe415%,thoughrecentNHSNdatashowedaninfectionrateof24%.Postpartuminfectiouscomplicationsarecommonaftercesareandelivery.Endometritis(infectionoftheuterinelining)isusuallyidentifiedbyfever,malaise,tachycardia,abdominalpain,uterinetenderness,andsometimesabnormalorfoul-smellinglochia.Fevermayalsobetheonlysymptomofendometritis.cesareanadj.剖腹产的；n.剖腹产Postpartumadj.产后的adv.在产后Endometritisn.妇产子宫内膜炎uterineadj.子宫的；同母异父的malaisen.不舒服；心神不安tachycardian.内科心动过速；心跳过速lochian.恶露；产褥排泄物,3,Background,Endometritishasbeenreportedtooccurinupto24%ofpatientsinelectivecesareandeliveryanduptoapproximately60%ofpatientsundergoingnonelectiveoremergencysection.Riskfactorsforendometritisincludecesareandelivery,prolongedruptureofmembranes,prolongedlaborwithmultiplevaginalexaminations,intrapartumfever,andlowsocioeconomicstatus.Patientswithlowsocioeconomicstatusmayhavereceivedinadequateprenatalcare.prolongedruptureofmembranes延迟破膜vaginaladj.阴道的；叶鞘的intrapartumadj.分娩期的,4,Background,Thefactormostfrequentlyassociatedwithinfectiousmorbidityinpostcesareandeliveryisprolongedlaborinthepresenceofrupturedmembranes.Intactchorioamnioticmembranesserveasaprotectivebarrieragainstbacterialinfection.Ruptureofthemembraneexposestheuterinesurfacetobacteriafromthebirthcanal.Thevaginalfluidwithbacterialfloraisdrawnintotheuteruswhenitrelaxesbetweencontractionsduringlabor.Womenundergoinglaborformorethansixtoeighthoursinthepresenceofrupturedmembranesshouldbeconsideredathighriskfordevelopingendometritis.OtherriskfactorsforSSIsaftercesareandeliveryincludesystemicillness,poorhygiene,obesity,andanemia.morbidityn.发病率；病态；不健全chorioamnioticadj.绒毛膜羊膜的hygienen.卫生；卫生学；保健法anemian.贫血；贫血症,5,Organisms,Thenormalfloraofthevaginaincludestaphylococci,streptococci,enterococci,lactobacilli,diphtheroids,E.coli,anaerobicstreptococci(PeptococcusspeciesandPeptostreptococcusspecies),Bacteroidesspecies(e.g.,Bacteroidesbivius,B.fragilis),andFusobacteriumspecies.Endometritisinfectionsareoftenpolymicrobialandincludeaerobicstreptococcus(particularlygroupBb-hemolyticstreptococcusandenterococci),gram-negativeaerobes(particularlyE.coli),gram-negativeanaerobicrods(particularlyB.bivius),andanaerobiccocci(PeptococcusspeciesandPeptostreptococcusspecies).Ureaplasmaurealyticumhasbeencommonlyisolatedfromendometrialandsurgical-sitecultures.AdditionalcommonlyisolatedorganismsfromSSIsincludeStaphylococcusspeciesandenterococci.,6,staphylococcin.葡萄状球菌streptococcin.链球菌enterococci肠球菌lactobacillin.乳酸杆菌diphtheroidsadj.似白喉的n.类白喉anaerobicstreptococci厌氧链球菌Bacteroidesspecies拟杆菌属物种Fusobacteriumspecies梭菌属的物种aerobicstreptococcus有氧链球菌hemolyticstreptococcus溶血性链球菌aerobesn需氧菌anaerobicrods厌氧杆菌anaerobiccocci厌氧球菌Ureaplasmaurealyticum解脲支原体Peptococcusspecies球菌属Peptostreptococcusspecies消化链球菌属Staphylococcusspecies葡萄球菌,7,Efficacy,Whiletheuseofantimicrobialprophylaxisinlow-riskprocedures(i.e.,thosewithnoactivelaborandnoruptureofmembranes)hasbeenbroughtintoquestionbytheresultsofseveralrandomized,placebo-controlledstudiesthatfoundnoreductionininfectiouscomplications(fever,SSI,urinarytractinfection,orendometritis)withtheuseofprophylaxis,themajorityoftheseevaluationswereunderpoweredandincludedadministrationofantimicrobialprophylaxisatcordclamping.However,theefficacyofantimicrobialprophylaxisincesareandeliveryhasbeenshowninseveralstudiesandtwometaanalysesforbothelectiveandnonelectiveprocedures.Therefore,prophylaxisisrecommendedforallpatientsundergoingcesareandelivery.,8,Efficacy,Onemeta-analysisthatreviewed7placebo-controlledrandomizedtrialsinlow-riskelectivecesareandeliveryfoundthatprophylaxiswasassociatedwithasignificantdecreaseinendometritisandfever.Alargermeta-analysisof81randomizedtrialswith11,937womenundergoingbothelectiveandnonelectivecesareandeliveryfoundthatantimicrobialprophylaxiswasassociatedwithasignificantreductioninriskoffever,endometritis,SSI,urinarytractinfection,andseriousinfection.Therelativeriskforendometritisinelectivecesareansectionwas0.38(95%CI,0.220.64)inthosereceivingantimicrobialprophylaxiscomparedtothosereceivingnoprophylaxis.,9,Choiceofagent,Althoughseveraldifferentantimicrobialsusedaloneorincombinationforantimicrobialprophylaxisduringcesareandeliveryhavebeenevaluated,theuseoffirstgenerationcephalosporins(specificallycefazolin)hasbeenadvocatedbyACOGandtheAmericanAcademyofPediatrics(AAP),basedontheirefficacy,narrowspectrumofactivity,andlowcost.Thisrecommendationissupportedbyameta-analysisof51randomizedcontrolledtrialscomparingatleasttwoantimicrobialregimensthatconcludedthatampicillinandfirst-generationcephalosporinshavesimilarefficacy.cephalosporins头孢菌素类,10,Choiceofagent,Newerprospectiverandomizedcontrolledandcohortstudieshaveevaluatedtheadditionofmetronidazole,azithromycin,ordoxycyclinetoafirst-orsecondgenerationcephalosporintoextendthespectrumofactivityagainstcommonorganismsisolatedfromendometrialandsurgical-sitecultures,specificallyU.urealyticumandMycoplasmaspecies.Thesestudiesfoundsignificantlylowerratesofpostoperativeinfections(includingendometritisandSSI)andashorterdurationofhospitalstaycomparedwithprophylaxiswithafirst-orsecond-generationcephalosporinalone.Antibioticadministrationoccurredeitherpostoperativelyoraftercordclampinginthesestudies.Furtherstudy,particularlywithpreoperativeantimicrobialadministration,isneededtoconfirmthesepreliminaryfindingsandestablishaplaceintherapyforthispractice.metronidazolen甲硝唑azithromycinn阿奇霉素doxycyclinen多西环素U.urealyticumn解脲支原体Mycoplasman支原体cordclamping断脐,11,Timing,Historically,administrationofantimicrobialsincesareandeliverywasdelayeduntilaftercordclamping.Theprincipalreasonsweretoavoidsuppressionoftheneonatesnormalbacterialflorathatcouldpromotetheselectionofresistantorganismsandconcernthattheantimicrobialscouldpotentiallymaskneonatalinfection,complicatingevaluationofneonatalsepsis.However,morecontemporarydatasupporttheadministrationofantimicrobialprophylaxisbeforesurgicalincisiontoprotectagainstbacterialcontaminationofthesurgicalsiteanddecreasetheriskofinfection.ThepracticeofantimicrobialprophylaxisadministrationbeforesurgicalincisionisendorsedbyACOGandAAP.SeetheCommonPrinciplessectionoftheseguidelinesforadditionaldiscussiononantimicrobialtiming.neonaten婴儿sepsisn败血症,12,Timing,Ameta-analysisofthreerandomizedcontrolledtrialsandtwononrandomizedcontrolledstudiesprovidedevidencethatpreoperativeantimicrobialadministrationsignificantlydecreasedtherateofendometritiscomparedwithadministrationaftercordclamping(3.9%and8.9%,respectively;p=0.012).AlowerSSIratewasalsoseenwithpreoperativeantimicrobialadministration(3.2%versus5.4%),thoughthisdifferencewasnotsignificant.Theoverallrateofinfection-relatedmorbiditywasalsosignificantlylower.Nodifferencesbetweenthegroupswereseeninneonataloutcomes,includingsepsis,sepsisworkups,andneonatalintensivecareunitadmissions.Thelargeststudyincludedinthismeta-analysiswasaprospective,randomized,controlled,doubleblind,single-center,double-dummystudyof357patientscomparingcefazolin1gi.v.givenpreoperativelyandaftercordclamping,whichhadresultsconsistentwiththeoverallmeta-analysis.double-dummy双安慰剂,13,Timing,Inarecentrandomizedtrialofmorethan1100womenundergoingcesareansectionbetween2004and2010,WittandcolleaguesfoundnodifferenceinSSIratesforpatientshavingantimicrobialadministrationbeforesurgicalincisioncomparedwiththosewhoreceivedantimicrobialprophylaxisatthetimeofcordclamping.Allpatientsreceivedasingledoseofcefazolin2g.,14,Duration,Ameta-analysisof51studiesfoundthatmultidoseregimensprovidednoapparentbenefitoversingle-doseregimens.Theuseofsingle-doseprophylaxisissupportedbyACOGandAAPforprocedureslastinglessthantwohours.Additionalintraoperativedosesmaybewarrantedforpatientswithexcessivebloodlossorforwhomthedurationoftheprocedureisextended.Foradditionaldiscussionofdosing,seetheCommonPrinciplessectionoftheseguidelines.,15,Recommendation,Therecommendedregimenforallwomenundergoingcesareandeliveryisasingledoseofcefazolinadministeredbeforesurgicalincision(Table2).(Strengthofevidenceforprophylaxis=A.)Forpatientswithb-lactamallergies,analternativeregimenisclindamycinplusgentamicin.clindamycinn克林霉素gentamicinn庆大霉素,16,Thanks,17,
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