Na prática clínica todo mundo sabe que a profilaxia para a cesariana é fundamental. O que pouca gente sabe é que houve atualizações sobre como fazê-la de forma adequada.
O objetivo da profilaxia é PREVENIR infecção, não curar ou tratar a doença, portanto deve ser administrada antes da exposição potencial e geralmente por um curto período (menos de 24 horas). Já se sabe que a profilaxia pode levar à resistência bacteriana, por isso conhecer o melhor antibiótico e a menor dose é essencial para evitar aumento de flora resistente no pós-operatório. Além disso, é importante lembrar que ela não é isenta de risco, sendo as reações alérgicas e a anafilaxia as complicações mais temidas.
A cesariana por si só é o fator de risco mais importante para as infecções pós-parto. Em revisão recente da Cochrane que incluiu 95 estudos com mais de 15.000 mulheres e que fez comparação entre placebo e profilaxia, as pacientes que receberam profilaxia apresentaram redução em 60% na incidência de infecção da ferida, 62% de endometrite e 69% de complicações maternas infecciosas graves. Quando avaliadas as cesarianas eletivas, houve redução na incidência de infecções de feridas em 38% e endometrite em 62%.
Qual antibiótico, dosagem e em que momento fazer?
O antibiótico a ser utilizado é a cefazolina em dose única e a recomendação da FEBRASGO é que seja utilizado 2 g em pacientes de até 120 kg e de 3 g nas pacientes acima de 120 kg. Em caso de alergia, deve-se utilizar clindamicina 900 mg EV + gentamicina 3,5 a 5 mg/kg de peso.
No passado, a profilaxia era feita após o clampeamento do cordão umbilical, mas os estudos mais recentes sugerem que o ideal é que seja realizada de 30 a 60 minutos antes da incisão e, em caso de cesariana de emergência, deve-se fazer o mais breve possível.
Profilaxia antibiótica tópica
A limpeza da pele (com clorexidina alcoólica, por exemplo) e a limpeza vaginal (com iodopovidona ou clorexidina aquosa) devem ser realizadas antes da cesariana em pacientes em trabalho de parto e aquelas com rotura de membranas, com redução de 50 a 80% nas complicações infecciosas, de forma que essa orientação também se tornou recomendação da Organização Mundial de Saúde (OMS) para todas as cesarianas, mesmo que eletivas.
Em síntese, a profilaxia antibiótica para a cesariana deve ser realizada para todas as pacientes na forma endovenosa, tópica na pele e tópica vaginal.
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