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Duffy CR, Oberhardt M, Ross N, Ewing J, Messina M, Fitzgerald K, Saiman L, Goffman D. Perioperative Antibiotics and Other Factors Associated with Postcesarean Infections: A Case-Control Study. Am J Perinatol 2024; 41:e520-e527. [PMID: 35858646 DOI: 10.1055/a-1904-9583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our objective was to determine modifiable risk factors associated with surgical site infection (SSI) and postpartum endometritis. We hypothesized that inappropriate surgical antibiotic prophylaxis would be a risk factor for both types of infections. STUDY DESIGN This was a single-center case-control study of SSI and endometritis after cesarean delivery over a 2-year period from 2016 to 2017. Cases were identified by International Classification of Diseases, 10th Revision diagnosis codes, infection control surveillance, and electronic medical records search and were subsequently confirmed by chart review. Three controls were randomly selected for each case from all cesareans ± 48 hours from case delivery. Demographic, pregnancy, and delivery characteristics were abstracted. Separate multivariable logistic regression models were used to assess factors associated with SSI and endometritis. Postpartum outcomes, including length of stay and readmission, were also compared. RESULTS We identified 141 cases of SSI and endometritis with an overall postpartum infection rate of 4.0% among all cesarean deliveries. In adjusted analysis, factors associated with both SSI and endometritis were intrapartum delivery, classical or other (non-low-transverse) uterine incision, and blood transfusion. Factors associated with SSI only included inadequate antibiotic prophylaxis, public insurance, hypertensive disorder of pregnancy, and nonchlorhexidine abdominal preparation; factors only associated with endometritis included β-lactam allergy, anticoagulation therapy, and chorioamnionitis. Among cases, 34% of those with SSI and 25% of those with endometritis did not receive adequate antibiotic prophylaxis, compared with 12.9 and 13.5% in control groups, respectively. Failure to receive appropriate antibiotic prophylaxis was associated with an increased risk of SSI (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 1.3-15.6) but not endometritis (aOR 0.9, 95% CI 0.4-2.0). CONCLUSION Inadequate surgical antibiotic prophylaxis was associated with an increased risk of SSI but not postpartum endometritis, highlighting the different mechanisms of these infections and the importance of prioritizing adequate surgical prophylaxis. Additional potentially modifiable factors which emerged included blood transfusion and chlorhexidine skin preparation. KEY POINTS · Inadequate antibiotic prophylaxis is associated with a four-fold risk in surgical site infections.. · The most common cause for failure to achieve adequate surgical prophylaxis was inappropriate timing of antibiotics at or after skin incision.. · Blood transfusions are strongly associated (>10-fold risk) with both SSI and endometritis..
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
| | - Matthew Oberhardt
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- NewYork-Presbyterian Value Institute, New York, New York
| | - Naima Ross
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Julie Ewing
- NewYork-Presbyterian Value Institute, New York, New York
| | - Maria Messina
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
- Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Kelly Fitzgerald
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
- Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
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Dong H, Song J, Jia Y, Cui H, Chen X. A comprehensive study on the risk factors and pathogen analysis of postoperative wound infections following caesarean section procedures. Int Wound J 2024; 21:e14609. [PMID: 38272798 PMCID: PMC10801270 DOI: 10.1111/iwj.14609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/27/2024] Open
Abstract
Postoperative wound infections (PWIs), a subtype of surgical site infections, are a significant concern for patients undergoing caesarean sections (C-sections). Understanding risk factors and pathogen profiles can greatly assist in early diagnosis and effective treatment. This study aimed to identify risk factors and analyse the pathogenic landscape contributing to PWIs in C-sections. A nested case-control study was carried out, utilising stringent criteria for case selection and control matching. Diagnostic criteria for surgical site infections included both clinical and microbiological parameters. Risk variables examined included patient age, Body Mass Index, duration of surgery and several other clinical indicators. Microbiological analysis was performed using the BD Phoenix-100 Automated Bacterial Identification System. Statistical analyses were conducted using SPSS version 26.0, and risk factors were evaluated through both univariate and multivariate analyses. A total of 50 patients, aged between 20 and 45 years (mean age 26.3 ± 5.6), developed PWIs following C-sections. The study revealed a temporal distribution and various clinical indicators of PWIs, including elevated white blood cell count and C-reactive protein levels. Gram-negative bacteria were found to be more prevalent at 57.4%. Notable pathogens included Pseudomonas aeruginosa and Acinetobacter baumannii. Antimicrobial resistance patterns were also identified, highlighting the need for a targeted antibiotic approach. Increased infection risks were linked to lack of prophylactic antibiotics, absence of preoperative povidone-iodine antisepsis, operations over an hour, anaemia, amniotic fluid contamination, diabetes, GTI, premature rupture of membranes and white blood cells counts above 10 × 109 /L. The study provides critical insights into the risk factors and microbial agents contributing to PWIs following C-sections. Our findings emphasise the importance of early diagnosis through clinical and laboratory parameters, as well as the need for constant surveillance and reassessment of antibiotic stewardship programs.
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Affiliation(s)
- Hui Dong
- School of Medicine, Nankai UniversityTianjinChina
- Tianjin Key Laboratory of Human Development and Reproductive RegulationTianjinChina
- Tianjin Central Hospital of Obstetrics and GynecologyTianjinChina
| | - Jie Song
- Tianjin Central Hospital of Obstetrics and GynecologyTianjinChina
- Tianjin Medical UniversityTianjinChina
| | - Yanju Jia
- Tianjin Central Hospital of Obstetrics and GynecologyTianjinChina
| | - Hongyan Cui
- Tianjin Central Hospital of Obstetrics and GynecologyTianjinChina
| | - Xu Chen
- School of Medicine, Nankai UniversityTianjinChina
- Tianjin Key Laboratory of Human Development and Reproductive RegulationTianjinChina
- Tianjin Central Hospital of Obstetrics and GynecologyTianjinChina
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Sood N, Lee RE, To JK, Cervellione KL, Smilios MD, Chun H, Ngai IM. Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. Birth 2022; 49:141-146. [PMID: 34490654 DOI: 10.1111/birt.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reduction in the incidence of surgical site infection (SSI) serves as a measure of patient safety and quality improvement. Cesarean birth (CB) accounts for 31.9% of all childbirths in the United States. However, our understanding of SSI prevention bundles predominantly stems from gynecological and colorectal surgeries. This study aimed to determine the efficacy of a standardized perioperative bundle designed to reduce SSI in CBs. METHODS All CB patients at Flushing Hospital Medical Center from 2017 to 2019 were included in a retrospective analysis. Patients were divided into three groups based on the timing of intervention: prebundle/control, transition, and postbundle. Baseline demographics and clinical characteristics were summarized using descriptive statistics. Multiple logistic regression was performed to determine the association between bundle group and SSI, considering variables different between groups at baseline (P < 0.10). RESULTS Two thousand eight hundred and seventy-five CBs were performed: 1086 in prebundle, 812 in transition, and 977 in postbundle phase. In the prebundle phase, 25 CBs (2.3%) were complicated by SSIs; in the transition phase, 10 (1.2%) had SSIs; and in the postbundle phase, 7 (0.7%; P = 0.009) had SSIs. In a logistic regression model, only use of the CB bundle (OR 0.26 [95% CI 0.07-0.94]; P = 0.04), rupture of membranes (0.29 [0.09-0.87]; P = 0.03), and operating room time (1.02 [1.01-1.04]; P = 0.01) were significant in prediction of SSI. SSI postbundle was significantly reduced from prebundle (0.04). CONCLUSIONS Thus, introduction of a hospital-wide perioperative bundle significantly reduced SSI rates, and should be developed as a mainstay of CB surgical care.
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Affiliation(s)
- Neha Sood
- Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | - Rachel E Lee
- Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | - Justin K To
- Minimally Invasive Gynecological Surgery, Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | | | | | - Hajoon Chun
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | - Ivan M Ngai
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
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Chaboyer W, Ellwood D, Thalib L, Kumar S, Mahomed K, Kang E, Gillespie BM. Incidence and predictors of surgical site infection in women who are obese and give birth by elective caesarean section: A secondary analysis. Aust N Z J Obstet Gynaecol 2021; 62:234-240. [PMID: 34506037 DOI: 10.1111/ajo.13428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/23/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgical site infection (SSI) after a caesarean section is of concern (CS) is of concern to both clinicians and women themselves. AIMS The aim of this study is to identify the cumulative incidence and predictors of SSI in women who are obese and give birth by elective CS. MATERIALS AND METHODS The method used was planned secondary analysis of data from women with a pre-pregnancy body mass index (BMI) ≥30 kg/m2 giving birth by elective CS in a multicentre randomised controlled trial of a prophylactic closed-incision negative pressure wound therapy dressing. Data were collected from medical records, direct observations of the surgical site and self-reported signs and symptoms from October 2015 to December 2019. The Centers for Disease Control and Prevention definition was used to identify SSI. Women were followed up once in hospital just before discharge and then weekly for four weeks after discharge. Blinded outcome assessors determined SSI. After the cumulative incidence of SSI was calculated, multiple variable logistic regression models were used to identify independent risk factors for SSI. RESULTS SSI incidence in 1459 women was 8.4% (122/1459). Multiple variable-adjusted odds ratios (OR) for SSI were BMI ≥40 kg/m2 (OR 1.55, 95% confidence interval (CI) 1.30-1.86) as compared to BMI 30-34.9 0 kg/m2 , ≥2 previous pregnancies (OR 1.38, 95% CI 1.00-1.80) as compared to no previous pregnancies and pre-CS vaginal cleansing (OR 0.55, 95% CI 0.33-0.99). CONCLUSIONS Our findings may inform preoperative counselling and shared decision-making regarding planned elective CS for women with pre-pregnancy BMI ≥30 kg/m2 .
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Affiliation(s)
- Wendy Chaboyer
- NHMRC Centre of Research Excellence in Wiser Wound Care and Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - David Ellwood
- School of Medicine, Griffith University, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Lukman Thalib
- Department of Biostatistics, Faculty of Medicine, Istanbul Aydin University, Istanbul, Turkey
| | - Sailesh Kumar
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Mothers' Hospital, Brisbane, Queensland, Australia
| | - Kassam Mahomed
- Department of Obstetrics and Gynaecology and Faculty of Medicine, University of Queensland, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Evelyn Kang
- School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Brigid M Gillespie
- NHMRC Centre of Research Excellence in Wiser Wound Care and Menzies Health Institute Queensland & Gold Coast University Hospital, Griffith University, Gold Coast, Queensland, Australia
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Lavie M, Lavie I, Cohen A, Levin I, Many A, Fouks Y. Cefazolin prophylaxis in minimally invasive gynecologic surgery - are dosage and timing appropriate? Prospective study using resampling simulation. J Gynecol Obstet Hum Reprod 2021; 50:102154. [PMID: 33905919 DOI: 10.1016/j.jogoh.2021.102154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/20/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Cefazolin is a widely used antimicrobial prophylactic agent, however the appropriate dosage, timing, pharmacology and microbial coverage have not been well-established for gynecologic procedures. We aimed to describe serum concentrations and pharmacokinetics of Intravenous cefazolin given to women prior to scheduled minimally invasive gynecologic surgeries, and to determine whether appropriate antimicrobial coverage had been achieved in short time from prophylactic administration to surgical start time. METHODS A prospective cohort analysis study, using a resampled dataset, of women undergoing scheduled gynecological surgeries in a university affiliated tertiary medical center. IV cefazolin (1 or 2 gr) was administered prior to incision to women weighing <80 kg (Group A) and ≥80 kg (Group B), respectively. Cefazolin serum levels were obtained at the time of skin incision (Time 0) and 30 min later (Time 30), measured by high-pressure liquid chromatography (HPLC). Appropriate antimicrobial coverage was defined when cefazolin serum levels were above minimal inhibitory concentrations (MIC) for Enterobacteriaceae. RESULTS Overall, 21 women were included. The mean time interval between drug administration and incision did not differ between the two groups (18 ± 10 min vs. 11 ± 10 min, respectively, p = .0.25). A hierarchical mixed linear regression model, using a simulation of multiple random bootstrap resampling (n = 1,000), revealed that cefazolin serum levels exceeded MIC, regardless of the timing of administration in the sampling intervals. Mean cefazolin serum levels in time 0 and time 30 min were not affected by BMI in patients receiving 1 gr. CONCLUSION A single dose of IV cefazolin given shortly prior to skin incision provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled minimally invasive gynecologic surgery.
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Affiliation(s)
- Michael Lavie
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Inbar Lavie
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviad Cohen
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ishai Levin
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yuval Fouks
- Department of Obstetrics and Gynecology, Lis Hospital for Women, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Adaji JA, Akaba GO, Isah AY, Yunusa T. Short versus Long-Term Antibiotic Prophylaxis in Cesarean Section: A Randomized Clinical Trial. Niger Med J 2020; 61:173-179. [PMID: 33284877 PMCID: PMC7688029 DOI: 10.4103/nmj.nmj_197_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 12/05/2022] Open
Abstract
Objective: The objective of the present study was to compare the efficacy of intravenous (IV) 48 h course of cefuroxime/metronidazole with long-term course using 48 h cefuroxime/metronidazole plus 5 days oral regimen of cefuroxime and metronidazole for the prevention of post cesarean section wound infection. Methods: Two hundred and forty-eight women were randomized into two equal groups. Women in each arm of the study received IV cefuroxime 750 mg twelve hourly and IV metronidazole 400 mg eight hourly for 48 h. Those in the long-term arm received additional tablets of cefuroxime 500 mg twelve hourly and Tabs 400 mg of metronidazole eight hourly for 5 days. After the surgery, surgical site infections were evaluated. Length of hospital stay and the cost of antibiotics were also assessed. Results: The wound infection rate was not statistically significantly different between the 2 groups (1.3% vs. 3.3%, P = 0.136). The incidence of endometritis was 2.1%, with no statistically significant difference seen between the two groups (0.4% vs. 1.6%, P = 0.213). Escherichia coli was the most common isolate seen in 36.4% of infected wounds. The short arm group stayed for significantly shorter days in the hospital (2.9 ± 1.0 vs. 3.8 ± 1.1 days,P < 0.001), and the cost of antibiotics was also significantly less in the short arm group (P < 0.001). Organisms associated with nosocomial infections were seen only in the long arm that stayed in the hospital for longer days. Conclusions: Short-term prophylactic antibiotics are as effective as long-term prophylaxis and have other benefits such as shorter duration of hospital stay, reduced cost of antibiotics, and reduction of nosocomial infections.
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Affiliation(s)
- James A Adaji
- Department of Obstetrics and Gynaecology, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Godwin O Akaba
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Aliyu Y Isah
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Thairu Yunusa
- Department of Medical Microbiology, College of Health Sciences, University of Abuja, Abuja, Nigeria
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Fouks Y, Ashwal E, Yogev Y, Amit S, Ben Mayor Bashi T, Sinai N, Firsow A, Hasson E, Gamzu R, Many A. Calculating the appropriate prophylactic dose of cefazolin in women undergoing cesarean delivery. J Matern Fetal Neonatal Med 2020; 35:2518-2523. [PMID: 32662688 DOI: 10.1080/14767058.2020.1786529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgical site infection and other postoperative complications are relatively common in obstetrical procedures, and they are associated with morbidity, prolonged hospital stay, and readmissions. Appropriate levels of antimicrobial agents given directly before skin incision can prevent the establishment of surgical-related infection caused by endogenous microorganisms present on the woman's skin. We aimed to determine serum concentrations of cefazolin given to pregnant women prior to scheduled cesarean delivery and to compare their drug concentrations and pharmacokinetics in 2 weight groups. STUDY DESIGN We conducted a prospective cohort analysis of the pharmacokinetics of cefazolin in women undergoing cesarean delivery (August 2017 to September 2018). One or two grams of intravenous cefazolin was administered within 30 min prior to skin incision to women weighing <80 kg and ≥80 kg, respectively. Maternal serum samples were obtained at skin incision and 30 min later. The serum concentration of cefazolin was measured by high-pressure liquid chromatography. Antimicrobial coverage was defined as being appropriate when the cefazolin levels were above the minimal inhibitory concentration. Pharmacokinetic parameters were estimated using a one-compartment model. RESULTS A total of 61 women were enrolled, of whom 47 underwent cesarean delivery (study group). The mean time that had elapsed between drug administration to incision was 13 ± 6.9 min (95% confidence interval 10.6-16.2 min). The drug levels after 30 min in women who weighed >80 kg and in women who received 2 g cefazolin, after 30 min from incision differed significantly (87.0 ± 26.0 vs 55.4 ± 16.6 μg/ml, p = .0001). CONCLUSION A single 1- or 2-g dose of cefazolin provides serum concentrations above minimal inhibitory concentrations for susceptible pathogens in most women undergoing scheduled cesarean delivery.
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Affiliation(s)
- Yuval Fouks
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Sharon Amit
- The Department of Clinical Microbiology and Infectious Diseases, Hadassah University Hospital, Jerusalem, Israel
| | - Tali Ben Mayor Bashi
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Noa Sinai
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Anastasia Firsow
- The Clinical Biochemistry Laboratory, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Hasson
- The Clinical Biochemistry Laboratory, Tel-Aviv Medical Center, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ronni Gamzu
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel-Aviv, Israel
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Abstract
Postoperative infections remain a serious concern after cesarean delivery, the most common major surgical procedure in the United States. Multiple strategies have been proposed to combat this problem, including the addition of azithromycin to the standard preoperative antibiotic prophylaxis. However, as obstetricians, we have failed to uniformly adopt precesarean vaginal preparation despite convincing evidence from randomized controlled trials that this technique reduces postoperative rates of endometritis by more than 50%. This reduction is similar to that seen with the addition of azithromycin. Vaginal preparation with povidone-iodine solution may target the same genital pathogens as azithromycin, which are commonly implicated in endometritis, a polymicrobial infection that may be under-addressed by our current antiseptic techniques. A recent review of maternal-fetal medicine fellows' practices at the time of cesarean delivery and recent publications on precesarean vaginal cleansing suggest that this practice has not yet gained hold in the United States.
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Douville SE, Callaway LK, Amoako A, Roberts JA, Eley VA. Reducing post-caesarean delivery surgical site infections: a narrative review. Int J Obstet Anesth 2019; 42:76-86. [PMID: 31606251 DOI: 10.1016/j.ijoa.2019.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/22/2019] [Accepted: 08/28/2019] [Indexed: 01/15/2023]
Abstract
Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.
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Affiliation(s)
- S E Douville
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - L K Callaway
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Department of Obstetrics and Gynaecology/Obstetric Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - A Amoako
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Department of Obstetrics and Gynaecology/Obstetric Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - J A Roberts
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Queensland, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Herston, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy and Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Herston, Qld, Australia
| | - V A Eley
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.
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Molla M, Temesgen K, Seyoum T, Melkamu M. Surgical site infection and associated factors among women underwent cesarean delivery in Debretabor General Hospital, Northwest Ethiopia: hospital based cross sectional study. BMC Pregnancy Childbirth 2019; 19:317. [PMID: 31464598 PMCID: PMC6716814 DOI: 10.1186/s12884-019-2442-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/30/2019] [Indexed: 01/22/2023] Open
Abstract
Background Cesarean section rates have been increasing dramatically during the past three decades and surgical site infections are becoming a leading cause of morbidity and mortality among women undergoing cesarean deliveries. However there is lack of sound evidence on both the magnitude of the problem and the associated factors in developing countries including Ethiopia. The purpose of this study was to assess proportion of surgical site infection and associated factors among women undergoing cesarean delivery in Debretabor General Hospital. Methods An institution based cross sectional study was conducted from May to December / 2017. All women delivered by cesarean section in Debretabor General Hospital during data collection period were our study population. Data were collected using Pre-tested, semi-structured questionnaire/ data extraction tool and post discharge phone follow up and analyzed using SPSS version 20. Logistic regression model was used to determine the association of independent variables with the outcome variable and odds ratios with 95% confidence interval were used to estimate the strength of the association. Results Proportion of surgical site infection among cesarean deliveries was about 8% (95%Cl: 5.4, 11.6). Pregnancy induced hypertension (AOR = 4.75, 95%CI: 1.62, 13.92), chorioaminitis (AOR = 4.37, 95%CI: 1.53, 12.50), midline skin incision (AOR = 5.19, 95% CI: 1.87, 14.37 and post-operative hemoglobin less than 11 g/deciliter (AOR = 5.28, 95%CI: 1.97, 14.18) were significantly associated with surgical site infection. Conclusions Pregnancy induced hypertension, chorioaminitis, midline skin incision and post-operative hemoglobin of less than 11 g/deciliter were independent factors associated with surgical site infection. Cesarean deliveries with concomitant pregnancy induced hypertension, chorioaminitis and post-operative anemia needs special care and follow up until surgical site infection is ruled out. It is also advisable to reduce generous midline skin incision and better replaced with pfannensteil incision.
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Affiliation(s)
- Mihretu Molla
- Department of Midwifery College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Kiber Temesgen
- Department of Midwifery College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tewodros Seyoum
- Department of Midwifery College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mengstu Melkamu
- Department of Midwifery College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology. Clin Microbiol Rev 2019; 32:32/4/e00125-18. [PMID: 31413046 DOI: 10.1128/cmr.00125-18] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.
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Abstract
PURPOSE OF REVIEW Cesarean sections are common surgical procedures performed in a healthy population and are unique because of a relatively high rate of postoperative infection. There have been many important advances in understanding the pathogenesis of infection and evaluation of interventions to prevent post cesarean section infections in the last few years. Our purpose in this review is to analyze these new data, discuss unanswered questions, and propose changes in standard of care. RECENT FINDINGS Wound closure techniques including subcuticular sutures and subcutaneous suturing have been shown to be effective at reducing surgical site infections. Wound dressings including negative pressure dressings likely do not decrease infection rates. The type, timing, and duration of preoperative prophylactic antibiotics, including adjunctive azithromycin for laboring women and multidose antibiotics in obese women, have also yielded mixed results. Our understanding of normal uterine microbiome and the impact of intrapartum antibiotics on the newborn is emerging. SUMMARY The pathogenesis of surgical site infections after Cesarean section is complex and multifactorial. Many interventions to reduce infections have been studied with varying degrees of effectiveness. Despite advances in the area, important questions remain unanswered.
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Hodgetts Morton V, Wilson A, Hewitt C, Weckesser A, Farmer N, Lissauer D, Hardy P, Morris RK. Chlorhexidine vaginal preparation versus standard treatment at caesarean section to reduce endometritis and prevent sepsis-a feasibility study protocol (the PREPS trial). Pilot Feasibility Stud 2018; 4:84. [PMID: 29881638 PMCID: PMC5985577 DOI: 10.1186/s40814-018-0273-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/18/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Worldwide caesarean section (CS) delivery is the most common major operation. Approximately 25% of pregnant women undergo a CS in the UK for delivery of their babies. Sepsis and post-natal infection constitute significant maternal mortality and morbidity. Infection following a CS has a number of primary sources including endometritis occurring in 7-17% of women. Sepsis reduction and reduction in antibiotic use have been identified as a national and international priority. The overarching aim of this research is to reduce infectious morbidity from caesarean sections. METHODS This is a parallel group feasibility randomised controlled trial comparing vaginal cleansing using chlorhexidine gluconate versus no cleansing (standard practice) at CS to reduce infection. Women will be recruited from four National Health Service maternity units. Two hundred fifty women (125 in each arm) undergoing elective or emergency CS, who are aged 16 years and above, and at least 34 weeks pregnant will be randomised. Allocation to treatment will be on a 1:1 ratio. The study includes a qualitative aspect to develop women centred outcomes of wellbeing after delivery. DISCUSSION The success of the feasibility study will be assessed by criteria related to the feasibility measurements to ascertain if a larger study is feasible in its current format, needs modification or is unfeasible, and includes recruitment, adherence, follow-up and withdrawal measures. TRIAL REGISTRATION The PREPS trial has been registered with ISRCTN (ISRCTN 33435996).
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Affiliation(s)
- V. Hodgetts Morton
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
| | - A. Wilson
- Birmingham Clinical Trials Unit, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - C. Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - A. Weckesser
- School of Health and Social Care, Birmingham City University, Birmingham, B15 3TN UK
| | - N. Farmer
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
| | - D. Lissauer
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - P. Hardy
- Birmingham Clinical Trials Unit, Institute of Applied Health Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - R. K. Morris
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
- Birmingham Women’s and Children’s Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG UK
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14
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Martin EK, Beckmann MM, Barnsbee LN, Halton KA, Merollini KMD, Graves N. Best practice perioperative strategies and surgical techniques for preventing caesarean section surgical site infections: a systematic review of reviews and meta-analyses. BJOG 2018; 125:956-964. [DOI: 10.1111/1471-0528.15125] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 12/16/2022]
Affiliation(s)
- EK Martin
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane QLD Australia
| | - MM Beckmann
- Mater Health Services; Brisbane QLD Australia
| | - LN Barnsbee
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane QLD Australia
| | - KA Halton
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane QLD Australia
| | - KMD Merollini
- Faculty of Science, Health, Education and Engineering; University of the Sunshine Coast; Maroochydore QLD Australia
| | - N Graves
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane QLD Australia
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Scheck SM, Blackmore T, Maharaj D, Langdana F, Elder RE. Caesarean section wound infection surveillance: Information for action. Aust N Z J Obstet Gynaecol 2017; 58:518-524. [DOI: 10.1111/ajo.12755] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/06/2017] [Indexed: 01/23/2023]
Affiliation(s)
- Simon M. Scheck
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
| | - Timothy Blackmore
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
| | - Dushyant Maharaj
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
- School of Medicine; University of Otago; Otago New Zealand
| | - Fali Langdana
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
- School of Medicine; University of Otago; Otago New Zealand
| | - Rosalie E. Elder
- Wellington Regional Hospital; Capital and Coast District Health Board; Wellington New Zealand
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Zuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Womens Health 2017; 9:81-88. [PMID: 28255256 PMCID: PMC5322852 DOI: 10.2147/ijwh.s98876] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%-15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI.
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Affiliation(s)
| | - Noah Zafran
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gali Garmi
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Raed Salim
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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17
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Survey of Cesarean delivery infection prevention practices across US academic centers. Infect Control Hosp Epidemiol 2015; 36:1245-7. [PMID: 26190044 DOI: 10.1017/ice.2015.161] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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