correspondence
does not formally rule out the possibility that those
events may happen or be detected in the future,
but it makes the development of resistance of
worms to antiwolbachial chemotherapy a very re-
mote possibility.
Achim Hoerauf, M.D.
University Clinic Bonn
Bonn, Germany
Case 33-2009: A Woman with Fever after Cesarean Section
To the Editor: In the Case Record, de Moya and
colleagues (Oct. 22 issue)1 describe a patient who
received cefazolin after clamping of the umbili-
cal cord, and a discussant states “the patient re-
ceived appropriate prophylactic antibiotic cover-
age.” Historically, prophylactic antibiotics during
cesarean delivery have been administered after
cord clamping, out of concern for fetal exposure.
Studies in the past few years suggest that antibi-
otic coverage during cesarean delivery should be
consistent with general surgical antimicrobial pro-
phylaxis (i.e., administered before skin incision).2-4
There is no increase in neonatal workups, sepsis,
or other consequences after administration of
prophylactic antibiotics before skin incision.2-4
Cesarean delivery is associated with a higher in-
cidence of surgical-site infections than compara-
ble surgeries, with potential catastrophic conse-
quences, as described in the case reported on by
de Moya et al. Multiple investigations have shown
that prophylactic antibiotic coverage within 60
minutes before skin incision reduces the inci-
dence of fever and infection by up to 50% without
adverse consequences for the neonate.2-4 Anti­
microbial prophylaxis for cesarean delivery should
be administered before skin incision, under the
same guidelines as surgical antibiotic coverage.5
Rayna Clay, M.D.
William Camann, M.D.
Brigham and Women’s Hospital
Boston, MA
wcamann@partners.org
No potential conflict of interest relevant to this letter was re-
ported.
1. Case Records of the Massachusetts General Hospital (Case
33-2009). N Engl J Med 2009;361:1689-97.
2. Owens SM, Brozanski BS, Meyn LA, Wiesenfeld HC. Antimi-
crobial prophylaxis for cesarean delivery before skin incision.
Obstet Gynecol 2009;114:573-9.
3. Tita ATN, Rouse DJ, Blackwell S, Saade GR, Spong CY, An-
drews WW. Emerging concepts in antibiotic prophylaxis for ce-
n engl j med 362;3  nejm.org  january 21, 2010
The New England Journal of Medicine
Downloaded from nejm.org on January 31, 2011. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.
Since publication of his article, the author reports no further
potential conflict of interest.
1. Mand S, Pfarr K, Sahoo PK, et al. Macrofilaricidal activity
and amelioration of lymphatic pathology in bancroftian filaria-
sis after 3 weeks of doxycycline followed by single-dose diethyl-
carbamazine. Am J Trop Med Hyg 2009;81:702-11.
2. Hotopp JC, Clark ME, Oliveira DC, et al. Widespread lateral
gene transfer from intracellular bacteria to multicellular eukary-
otes. Science 2007;317:1753-6.
sarean delivery: a systematic review. Obstet Gynecol 2009;113:
675-82.
4. Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP,
Soper D. Administration of cefazolin prior to skin incision is
superior to cefazolin at cord clamping in preventing postcesar-
ean infectious morbidity: a randomized controlled trial. Am J
Obstet Gynecol 2007;196(5);455.e1-455.e5. [Erratum, Am J Obstet
Gynecol 2007;197:333.]
5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR.
Guideline for Prevention of Surgical Site Infection, 1999: Cen-
ters for Disease Control and Prevention (CDC) Hospital Infec-
tion Control Practices Advisory Committee. Am J Infect Control
1999;27:97-132.
The Discussants Reply: We thank Clay and Ca-
mann for their comments regarding the timing
of antibiotic prophylaxis for surgical delivery. Our
statement that “the patient received appropriate
prophylactic antibiotic coverage” was meant to
indicate that the choice of antibiotic — cefazolin
— was appropriate, and we did not specifically
address the timing of antibiotic prophylaxis. Al-
though in the past, the administration of antibiot-
ics was delayed until after cord clamping to avoid
interference with neonatal cultures,1 we agree
that antibiotic therapy before incision should be
the standard for all surgical procedures, including
delivery by cesarean section. Randomized trials
that have compared the administration of antibi-
otics before incision with administration after
cord clamping have shown that delivery of anti-
biotics before incision is more effective in prevent-
ing infectious complications (relative risk, 0.50;
95% confidence interval, 0.33 to 0.78).2-5
Marcela G. del Carmen, M.D., M.P.H.
Marc A. de Moya, M.D.
Massachusetts General Hospital
Boston, MA
Since publication of their article, the authors report no fur-
ther potential conflict of interest.
1. Cunningham FG, Leveno KJ, DePalma RT, Roark M, Rosen-
feld CR. Perioperative antimicrobials for cesarean delivery: be-
fore or after cord clamping? Obstet Gynecol 1983;62:151-4.
273
 The n e w e ng l a n d j o u r na l
2. Thigpen BD, Hood WA, Chauhan S, et al. Timing of prophy-
lactic antibiotic administration in the uninfected laboring grav-
ida: a randomized clinical trial. Am J Obstet Gynecol 2005;192:
1864-8.
3. Wax JR, Hersey K, Philput C, et al. Single dose cefazolin
prophylaxis for postcesarean infections: before vs. after cord
clamping. J Matern Fetal Med 1997;6:61-5.
4. Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP,
Contaminated Dietary Supplements
To the Editor: With regard to the Perspective
article by Cohen (Oct. 15 issue)1: I would argue
that the challenge posed by the inclusion of un-
declared drug ingredients in supplements bears
no relation to any purported shortcomings of the
Dietary Supplement Health and Education Act
(DSHEA). Such practices are already prohibited
under federal law, including amendments made
by the DSHEA, and they are punishable by civil
and criminal penalties. A manufacturer that does
not already comply with existing laws should not
be expected to comply with new laws. Any new
laws would most likely have the perverse effect of
placing additional burdens on an overstretched
Food and Drug Administration (FDA) and of plac-
ing scrupulous supplement manufacturers at a fur-
ther competitive disadvantage as compared with
those who flout the law.
What is needed is not new laws, but a con-
certed effort to enforce existing laws and to edu-
cate consumers so that they can make more in-
formed purchasing decisions. The importance of
consumer education cannot be overstated, given
the ease with which nearly all products can be
marketed and purchased over the Internet. As
noted by Cohen, these are efforts in which phy-
sicians can play a valuable role.
Ricardo Carvajal, J.D.
Hyman, Phelps, and McNamara
Washington, DC
rcarvajal@hpm.com
As an attorney, the author provides regulatory counseling to
manufacturers and marketers of dietary supplements. No other
potential conflict of interest relevant to this letter was reported.
1. Cohen PA. American roulette — contaminated dietary sup-
plements. N Engl J Med 2009;361:1523-5.
The author replies: I agree that aggressive en-
forcement and consumer and physician education
274 n engl j med 362;3  nejm.org  january 21, 2010
The New England Journal of Medicine
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Copyright © 2010 Massachusetts Medical Society. All rights reserved.
of m e dic i n e
Soper D. Administration of cefazolin prior to skin incision is
superior to cefazolin at cord clamping in preventing postcesar-
ean infectious morbidity: a randomized controlled trial. Am J
Obstet Gynecol 2007;196(5);455.e1-455.e5. [Erratum, Am J Obstet
Gynecol 2007;197:333.]
5. Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of
perioperative antibiotics for cesarean delivery: a metaanalysis.
Am J Obstet Gynecol 2008;199(3):301.e1-301.e6.
are important. However, Carvajal’s claim that un-
safe dietary supplements are available solely be-
cause of lax FDA enforcement is inaccurate.1,2
The DSHEA assumes that all dietary supplements
are safe until proved harmful.3 Unfortunately,
this assumption creates a facade of safety for
both legal and illegal dietary supplements.
Regulatory frameworks can encourage or dis-
courage the availability of product information.4
Regulation that includes premarket testing of
safety can ensure that accurate and informative
product information is available. Currently, con-
sumers and physicians remain uninformed be-
cause premarket testing of supplement safety is
not required.3 This asymmetry of information be-
tween sellers and consumers leads to domination
of the market by low-quality products because the
regulatory framework creates financial disincen-
tives to sell high-quality supplements.5
Both regulatory reform and aggressive enforce-
ment are required to enhance the overall quality
of dietary supplements and to provide accurate
safety information.
Pieter Cohen, M.D.
Cambridge Health Alliance
Cambridge, MA
Since publication of his article, the author reports no further
potential conflict of interest.
1. Gardiner P, Sarma DN, Low Dog T, et al. The state of dietary
supplement adverse event reporting in the United States. Phar-
macoepidemiol Drug Saf 2008;17:962-70.
2. Miller RK, Celestino C, Giancaspro GI, Williams RL. FDA’s
dietary supplement CGMPs: standards without standardization.
Food Drug Law J 2008;63:929-42.
3. Cohen PJ. Science, politics and the regulation of dietary
supplements: it’s time to repeal DSHEA. Am J Law Med 2005;
31:175-214.
4. Carpenter D. Confidence games: how does regulation con-
stitute markets? In: Balleisen EJ, Moss DA, eds. Government and
markets: towards a new theory of regulation. New York: Cam-
bridge University Press, 2009:164-92.
5. Akerlof GA. The market for “lemons”: quality uncertainty
and the market mechanism. Q J Econ 1970;84:488-500.