Percentage of cesarean deliveries with documentation of antibiotic administration initiated within one hour before surgical incision

Postpartum infections, including endometritis and surgical site infections are common after cesarean deliveries.¹ Smaill & Hofmeyr conducted a large meta-analysis reviewing 81 randomized trials including 11,937 women undergoing elective or nonelective cesarean delivery.⁶ The analysis concluded that antimicrobial prophylaxis was associated with reduction in fever, endometritis, urinary tract infection, SSI, and serious infection.⁶ Historically, antibiotic prophylaxis was administered after cord clamping during cesarean delivery. However, recent studies suggest that prophylaxis should be administered before surgical incision to decrease the risk of maternal complications with no change in neonatal outcomes.^3,5 Further, the antibiotic should be infused before incision in order to achieve peak antimicrobial concentrations in the tissue at the time of incision.^1-2 Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics support the use of single dose prophylaxis administered within 60 minutes before cesarean delivery to prevent maternal infectious morbidity.⁴ 

60 minutes prior to Surgical Incision through Surgical Incision

• Elective, urgent, or emergent cesarean delivery as determined by the MPOG Obstetric Anesthesia Type phenotype:
  • Conversion (Labor epidural and cesarean delivery combined)
  • Cesarean Delivery
  • Cesarean Hysterectomy
  • Conversion (cesarean delivery portion)
  • Conversion (Cesarean Hysterectomy Portion)

• Obstetric Non-Operative Procedures (Determined using the MPOG Obstetric Anesthesia Type phenotype)
• Cesarean delivery with documentation of infection prior to incision and mapped to one of the following MPOG concepts:
  • 50181 Compliance- Prophylactic Antibiotic Variance Note
  • 50182 Compliance- Prophylactic Antibiotic Variance Note Detail

Documentation of at least one antibiotic administration within one hour of surgical incision. See ‘Other Measure Build Details’ for emergency cases and antibiotic timing exceptions.

Measure Start Time:

1. 60 minutes before measure end time (see below). For Vancomycin, 120 minutes before measure end time.

Measure End Time:

1. 50235 Surgical Incision Time (latest if multiple available), if not available then
2. 50006 AACD Procedure Start Date/Time (latest if multiple available).

• For cases without a documented surgical incision time or procedure start time, the case will be flagged for review.
• For cases with more than one Surgical Incision Time (50235) documented, the latest time will be used. If there is no surgical incision time documented, AACD Procedure Start Date/Time (50006) will be used. If there is more than one procedure start time, the latest procedure start time will be used.
• For emergency cases, Measure End is defined as Anesthesia End.

Acceptable Antibiotics and Associated Timing:

*Any of these antibiotics administered within the timeframe will result in success for this measure focused on antibiotic timing, rather than selection.

• If one of the appropriate antibiotics listed in the table above was given as a bolus in the appropriate time frame, the case will pass and any additional antibiotic infusions will not be considered.
• If only one antibiotic is administered for the case and is documented with infusion start and end times, the following logic will be applied:
  • If the infusion start time or infusion end time is within 60 minutes before incision (120 minutes for vancomycin), the case will pass. If the infusion is still running at the time of incision, the case will pass.
  • If the infusion started after or at the same time as incision, the case will be flagged as ‘antibiotic administered late’. See last bullet point below for details regarding emergency cases.
  • Exceptions: 
    • If case is emergent, antibioitc can be administed after incision but must be before anesthesia end.
    • If azithromycin is started or ends within 60 minutes before incision through anesthesia end, the case will pass.
  • Measures will assigned the following results:
    • Passed - Antibiotic administered on time
    • Flagged - Antibiotic not administered on time
    • Flagged - Prophylactic antibiotic administered (Not documented in MAR)
    • Flagged - Antibiotic not ordered/indicated per surgeon
    • Flagged - Incision/procedure start time documented: No
    • Flagged - Antibiotic administered too late
    • Flagged - Antibiotic administered too early
    • Flagged - Not administered for medical reasons
    • Excluded - Scheduled antibiotics/documented infection

• Measure will only look for the prophylactic variance note (50181 or 50182) to be documented if an antibiotic is not documented within the measure time frame. 
• For cases with documentation indicating ‘prophylactic antibiotic administered’ (concept ID: 50181 or 50182 or 50622) but the antibiotic(s) administration with dose, route, and time are not documented in the electronic medication administration record will be flagged for review.
• Cases will be flagged for review if there is documentation that an antibiotic was not ordered or there is documentation that the antibiotic is ‘not indicated.’

Not applicable.

All anesthesia providers signed in at the time of incision. If surgical incision time is not documented (50235) then providers signed in at the procedure start time (50006) will be attributed. If procedure start time (50006) is not documented, then providers signed in at anesthesia start (50002) will be attributed. 

1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA, American Society of Health-System Pharmacists (ASHP), Infectious Diseases Society of America (IDSA), Surgical Infection Society (SIS), Society for Healthcare Epidemiology of America (SHEA): Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect 2013; 14:73–156
2. Committee on Practice Bulletins-Obstetrics: ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol 2018; 132:e103–19
3. Costantine MM, Rahman M, Ghulmiyah L, Byers BD, Longo M, Wen T, Hankins GDV, Saade GR: Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008; 199:301.e1–6
4. Guidelines for Perinatal Care Seventh Edition at <https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/medicaid/pdfs/ACOG-Guidelines-for-Perinatal-Care.pdf>
5. Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK: Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. Cochrane Database Syst Rev 2014:CD009516
6. Smaill F, Hofmeyr GJ: Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev 2002:CD000933