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Effectiveness and use of prophylactic antibiotics in elective and emergency caesarean section at tertiary care hospital

Background: Post-operative infections in obstetrics and gynecological settings have been higher compared to other specialties. Women undergoing caesarean section have 5 to 20-fold greater risk for infection compared with vaginal delivery. Many studies reported antimicrobial prophylaxis prevent post-operative infections. Hence this study concentrates the evaluation of the prescribing antimicrobial use and to assess the frequency of post-operative morbidity related to infection in subjects undergoing caesarean section. The aim of the study was to analysis the effectiveness, prophylactic antibiotics (amoxicillin versus ceftriaxone) and to evaluate the post-operative (caesarean) infections in patients undergoing lower segment caesarean section (elective and emergency). Methods: This is a prospective observational study which assessed the effectiveness and use of prophylactic antibiotics in patients undergoing cesarean section at department of obstetrics and gynecology. The study was conducted over a period of one year. Results: The corresponding mean age of all the study population in amoxicillin group (n=113) was 56.5±28.5 and in ceftriaxone group (n=97) was 48.5±26.5 respectively. The participant who underwent previous cesarean section in amoxicillin group is 65.48% similarly in ceftriaxone group is 47.42%. The patients with fetal distress in ceftriaxone group are 14.77% and in amoxicillin group is 8.92%. Failed induction in amoxicillin group is 9.82% and in ceftriaxone group is 6.81%. The number of days in hospital stay in amoxicillin group is 42.42% and in ceftriaxone group is 45.94%. The post-operative complications in amoxicillin group reported, with Febrile Illness are 40% and wound Infection is 60%. Conclusions: Administration of pre-operative antibiotics significantly reduce post-operative infections. Use of ceftriaxone as a prophylactic antibiotic in patients undergoing lower segment caesarean section (elective and emergency) is more effective than Amoxicillin in preventing post-operative infections.

prescribed in obstetrics and gynaecological practice prophylactic during pre-operative and post-operative procedures (C-section) or to treat ongoing infections (vaginitis, endometriosis, urinary tract infection etc.). The solely use of prophylactic use of antibiotics is not to sterilize the tissue but it acts as an adjunct to decrease the intra-operative microbial load to a level which can be managed by the host innate and adaptive immune responses. 2 The use of antibiotics in women for childbearing age group is important because it effects this population and there next generations.
Surgical site infections are common complication of obstetrics and gynaecological procedures. Several studies proved the use of antimicrobial prophylaxis for C-section been effective in reducing post-operative morbidity, cost and duration of hospitalization. 3 Usage of antibiotics although becoming inevitable but it should be under low level. 4 Incidence of post-partum infections for both mother and neonates is prevented by prophylactic use of antibiotics. 5 Hence present study was carried out to evaluate the usage of antimicrobial prophylaxis in women undergoing C-section.

METHODS
This is prospective observational study was conducted in department of obstetrician and gynecology at NRI General Hospital, Guntur. Approximately 30-60 patients will undergo cesarean section (elective and emergency) in the department per month. The study was conducted over a period of one year from July 2018 to June 2019. The patients included in the study were patients undergoing elective and emergency lower segment cesarean section and excluded patients with patients on long term steroids, or immune suppressants, patients who are allergic to any of the drugs under study, patients who have established infections before surgery, e.g. chorioamnionitis, patients with febrile conditions of unknown etiology, patients whose data is insufficient.
After approval from the Institutional Human Ethical Committee and taking informed consent from the study subjects the relevant and necessary data were obtained using a data collection form with the following details, treatment charts and laboratory data reports and in-patient progress. All the patients were monitored from the day of admission to the day of discharge for any post-operative events that may occur after cesarean section. All the data was subjected to analysis in order to assess the effectiveness of antibiotics during cesarean section. 5

Statistical analysis
The data was analyzed and the percentage value was calculated for the use of different class of antibiotics with respect to various parameters such as indication, dose, frequency and duration and time of administration of antibiotics was assessed by analyzing the collected data against standard texts, relevant literature and available antibiotic guidelines. Averages/means, standard deviations and percentages were obtained by using student t-test and Microsoft excel.

RESULTS
During the study 210 patients who underwent caesarean section were enrolled and were divided into two groups amoxicillin and ceftriaxone groups. Various parameters were evaluated for the effectiveness of the prescribed antibiotics. The study subjects in amoxicillin group with age groups 15-25 and 25-35 were found to be 75.22, 24.77% respectively and in ceftriaxone group was found to be 77.31 and 22.68% respectively and there mean age of this study subjects in amoxicillin group is 56.5±28.5 and 48.5±26.5 in ceftriaxone group. The socio-economic status in amoxicillin group categorized as employed and unemployed are 36.28 and 63.71% respectively, similarly in ceftriaxone group it is 41.23 and 58.76 %.
The mean socio-economic status of this study in amoxicillin group is 56.5±15.5 and in ceftriaxone group is 48.5±8.5. The education level in groups standard <10 th and above 10th standard group in amoxicillin is 53.09 and 46.90 respectively, similarly in ceftriaxone group is 61.85 and 38.14 ( Table 1).   Table 2).
Out of 210 subjects, 59 reported with co-morbidities in amoxicillin group and 56 reported with co-morbidities in ceftriaxone group. Oligohydramnios condition in amoxicillin group is 10.61 and in ceftriaxone group is 11.34% gestational diabetes mellitus in ceftriaxone group is 4.42% followed by anaemia in amoxicillin group is 8.84 %, gestational hypertension in ceftriaxone group 9.27% and pre-eclampsia and hyperthyroidism in amoxicillin group is 5.08% and 2.65% (Table 3). Indication for current caesarean section in study population of previous c-section of amoxicillin group is 30.35 and 26.13% in ceftriaxone group. The patients with foetal distress in ceftriaxone group are 14.77% and in amoxicillin group is 8.92%. Failed induction in Amoxicillin group is 9.82% and in ceftriaxone group is 6.81%. Breech presentation in amoxicillin groups is 3.57% and in ceftriaxone group is 4.56%. Twin pregnancy in amoxicillin group 2.67% and 1.13% in ceftriaxone group (Table 4). The participants who reported with pyrexia in amoxicillin group is 4.42% in amoxicillin group and in ceftriaxone group is 4.12% (Table 5). The post-operative event in amoxicillin group reported with febrile illness is 40% and wound infection is 60% (Table 8) whereas none of the study subjects in ceftriaxone group reported febrile illness and wound infection.   Table 6: Intra-operative events.

DISCUSSION
Postoperative infections at obstetrics and gynecology are higher when compared to other specialties. As there is higher occurrence of caesarean delivery and it is the mostly commonly performed major surgical procedures in the department of obstetrics and gynecology. This causes a significant burden in terms of patient morbidity and cost to health services around the world. 6 The mean age of this study subjects in amoxicillin group is Concerning the indication for current caesarean section previous c-section of amoxicillin group is 30.35 and 26.13% in ceftriaxone group. This is agreed nearly with Prathima S et al, which showed that the percent of repeated caesarean section as primary indication was 29.2%. 8 The incidence of post-operative febrile illness 2% and wound infection 3% and no post-operative febrile illness and wound infection were found in cephalosporin group this results are not in agreement with Ibrahim WH et al, who reported post-operative fever was significantly higher in amoxicillin group (12%) versus (3%) in cephalosporin group. 7 There was reduction of wound infections in cephalosporin group which is in agreement with Dlamini LD. 11 Use of ceftriaxone as a prophylactic antibiotic in patients undergoing lower segment caesarean section (elective and emergency) is more effective than amoxicillin in preventing post-operative infections reduce the rates of post-operative complications like surgical site wound infection, febrile morbidity, and urinary tract infections irrespective of time of administration which can reduces the length of hospital stay that in turn increases the quality of patient care. 12

CONCLUSION
Administration of preoperative antibiotics before surgery significantly reduced to post-operative infections. Use of ceftriaxone as a prophylactic antibiotic in patients undergoing lower segment caesarean section (elective and emergency) is more effective than amoxicillin in preventing post-operative infections. Based on the findings of the present study it concluded that: use of ceftriaxone as a prophylactic antibiotic in patients undergoing lower segment caesarean section (elective and emergency) is more effective than Amoxicillin in preventing post-operative infections.