Prophylactic Antibiotics for Vaginal Delivery — Benefits and Possible Harms

This editorial evaluates findings from the A-PLUS trial, a placebo-controlled, randomized study conducted in eight low- and middle-income countries to assess the efficacy of single-dose oral azithromycin (2 g) administered to women undergoing vaginal delivery. Results from 29,278 randomized participants showed a significant reduction in maternal sepsis or death (RR 0.67), with benefits driven largely by decreased maternal sepsis. Secondary outcomes, including endometritis and wound infection, also improved, while neonatal outcomes showed no significant difference. The editorial underscores the longstanding role of prophylactic antibiotics in obstetric care but warns against the unchecked use of azithromycin due to rising macrolide resistance, especially among genital pathogens like Mycoplasma genitalium and Ureaplasma spp. The piece concludes that while single-dose azithromycin may offer substantial maternal benefits, universal application demands further antimicrobial resistance data and contextual consideration of local health system capacity.

This editorial evaluates findings from the A-PLUS trial, a placebo-controlled, randomized study conducted in eight low- and middle-income countries to assess the efficacy of single-dose oral azithromycin (2 g) administered to women undergoing vaginal delivery. Results from 29,278 randomized participants showed a significant reduction in maternal sepsis or death (RR 0.67), with benefits driven largely by decreased maternal sepsis. Secondary outcomes, including endometritis and wound infection, also improved, while neonatal outcomes showed no significant difference. The editorial underscores the longstanding role of prophylactic antibiotics in obstetric care but warns against the unchecked use of azithromycin due to rising macrolide resistance, especially among genital pathogens like Mycoplasma genitalium and Ureaplasma spp. The piece concludes that while single-dose azithromycin may offer substantial maternal benefits, universal application demands further antimicrobial resistance data and contextual consideration of local health system capacity.