Are prophylactic adjunctive macrolides efficacious against caesarean section surgical site infection: A systematic review and meta-analysis

Surgical site infection (SSI) post- caesarean section (CS) remains high, prophylactic adjunctive macrolides may reduce this. This systematic review and meta-analysis evaluated whether adjunctive prophylactic macrolides administered at CS reduce the risk of endometritis and wound infection. MEDLINE, EMBASE, CINHAL and the Cochrane library were searched from inception to July-2018. Observational and randomised studies investigating women undergoing a CS receiving standard prophylactic antibiotics, adjunctive prophylactic macrolides and assessed any SSI outcome was included. Data was double-extracted. Studies were included in a meta-analysis if the same study design and SSI outcome was used. Risk ratios were calculated and heterogeneity was assessed using the I2 test. Five studies were included in the systematic review and four in the meta-analysis. Two RCT’s (n = 2610) found that macrolides significantly reduce the risk of wound infection RR [0.34; 95 %, 0.22 0.53] P = 0.00001 and endometritis RR [0.66; 95 %, 0.52, 0.85] P = 0.001 with no evidence of heterogeneity (I2 = 0 %). Two cohort studies (n = 13,809) found that azithromycin significantly reduces the risk of endometritis RR [0.16; 95 %, 0.04–0.62] P = 0.008, however significant heterogeneity was seen. Macrolides significantly reduce the risk of endometritis and wound infection post-CS. An effectiveness evaluation of post-cord clamping administration is needed to eliminate fetal antibiotic exposure and the long term infant implications this may have.