Comment on “Risk of Infection and Wound Dehiscence After Use of Prophylactic Antibiotics in Episiotomy or Second Degree Tear (REPAIR Study): Single Centre, Double Blind, Placebo Controlled Randomised Trial”

Episiotomies and second-degree lacerations are the most common obstetric injuries. Evidence supporting prophylactic antibiotics to prevent and treat complications, such as infection and wound dehiscence, remains limited. A 2017 Cochrane review found that the evidence to support antibiotic use after episiotomy was insufficient, but it included only one study with methodological limitations. No Cochrane reviews exist on antibiotic use for second-degree tears. Two randomized controlled trials (RCTs) conducted in India found no protective effect from prophylactic antibiotics. Yet a large RCT, known as the ANODE trial, found that intravenous antibiotics decreased wound infection or dehiscence, or both, in instrumental deliveries. The aim of the current study was to assess whether prophylactic antibiotics reduce wound infection, wound dehiscence, or both, in women with episiotomy or second-degree tears. The REPAIR study was a double-blind, randomized, placebo-controlled trial conducted in a single center in Denmark. Included were women ≥18 years who had an episiotomy or second-degree tear between March 22 and December 24, 2023. Excluded were those who had an episiotomy with extension to the anal sphincter, had a cesarean delivery, had antibiotic allergies, or were treated with antibiotics within 24 hours of delivery. Study participants were randomly assigned to a treatment group that received 3 oral doses of amoxicillin (500 mg) plus clavulanic acid (125 mg) within the first 22 hours postpartum and a placebo group. The primary outcome was any wound complication, including wound dehiscence, wound infection, or both. The secondary outcome was clinically relevant wound complications, or complications severe enough to require follow-up due to size, pain, or infection. A total of 433 randomized women were included in the intention-to-treat analysis, with 218 in the treatment group and 215 in the placebo group. There was no significant difference in wound complications between the treatment group and placebo group (22% vs. 29%; P =0.10). However, the treatment group had significantly lower wound complications than the placebo group (9% vs. 17%; P =0.01). The number needed to treat was 12 (95% CI, 7-56). In conclusion, prophylactic oral antibiotics did not significantly reduce overall wound complications in women with episiotomies or second-degree tears. However, antibiotic use did significantly reduce clinically relevant wound complications. (Summarized from Perslev K, Klarskov N, Bergholt T, et al. Risk of infection and wound dehiscence after use of prophylactic antibiotics in episiotomy or second degree tear (REPAIR study): Single centre, double blind, placebo controlled randomised trial. BMJ . 2025;391:e084312. doi:10.1136/bmj-2025-084312).