Percentage of non-elective cesarean deliveries in which azithromycin was administered within 60 minutes before incision.

Cesarean delivery is a significant risk factor for postpartum uterine infection, associated with a 5-to-10-fold increase in infectious morbidity compared to vaginal delivery¹. The use of azithromycin in women undergoing non-elective cesarean deliveries has been shown to reduce the risk of postoperative infections¹. Moreover, azithromycin use significantly decreases the rates of endometritis, wound infections, and serious maternal adverse events².  Research by Sanusi et al. indicates that administering azithromycin up to 60 minutes before incision is effective in reducing the risk of postoperative infection, a practice also supported by the American College of Obstetricians and Gynecologists (ACOG) ^1,3.  It is recommended that the antibiotic be infused before the incision to achieve peak antimicrobial concentrations in the tissue at the time of incision¹. Skeith et al. used a TreeAge cost-effectiveness model to compare outcomes of a theoretical cohort of 700,000 women⁴. They found that for women who undergo cesarean delivery during labor or after membrane rupture adding azithromycin to cephalosporin is less costly and results in better maternal outcomes in the index and subsequent deliveries⁴.

60 min before Surgical Incision through Surgical Incision

• Non-elective cesarean delivery cases as determined by the Obstetric Anesthesia Type Phenotype (value codes 1 & 7).

• Non-obstetric cases (determined by Obstetric Anesthesia Type value code 0)
• Scheduled cesearen delivery (determined by Obstetric Anesthesia Type value code 2)
• Labor Epidurals (determined by Obstetric Anesthesia Type value codes 3 & 6) including Obstetric non-operative procedures (CPT: 01958).
• Cesarean hysterectomy (determined by Obstetric Anesthesia Type value code 4 & 8)
• Obstetric cases - unable to determine if cesarean delivery (determined by Obstetric Anesthesia Type value code 5)
• Patients already on scheduled antibiotics or had a documented infection prior to surgery, as specified by Patient on Scheduled Antibiotics/Documented Infection value of the ABX Notes Phenotype.

Non-elective cesarean patients who received azithromycin within the measure time period.

Measure Start Time: 

60 minutes before measure end time (see below). 

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.
• Only PO and IV routes will be considered.
• Measure will only look for the prophylactic variance note (as determined by the ABX Notes Phenotype) if an antibiotic is not documented within the measure time frame. 
• Cases will be flagged for review if there is documentation that an antibiotic was not ordered or indicated.
• Cases will be assigned one of the following results:
  • Passed - Antibiotic administered on time
  • Flagged - No Azithromycin Administered
  • Flagged - Antibiotic not ordered/indicated per surgeon
  • Flagged - Incision/procedure start time documented: No
  • Flagged - Azithromycin administered too late
  • Flagged - Azithromycin administered too early
  • Excluded - Chorioamnionitis diagnosis
  • Excluded - Scheduled antibiotics/documented infection
  • Excluded - Excluded procedure 

*This measure will include only valid MPOG cases as defined by the Is Valid Case phenotype.

Not Applicable.

All providers signed in during measure time period.

References:

1. Sanusi, A, YeY, Boggess, K, Saade,G, Longo, S, Clark E, Esplin S, Cleary, K, Wapner, R, Owens, M,  Blackwell, S, Szychowski, JM, Tita, ATN, Subramaniam A. Timing of Adjunctive Azithromycin for Unscheduled Cesarean Delivery and Post Delivery Infection. Obstet Gynecol.  2022 June 1;139(6):1043-1049.doi: 10.1097/AOG.0000000000004788. Epub 2022, May 2.
2. Tita, AT, Szychowski, JM, Boggess, K, Saade, G, Longo, S, Clark, E, Esplin, S, Cleary, K, Wapner, R, Letson, K, Owens, M, Abramovici, A, Ambalavanan, N, Cutter, G, Andrews, W; C/SOAP Trial Consortium. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med. 2016 Sep 29;375(13):1231-41. doi: 10.1056/NEJMoa1602044. PMID: 27682034; PMCID: PMC5131636.
3. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstetrics & Gynecology 132(3):p e103-e119, September 2018. | DOI: 10.1097/AOG.0000000000002833 
4. Skeith AE, Niu B, Valent AM, Tuuli MG, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis: A cost-effectiveness analysis.  Obstet Gynecol. 2017 Dec; 130(6):1279-1284.