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To evaluate if a prophylactic postpartum course of broad spectrum antibiotics is cost-effective for the prevention of surgical site infections in obese women post-cesarean deliveries.
A decision-analytic model was developed to compare prophylactic, postpartum antibiotics and standard care after cesarean deliveries in obese women (prepregnancy BMI ≥30 kg/m2) stratified by amniotic membrane status - ruptured vs intact membranes at time of delivery. Prevention of surgical site infections (SSI), long term morbidities (sepsis and venous thromboembolism), and maternal death were estimated from costs and probabilities derived from the literature. Antibiotic costs, probabilities of surgical site infections, and relative risks for SSI using post-cesarean antibiotics were obtained from a double-blinded randomized control trial studying a 48 hr course of post-cesarean, prophylactic cephalexin and metronidazole for the prevention of surgical site infections in obese women. A cost-effectiveness threshold was set at $100000 per quality-adjusted life years (QALYs). Sensitivity analyses to examine the impact of various inputs on the robustness of the model were performed.
In a population of approximately 459000 obese women who undergo cesarean delivery within the US annually, prophylactic post-operative antibiotics would result in 45900 fewer SSI, 9180 fewer women suffering from long-term morbidities, and 5 less maternal deaths. Even after stratification for membrane status, intervention was the dominant strategy to prevent maternal morbidity and mortality. An annual societal savings of $1 billion and 973080 additional QALYs for women with ruptured membranes and $137 million plus 156060 additional QALYs for intact membranes are probable with the intervention. Postpartum antibiotics are cost-saving up to $357 and cost-effective up to $33557 for obese women with intact membranes and an even more dramatic investment for women with ruptured membranes with cost-saving up to $2278 and cost-effective up to $214418.
Prophylactic post-cesarean antibiotics would prevent significant morbidity and are cost-effective in obese women, particularly with ruptured membranes. Strong consideration to their adoption should be given.