Connect the Dots—December 2017

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Adding Azithromycin to Cephalosporin for Cesarean Delivery Infection Prophylaxis: A Cost-Effectiveness Analysis
Obstet Gynecol 2017;130:1279–84
JOURNAL/obsgy/04.02/00006250-201712000-00028/math_28MM1/v/2017-11-26T173509Z/r/image-tiff
It is known that in medicine we are generally slow to change practice. A randomized trial shows that a significant benefit accrues if we add or subtract a step in the care of our patients, but then we want more evidence to suggest that there isn't harm added or that the cost is not worsened. Then we want the study repeated in a different setting to make sure. This reticence to alter practice makes sense. As obstetrician–gynecologists we are still dealing with the adoption of unproven technologies with unexpected and negative sequelae, such as continuous electronic fetal monitoring, intravaginal mesh, and uncontained power morcellation of uterine leiomyomas.
In 2016, Tita and his co-authors at 14 centers reported that azithromycin given to women in conjunction with standard cephalosporin prophylaxis at the time of cesarean delivery in women in labor or with ruptured membranes reduces the risk of a composite of endometritis, wound infection, or other infection occurring within 6 weeks by about 50% (Tita ATN, Boggess K, Saade G. Adjunctive azithromycin prophylaxis for cesarean delivery [letter]. N Engl J Med 2017;376:182). The additional layers of supporting information are now being reported. In this issue, Skeith and co-authors (see page 1279) report that this intervention is cost-effective until the drug costs more than $900 (its current cost is less than $30).1 The authors include literature-based risks of negative maternal outcomes in the index pregnancy, including endometritis, wound infection, sepsis, venous thromboembolism, and maternal death, as well as future pregnancy risks of uterine rupture, cesarean hysterectomy, and maternal death.
Hopefully, purposeful analysis and reporting of this type of information will accelerate the adoption of this inexpensive, effective intervention that can improve outcomes for many of our patients.
Nancy C. Chescheir, MD
University of North Carolina, Chapel Hill, North Carolina
1. Skeith AE, Niu B, Valent A, Tuuli M, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis: a cost-effectiveness analysis. Obstet Gynecol 2017;130:1279–84.
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