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In 2016, out of the New England Journal of Medicine, out of a fantastic group of researchers of which Alentita was a part of. So yes, it's True. We add Zithromax 500mg IV in addition to standard first generation cephalosporins for patients that are intrapartum and get a section or who are ruptured and get a section. And then the latest patient characteristic that was added to that was patients with obesity. Notice I said patients with obesity and not obese patients because whatever. Anyway, that's out of the IRAS trial, the enhanced recovery after surgery. Some would call the IRAC trial enhanced recovery after cesarean. Nonetheless, we have three different patient groups who could benefit with Zithromax in addition to first generation ceph. Those are intrapartum sections, sections where they are ruptured with or without labor, and then patients who are living with with obesity as if obesity was their roommate. So that's what we're doing with Zithromax. This issue, though, came into play from one of our podcast family members and it's a really good question and the data you gotta go digging for for an answer. Let me explain. So this comes from one of our podcast family members who said, well, in our location in our hospital, it's not really a global supply chain issue anymore. It was during COVID But our hospital issue right now is that we're kind of out of Zithroma. There an alternative to patients who would Otherwise get the 500mg IV for prophylaxis for C section. What is a good evidence based alternative here and because there's, there's really nothing that says if this is not available, use this one, we've got to go again digging through the data. But, but there is an answer. You can do something pre op and I'm going to explain that or you can do something post op and we're going to address that as well. We're also going to get into the issue of gent and clinda because gent and clinda of course is the ACOG and Infectious Disease Society of America and SMFM first line recommendation for patients who have real beta lactam allergy for which a cephalosporin may be contraindicated. All right. Now that is an alternative to the first generation cephalosporin. But is that a sufficient alternative to also cover for urea, plasma and mycoplasma, which is what this microlide edition of Zithromax is trying to cover? Let me spoil this for you right now on that one. No, because neither gent or clinda hit ureaplasma or mycoplasma, which some women have and increases the risk of metritis and overall wound infection. Now I have to clarify here just to be thorough it gent and clinda cover a lot of things, mainly of course anaerobic organisms. However, even though gent and clinda, and it's based on who you read, may have some activity against some types of mycoplasma in vitro in vivo, it doesn't seem to be a thing. Mycoplasma genitalia is very resistant to most typical antibiotics. That's why the standard treatment usually includes something like doxy or moxifloxacin or azithromycin. It's this atypical variety that typically is ordered for ureaplasma. Mycoplasma, gent and clinda hit anaerobes and it's kind of an indirect issue. Some have said, well because mycoplasma and ureoplasma travel with anaerobes, they're their travel buddy. If you knock out the anaerobes then it makes the environment less hospitable to mycoplasma and ureoplasma brother, that's way too much what ifs and what ifs and maybe might could. The issue is does it directly affect mycoplasma and ureoplasma? And the answer is no, gent and clinda are not standard therapies for these atypical non cell wall bacteria like mycoplasma or Ureaplasma. So while Gentin Calinda is absolutely first line for patients who have penicillin or cephalosporin allergy, it's not sufficient enough to cover for these atypicals that Zithromax is aimed for. So in this situation when we cannot get the first line, what are we supposed to do? I think you and I might need to purchase antibiotics. So this is a question that we're going to tackle in this episode. It's really good now you got to go digging through that data and thankfully we have something. During the COVID time we learned something because there was a real supply chain issue and there was a small study about 240 patients that gave us an alternative because they could not get Zithromax either. We're gonna address that and then we're gonna get into Amy's publication for postop prophylaxis. Amy Valent, phenomenal woman, great researcher, phenomenal MFM physician. I sat on several committees with her. She's phenomenal. And we're gonna take a look at her options post op. Of course most people agree that the optimum time to give antibiotics is about 30 minutes to an hour before the incision and Amy valence is in the post op interval. But we're going to address that as an alternative for wound infection. However, the big issue here is that Amy Valent's alternative doesn't really cover this issue of atypicals either. So we're left with one one publication from 2020 that can provide an alternative. So I think I've set it up enough. We will be right back. This is Dr. Chapa's obgyn no spin podcast. So remember the term is extended spectrum, not broad spectrum. Broad spectrum is a little bit different. Extended spectrum means just that means we're still kind of targeted. We're just extending that target a little bit more as opposed to a broad spectrum antibiotic coverage which can lead to resistance. And we don't want to do that. That's why it's first generation CEF or gent and Clinda in those who have Chondra indication to Cephalosporin with the addition of Zithromax as extended coverage in those patient characteristics that we discussed before. This all has to do with the CSOAP trial back in New England Journal of Medicine. As we said in the intro, which took 2013, 2013 women with non elective cesarean section and randomized some of those to Zithromax, 500 milligrams plus standard prophylaxis versus placebo. And sure enough, there was a 51% reduction in the composite outcome of endometritis, wound infection and or other infectious morbidity. So that's great. Since then there's been several meta analyses that have confirmed these benefits. And ACOG says, look, if you're going to choose to do a C section or it's one of those patient characteristics, especially intrapartum or ruptured membranes, because the patients with obesity is an ERAS thing, then definitely consider adjuvant azithromycin because it's low risk, potentially high reward. And that's a thing. We already get that. The question is, if Zithromax is not available, then what do we do? It would be nice if there was some kind of guidance that said if this is not available on the shelf, do this one. But there isn't. But Covid did provide some information for this. Out of 240 patients that were followed prospectively in this observational study, authors found out of plus one that adding clarithromycin and this was an oral dose about 30 minutes before surgery, clarithromycin also resulted in a 55% reduction in endometritis compared to standard cephalosporin use alone. So they said, hey, look, the effect size seems to be pretty similar to Zithromax. Why not? Now bear in mind this is one prospective study. Of course I'll put that link in our show notes. But this was in 2020 because you had to do something. I mean Zithromax was there was kind of a regional and or global shortage based on Covid. And so the idea was what do we treat? How do we get that patient protection when we don't have this? So again, this was at a plus one. It was 2020 and the title was Clarithromycin used for adjuvant surgical prophylaxis before non elective cesarean deliveries to adapt to zithromycin shortages in COVID 19. Pandemic. That's a long title but short to say they're like, hey, let's see if this thing works. It's a sister to azithromycin. And sure enough, in this one prospective observational study, it showed pretty darn near effect size and results that were similar. However, as of now, and we're doing this at the end of January 2026, we do not have any head to head randomized controlled trials that compare clarithromycin versus azithromycin for this adjuvant extended Spectrum coverage at C section. So the first question is, well, stick to the same. If you're gonna ask, what are we gonna do? The first answer is, stick to the same class. Clarithromycin is very close relative of azithromycin and taken orally with small sips of water is not gonna affect anything and still be NPO. It's okay within 30 minutes, definitely within the hour. And you seem to get the same coverage based on this one study, but at least it was prospective observational, and it found it did have some result. The other option is to go, well, we're not gonna do anything before surgery, we're gonna hit it after surgery. This is Amy Valent's paper in jama. And so they had the same idea. How do we try to decrease overall wound composite infection in a safe way? Now, the trick with Amy Valent's paper is that this was two days of post op antibiotics. So I get it, and Amy's great and I respect her a lot. But taking two days of metronidazole plus ceflexin Keflex, you know, taking 48 hours of an antibiotic, they're already like, they just want to concentrate with their child. They got to take two medications for two days. So you would think, and it's reasonable to conclude that outside of a research setting, compliance, you know, would be an issue. Now let me just touch on metronidazole real quick for mycoplasma activity, because traditionally the answer was no. I mean, keep with clinda, keep with flagyl for good anaerobic coverage. But traditionally the answer was it's not gonna hit mycoplasma. However, there are some in vitro studies that show, you know, maybe that's not always the case. There can be some activity because metronidazole can be also be considered a pro drug. And so the way that it's broken down, possibly it could hit some types of mycoplasma. There's also some data out of PID literature that, of course, if you add flagyl to the traditional antibiotics for pid, like doxy and ceftriaxone, then you can get improved outcomes. That has been published as well. One of them was called the Weissenfeld trial. So, yes, there is some indirect evidence that potentially adding flagyl could hit mycoplasma genatellum as an indirect kind of a pro drug approach. Again, same thing with the gent and the clinda that has an indirect microbiome. If you take away the antibiotic. I'm sorry, the anaerobic influence, then basically you make mycoplasma and ureoplasma less likely to hang around. All right, so while there is some direct activity that this works in vitro, it's kind of indirect in vivo. That's why the CDC does not include flagyl or cephalexin in the STI treatment guidance for mycoplasma Ureaplasma. All right, so controversial. But you can do two days of post op if Zithromax is gone, just give them two days of Flagyl and Keflex. But it's two days and it's multi dose administration. And it's unclear if that's really targeting mycoplasma. And just as a strict caveat, as a little informal caveat, rather remember that ureaplasma isn't always kind of a bad guy, okay? Ureaplasma can be a background part of the microflora. It's not necessarily, you know, an sti. Mycoplasm, on the other hand, mycoplasm is always bad, okay? Mycoplasm doesn't hang around in somebody's body. That is considered a traditional sti. Mycoplasma genitalum, whereas ureaplasma, it's kind of unclear. You can totally get ureoplasma through sex, but also you may not get it through sex. So ureoplasma is a little gray, but mycoplasma genitalium is considered an STI and is listed in the STI treatment guidance from the cdc. So what we've covered here, if Zithromax is gone and you've got to do something, it's a mini conundrum.
