When ZMAX if OUT for CS: Alternative?

We have learned a lot about extended spectrum coverage of prophylactic antibiotics for cesarean section. The landmark C/SOAP trial randomized 2,013 women undergoing nonelective cesarean delivery to azithromycin 500 mg IV plus standard prophylaxis versus placebo, demonstrating a 51% reduction in the composite outcome of endometritis, wound infection, or other infection. Adjuvant Zmax (plus standard first-generation cephalosporin) is now recognized as evidence-based antibiotic coverage for intrapartum cesarean, cesarean with ruptured membranes, and patients with obesity. This last patient characteristic comes from the ERAS latest update. But what is ZMAX is not available? Is there an evidence-based peri-op alternative in these cases? Does Gent and Clinda cover mycoplasma/Ureaplasma? What about postop flagyl? Listen in for details.

1. Tita AT, Szychowski JM, Boggess K, et al. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. The New England Journal of Medicine. 2016. 2. Yang M, Yuan F, Guo Y, Wang S. Efficacy of Adding Azithromycin to Antibiotic Prophylaxis in Caesarean Delivery: A Meta-Analysis and Systematic Review. International Journal of Antimicrobial Agents. 2022.

2. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery.

Obstetrics and Gynecology. 2018. Committee on Practice Bulletins-Obstetrics

3. Martingano D, Nguyen A, Nkeih C, Singh S, Mitrofanova A. Clarithromycin Use for Adjunct Surgical Prophylaxis Before Non-Elective Cesarean Deliveries to Adapt to Azithromycin Shortages in COVID-19 Pandemic. PloS One. 2020.

4. Valent AM, DeArmond C, Houston JM, et al. Effect of Post–Cesarean Delivery Oral Cephalexin and Metronidazole on Surgical Site Infection Among Obese Women: A Randomized Clinical Trial. The Journal of the American Medical Association. 2017.

5. Wood, G. E., et al. "In Vitro Susceptibility of Mycoplasma genitalium to Nitroimidazoles." Antimicrobial Agents and Chemotherapy

6. https://www.cdc.gov/std/treatment-guidelines/mycoplasmagenitalium.htm