Comparing of Cefazolin Plus Azithromycin Versus Cefazolin in Prevention of Febrile Morbidity After Emergency Cesarean Delivery

Study Overview
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Brief Summary
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Cesarean section is the common surgery in world wide. But the complication like febrile morbidity such as surgical site infection, fever, urinary tract infection and endometritis can be occurred even giving the standard antibiotics. Therefore if wider bacterial spectrum coverage antibiotic like azithromycin is added to the standard antimicrobial prophylaxis(1st generation cephalosporin), the incidence of febrile morbidity could be reduced. We will compare the regimen of cefazolin plus azithromycin and standard regimen of cefazolin alone in prevention of febrile morbidity after emergency cesarean section.

Detailed Description
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This study was designed to evaluate the effect of azithromycin on the incidence of febrile morbidity after the emergency cesarean section. The standard antimicrobial prophylaxis which is recommended by the ACOG is the 1st generation cephalosporin intravenously only but some of the bacteria that can cause the febrile morbidity after cesarean section wouldn't be killed by the 1st generation cephalosporin. The antibiotic that can cover them is macrolide group antibiotic such as azithromycin. Therefore this study will compare the regimen of standard antimicrobial prophylaxis and the regimen of standard antimicrobial prophylaxis with azithromycin intravenously in preventing the febrile morbidity after emergency cesarean section. Control group will receive the 1st generation cephalosporin intravenously and the intervention group will receive the 1st generation cephalosporin with azithromycin 500mg intravenously. Primary outcome is febrile morbidity which assessed at postoperative day 3. The definition of the febrile morbidity in this study is including surgical site infection, endometritis, urinary tract infection and fever alone. Secondary outcomes are febrile morbidity at postoperative day 7 and day30, neonatal outcome and adverse effect from azithromycin use.

Official Title
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Comparing of Cefazolin Plus Azithromycin Versus Cefazolin Alone in Prevention of Febrile Morbidity After Emergency Cesarean Delivery: A Randomized Controlled Trial

Conditions
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Febrile Morbidity After Emergency Cesarean Section

Intervention / Treatment
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* Drug: Azithromycin Injection [Zithromax]
* Drug: Cefazolin
* Drug: Sodium Chloride 0.9% Intravenous Solution


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Singleton pregnancy with a gestation of 24 weeks or more Undergoing non-elective cesarean delivery during labor or rupture of membrane more than 4 hr No allergy to macrolide such as azithromycin and clindamycin Provide informed consent Partner of participant allows the patient to participate the research Exclusion Criteria: Use of azithromycin within 7 days before enrollment Chorioamnionitis or other infection requiring postpartum antibiotic therapy (except for antibiotics for group B streptococcus) Liver disease (Cirrhosis or AST more than 3 times the upper normal limit) Serum creatinine level of more than 2.0 mg/dL or need dialysis Diarrhea at the time of enrollment Maternal heart disease Use of medication known to prolonged the QT interval

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Control group (Placebo)<br>Patient will receive standard antimicrobial prophylaxis(cefazolin intravenously weight dependent) and placebo(0.9% NaCl 100 ml intravenously) before the incision | Drug: Cefazolin<br>* All the participants will receive the cefazolin intravenously. The dosage of the cefazolin is depend on participant's weight. The participant with weight less than 80kg will receive cefazolin 1 gm and between 80-120kg will receive cefazolin 2 gm and for the participant with more than 120kg will receive cefazolin 3 gm before the incision.<br>* Other names: placebo comparator;Drug: Sodium Chloride 0.9% Intravenous Solution<br>* For the placebo group will receive the cefazolin intravenously and 0.9% NaCl 100ml before the incision<br>* Other names: placebo comparator;|
| Experimental: azithromycin<br>Patient will receive standard antimicrobial prophylaxis(cefazolin intravenously weight dependent) and azithromycin 500 mg intravenously before the incision | Drug: Azithromycin Injection [Zithromax]<br>* Intervention group patient will receive standard antimicrobial prophylaxis(cefazolin intravenously weight dependent) and azithromycin 500 mg intravenously before the incision<br>* Other names: azithromycin;Drug: Cefazolin<br>* All the participants will receive the cefazolin intravenously. The dosage of the cefazolin is depend on participant's weight. The participant with weight less than 80kg will receive cefazolin 1 gm and between 80-120kg will receive cefazolin 2 gm and for the participant with more than 120kg will receive cefazolin 3 gm before the incision.<br>* Other names: placebo comparator;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of febrile morbidity at postoperative day 3 | Patient will be assessed at postoperative day 3. Febrile morbidity is including surgical site infection, endometritis, urinary tract infection and fever. There is the questionnaire for the assessor to check if there is the febrile morbidity or not. (There are criteria diagnosis of febrile morbidity from the CDC in the questionnaire) | postoperative day 3 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| adverse drug effect | Any adverse drug effect of azithromycin such as diarrhea, urticaria, and anaphylactic shock | baseline and postoperative day 3, 7 and 30 | 
| Incidence of adverse Neonatal outcome | any adverse neonatal outcome such as NICU admission, neonatal sepsis, need phototherapy, respiratory distress, Apgar score, neonatal death and neonatal enterocolitis (Assessed and diagnosis by pediatric doctor) | baseline and postoperative day 3, 7 and 30 | 
| Incidence of febrile morbidity at postoperative day 7 and day 30 | Patient will be assessed at postoperative day 7 and day 30. Febrile morbidity is including surgical site infection, endometritis, urinary tract infection and fever. There is the questionnaire for the assessor to check if there is the febrile morbidity or not. (There are criteria diagnosis of febrile morbidity from the CDC in the questionnaire) | postoperative day 7 and day 30 |