Surgical Site Infection following Cesarean Delivery: Patient, Provider, and Procedure-Specific Risk Factors

Algerian postcaesarean surgical site infections: A cross-sectional investigation of the epidemiology, bacteriology, and antibiotic resistance profile

BACKGROUND

Surgical site infections (SSIs) are one of the most common health care-associated infections in low and middle-income countries. The aims of this cross-sectional descriptive study were to estimate the frequency of postcaesarean infection with associated clinical characteristics and the antibiotic resistance profile of bacterial isolates.

METHODS

Patients who underwent a cesarean section at the obstetrics and gynecology department of the hospital in Annaba, Algeria were included. Each woman was followed postoperatively for 30 days and sociodemographic data were collected. Culture-based microbiological methods were used to identify the causative bacteria and determine their antibiotic resistance phenotype and molecular characterization.

RESULTS

Among 1,810 patients, we recorded 36 (1.9%) SSIs. Most patients had undergone an emergency delivery (75%) and low educational level (72.2%). The most frequent maternal pathologies were Body Mass Index ≥ 30 (63.9%), scarred uteri (58.3%), anemia (55.6%), and an American Society of Anaesthesiologists score between II and III (33.3%). Of the 43 bacteria isolated, Enterobacteriaceae were the most frequent (62.8%), predominated by Escherichia coli strains (43.5%), a majority of which were extended-spectrum β-lactamases carriers (62.9%). Although gram-positive cocci were less frequent (37.2%), a majority of Enterococcus faecalis (56.2%) were observed and 2 strains of vancomycin-resistant Enterococcus faecium harboring the vanA gene were identified.

CONCLUSIONS

Extensive surveillance of at-risk populations should be integrated to prevent the occurrence of SSIs.

L, Agiwal V, Angaali N, A. Y. N, D. S, Haggerty C, Reddy PS. Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

BACKGROUND

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

MAIN OBJECTIVES

To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India.

METHODS

A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity.

RESULTS

The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%).

CONCLUSION

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Risk Factors Associated with Surgical Site Infection following Cesarean Section in Tertiary Care Hospital, Nepal

Background

Cesarean section (CS) is one of the most performed surgeries in obstetrics. Surgical site infection is the major cause of morbidity and mortality causing an increase in the duration of hospitalization as well as the cost of admission for the patient.

Objective

To determine incidence of surgical site infection following cesarean section, classify them according to CDC criteria, and identify the different risk factors. Methodology. This is a case-control study conducted at the Department of Obstetrics and Gynecology at Tribhuvan University Teaching Hospital (TUTH), main campus of Institute of Medicine (IOM), Kathmandu, Nepal. Surgical site infections (SSI) in patients who underwent cesarean sections from February 2019 to August 2019 were taken as cases, while the patients who underwent cesarean section before or after the procedure and did not develop SSI comprised the controls. Visual inspection during ward rounds, reports from laboratory, and postprocedure follow-ups for up to 30 days formed the basis of identifying infections on the patients. Risk factors were identified by bivariate and multivariate logistic regression.

Results

Out of 1135 cases of cesarean sections, 97 of them developed SSI with incidence rate of 8.54%. Among them, 94.85% were superficial incisional and 5.15% were deep incisional type of SSI with no organ space type. Cases had higher mean age 26.88 ± 4.38 years compared to 24.81 ± 5.08 years in controls. Host-related risk factors which led to higher odds of developing surgical site infection (SSI) were obesity with adjusted odds ratio (AOR) 15.72 (confidence interval (CI): 4.60-53.67), diabetes/hypertension in pregnancy with AOR 4.75(CI 1.69-13.32), and other medical diseases with AOR 9.38 (CI 2.89-30.46). Duration of the rupture of membrane for more than 18 hours with AOR 8.38 (CI 1.48-47.35), more than five per vaginal (PV) examination with AOR 1.93 (95% CI 1.03-3.64), and in labor status with AOR 6.52 (CI 1.17-36.38) were some procedure-related factors resulting into higher odds of infection.

Conclusion

Multiple risk factors like age, obesity, medical complications during pregnancy, occurrence of labor status during cesarean section, prolonged duration of rupture of membrane for more than 18 hours, and more than five vaginal examinations before the procedure increases the chance of surgical site infection (SSI) following cesarean section.

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle

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.

:

Background

We aimed to determine the prevalence and risk factors of surgical site infection (SSI) after cesarean delivery (CD) in a rural area in China.

Methods

We identified 155 patients with incisional and organ/space SSIs by International Classification of Disease codes and matched them with 465 patients (controls) in a time-matched retrospective quality assurance analysis. Multiple logistic regression analyses were performed to examine the risk factors for SSI: the work-years of providers, the number of antenatal care (ANC) visits, CD after labor, positive discharge culture, postoperative C-reactive protein (CRP) levels and fever.

Results

and discussion: During the study, 155 women with SSI were identified among the 8640 patients who delivered by CD. The incidence of SSIs was 179 per 10 000patients (95%CI: 151–207 per 10 000 patients). The total duration of hospitalization in patients with SSI was 14.49 ± 8.68 days compared with 7.96 ± 2.35 days in patients with no SSI (P < 0.01). Multiple logistic regression analysis showed that the work-years of providers (odds ratio [OR] = 3.729, 95% confidence interval [CI]: 1.463–9.501, p = 0.006), irregular ANC visits (OR = 3.245, 95% CI: 1.264–8.329, p = 0.028), CD after labor (OR = 2.545, 95% CI: 0.935–6.926, p = 0.020), postoperative CRP level (OR = 2.545, 95% CI: 0.935–6.926, p = 0.016) and a positive discharge culture (OR = 2.954, 95% CI: 0.305–28.643, p = 0.019) were positively associated with SSI. However, the rates of maternal request (OR = 0.186, 95% CI: 0.065–0.535, p = 0.002) and postoperative fever (OR = 0.208, 95% CI: 0.087–0.494, p = 0.001) were negatively related to SSI.

Conclusions

Special attentions should be paid to CD patients who had irregular ANC visits, attempted labor, a positive discharge culture, higher CRP levels and fever after surgery, who had a greater risk of SSI.

•

The incidence of SSIs was 179 per 10 000 patients (95%CI: 151–207).

•

Risk factors of SSIs included: irregular ANC visits, a positive discharge culture.

•

Higher CRP levels and fever after surgery had a greater risk of SSI.

Incidence, risk factors and management of post cesarean section surgical site infection (SSI) in a tertiary hospital in Egypt: a five year retrospective study

BACKGROUND

Surgical site infection (SSI) is one of the commonest complications following cesarean section (CS) with a reported incidence of 3-20%. SSI causes massive burdens on both the mother and the health care system. Moreover, it is associated with high maternal morbidity and mortality rate of up to 3%. This study aims to determine the incidence, risk factors and management of SSI following CS in a tertiary hospital.

METHODS

This was an observational case control retrospective study which was conducted at Minia maternity university hospital, Egypt during the period from January 2013 to December 2017 (Five years). A total of 15,502 CSs were performed during the studied period, of these, 828 cases developed SSI following CS (SSI group). The control group included 1500 women underwent cesarean section without developing SSI. The medical records of both groups were reviewed regarding the sociodemographic and the clinical characteristics.

RESULTS

The incidence of SSI post-cesarean section was 5.34%. Significant risk factors for SSI were; chorioamnionitis (adjusted odds ratio (AOR) 4.51; 95% CI =3.12-6.18), premature rupture of membranes (PROM) (AOR 3.99; 95% CI =3.11-4.74), blood loss of > 1000 ml (AOR 2.21; 95% CI =1.62-3.09), emergency CS (AOR 2.16; 95% CI =1.61-2.51), duration of CS of > 1 h (AOR 2.12; 95% CI =1.67-2.79), no antenatal care (ANC) visits (AOR 2.05; 95% CI =1.66-2.37), duration of labor of ≥24 h (AOR 1.45; 95% CI =1.06-2.01), diabetes mellitus (DM) (AOR 1.37; 95% CI =1.02-2.1 3), obesity (AOR 1.34; 95% CI =0.95-1.84), high parity (AOR 1.27; 95% CI = 1.03-1.88), hypertension (AOR 1.19; 95% CI = 0.92-2.11) and gestational age of < 37 wks (AOR 1.12; 95% CI = 0.94-1.66). The mortality rate due to SSI was 1.33%.

CONCLUSIONS

The obtained incidence of SSI post CS in our study is relatively lower than other previous studies from developing countries. The development of SSI is associated with many factors rather than one factor. Management of SSI is maninly medical but surgical approach may be needed in some cases.

REGISTRATION

Local ethical committee (Registration number: MOBGYN0040).

Risk for and temporal trends in cesarean surgical complications

OBJECTIVE

It is possible that in the setting of increasing patient comorbidity and obesity, risk for surgical injury and need for reoperation is increasing. It is also possible that with differential uptake of evidence-based recommendations and increasing prevalence of risk factors such as obesity, risk for surgical site complications is increasing. The objective of this study was to evaluate trends in, risk factors for, and racial disparities related to cesarean complications.

METHODS

This repeated cross-sectional study evaluated cesarean deliveries in the 2002-2014 National Inpatient Sample for women age 15-54. The primary outcome was a cesarean surgical complication composite including (i) surgical injuries, (ii) reoperation, and (iii) surgical site complications. Surgical injuries, reoperation, and surgical site complications were additionally evaluated individually as outcomes. Univariable and multivariable log linear regression models including demographic, clinical, and hospital factors were performed to assess risk for outcomes with unadjusted and adjusted risk ratios (aRR) with 95% confidence intervals (CI) as measures of association. Temporal trends were estimated using average annual percentage change from a joinpoint regression model. A stratified analysis was performed restricted to non-Hispanic black women. Data was weighted to provide national estimates.

RESULTS

A total of 16.2 million estimated cesarean deliveries (3.2 million unweighted cesarean deliveries) from 2002 to 2014 were included in this analysis. The prevalence of the cesarean surgical complication composite was 1.14%, surgical site complications occurred in 0.60%, surgical injuries in 0.49%, and reoperations in 0.10%. Comparing the end of the study (2012-2014) to the beginning of the study (2002-2003), adjusted risk for the composite was similar (aRR 0.93, 95% CI 0.92, 0.95). In comparison, surgical site complication risk was lower at the end of the study (aRR 0.77, 95% CI 0.75, 0.79) while risks for surgical injury (aRR 1.18, 95% CI 1.15, 1.22) and reoperation (1.18, 95% CI 1.10, 1.26) were higher. Non-Hispanic black women were at increased risk for surgical site complications (aRR 1.83, 95% CI 1.80, 1.87) and reoperation (aRR 1.44, 95% CI 1.37, 1.51), but not surgical injury (aRR 0.99, 95% CI 0.97, 1.02). In analyses stratified for non-Hispanic black women, there was a reduction in risk for surgical site complications at the end of the study period compared to the beginning similar to the primary analysis (aRR 0.76, 95% 0.72, 0.81) with a modest decrease in overall risk for the composite outcome (aRR 0.85, 95% CI 0.81, 0.89).

CONCLUSION

A decrease in risk for surgical site complications was offset by slightly increased risk for surgical injury and reoperation in adjusted analyses. Among non-Hispanic black women, surgical site complication risk decreased proportionately with this group still at significantly higher overall risk.

Determinants of post cesarean section surgical site infection at public hospitals in Dire Dawa administration, Eastern Ethiopia: Case control study

INTRODUCTION

Post cesarean section surgical site infection increases both the duration of a patient's hospital stay and unplanned hospital costs. It can delays recovery, prolongs hospitalization, necessitates readmission, and adds to hospital bills and other morbidities as well as mortalities.

METHOD

Facility-based case-control study was conducted from 1st March to 20th April, 2019 among all the mother records enrolled from 1st January to 31st December, 2018 at Public hospitals in Dire Dawa administration. The records of the mothers' who had post-cesarean section surgical site infection (119) was extracted by a census and every three consecutive controls (357) for each case were collected by trained data collectors using a structured data extraction tool. Variables which had p-value <0.25 in bivariate analysis were considered as candidates for multivariable analysis. Statistical significance was declared at P-value ≤0.05 with adjusted odd ratio and 95% confidence interval in the multivariable logistic regression model.

RESULT

Age 20-34 years (AOR:5.4; 95%CI:2.35,12.7), age >35 years (AOR:8.9; 95%CI:1.8,43.9), ≥4 per vaginal examinations (AOR: 4.2; 95%CI:2.16,8.22), current history of Chorioamnionitis (AOR:5; 95%CI:1.05,23.9), previous history of cesarean section (AOR:6.2; 95%CI: 2.72,14.36), provision of antibiotics prophylaxis (AOR:3.2; 95%CI:1.81,5.62), perioperative HCT level <30% (AOR:6.9; 95%CI:3.45,14.1) and duration of rupture of membrane >12 hours (AOR:5.4; 95%CI:1.84,15.87) were the independent determinants of post-cesarean section surgical site infection.

CONCLUSION

Increased in age of the mother, higher number of per vaginal examination, having a history of chorioamnionitis, having previous history of cesarean section, not receiving antibiotics prophylaxis, lower perioperative hematocrit level and longer duration of rupture of membrane were statistically significant in multivariable analysis. Therefore; emphasis should be given for mothers who have higher age category, previous cesarean scar and history of choriamnionitis. In addition; provision of antibiotics should be comprehensive for all mothers undergoing cesarean section.

Stepwise implementation of vaginal cleansing and azithromycin at cesarean: a quality improvement study

OBJECTIVE

We aimed to decrease our surgical site infection (SSI) rate by 30% by sequential implementation of vaginal cleansing and azithromycin for women who underwent a cesarean delivery (CD) after having labored or experienced rupture of membranes.

METHODS

This is a quality improvement project that assessed the stepwise implementation of two interventions within three time periods: (1) 12 months prior to implementation of either intervention; (2) 14 months of vaginal cleansing as infection prophylaxis; (3) 16 months of vaginal cleansing and azithromycin as infection prophylaxis. The primary outcome measure was the SSI as defined by the Center for Disease Control and Prevention and analyzed by control charts. The process measures were compliance rates of vaginal cleansing and azithromycin. Significance was detected by rules for determining a special cause variation. This study followed the SQUIRE 2.0 guidelines for reporting on quality improvement.

RESULTS

There were 1033 patients included from the three study periods. The total rate of SSI decreased from 22.8% to 15.2% after implementing vaginal cleansing. Special cause variation was detected with an 8-point shift starting 4 months after implementation of vaginal cleansing. This decrease was sustained during the following 26 months. Adding azithromycin did not significantly lower the SSI rate further. When examined separately, deep SSI (p = .009) and endometritis (p = .001) significantly decreased in the post-intervention periods. Pre-operative vaginal cleansing compliance rose to 74%, and then further increased to 85% 1 year after implementation. Azithromycin compliance rose to 75%. Total length of postpartum stay decreased over the study periods from 3.5 ± 1.4 days to 3.2 ± 0.8 days (p = .001).

CONCLUSION

In this quality improvement study, implementation of vaginal cleansing decreased the SSI rate by 33%, from 22.8% to 15.2%. The addition of azithromycin did not result in any additional change in SSI rate.

Study of incidence and risk factors of surgical site infections in lower segment caesarean section cases of tertiary care hospital of north India

OBJECTIVES

To determine the incidence density, risk factors and common pathogens associated with surgical site infections (SSI) following lower segment caesarean section (LSCS) surgeries.

METHODS

In this Non-interventional prospective observational study, a total of 611 post caesarean emergency and elective cases were enrolled among the 1018 LSCS cases conducted for the period of May-August 2016. The demographic, risk factors and clinical data for appearance of signs and symptoms of SSI were recorded in a preformatted proforma. SSI's were classified as superficial, deep and organ space as per Centre for Disease Control (CDC), USA definitions. Pus specimens were processed and antimicrobial susceptibility results of the organisms were determined as standard microbiological techniques.

RESULTS

The SSI rate was found to be 10.3 per 100 surgeries in our study with superficial SSI (66.7%) being most common. Inappropriate pre-surgical antibiotic prophylaxis, anaemia, previous LSCS as indication of LSCS, intra-operative blood transfusion and comorbid illness like heart disease, hypothyroidism, chronic liver and kidney disease were found to be significantly associated with SSI. Predominance of gram negative isolates (55.3%) was seen in comparison to gram positive isolates (44.7%) as cause of surgical site infections.

CONCLUSIONS

SSIs rates observed are much higher than those observed in NHSN participating hospitals. Many of the risk factors identified are low hanging fruits and can be targeted to effectively reduce SSI rates.

Effectiveness of negative pressure wound therapy in the prevention of surgical wound complications in the cesarean section at-risk population: a parallel group randomised multicentre trial-the CYGNUS protocol

INTRODUCTION

Caesarean delivery is steadily becoming one of the more common surgical procedures in Australia with over 100 000 caesarean sections performed each year. Over the last 10 years in Australia, the caesarean section rate has increased from 28% in 2003 to 33% in 2013. On the international stage, the Australian caesarean delivery rates are higher than the average for the Organisation for Economic Co-operation and Development, Australia ranked as 8 out of 33 and is second to the USA. Postoperative surgical site infections (SSIs) and wound complications are the most common and costly event following a caesarean section. Globally, complication rates following a caesarean delivery vary from 4.9% to 9.8%. Complications such as infection and wound breakdown affect the postpartum mother's health and well-being, and contribute to healthcare costs for clinical management that often spans the acute, community and primary healthcare settings. Published level one studies using advanced wound dressings in the identified 'at-risk' population prior to surgery for prophylactic intervention are yet to be forthcoming.

METHODS AND ANALYSIS

A parallel group randomised control trial of 448 patients will be conducted across two metropolitan hospitals in Perth, Western Australia, which provide obstetric and midwifery services. We will recruit pregnant women in the last trimester, prior to their admission into the healthcare facility for delivery of their child. We will use a computer-generated block sequence to randomise the 448 participants to either the interventional (negative pressure wound therapy (NPWT) dressing, n=224) or comparator arm (non-NPWT dressing, n=224). The primary outcome measure is the occurrence of surgical wound dehiscence (SSWD) or SSI. The Centres for Disease Control reporting definition of either superficial or deep infection at 30 days will be used as the outcome measure definition. SWD will be classified as per the World Union of Wound Healing Societies grading system (grade I-IV). We will assess recruitment rate, and adherence to intervention and follow-up. We will assess the potential effectiveness of NPWT in the prevention of postpartum surgical wound complications at three time points during the study; postoperative days 5, 14 and 30, after which the participant will be closed out of the trial. We will use statistical methods to determine efficacy, and risk stratification will be conducted to determine the SWD risk profile of the participant. Follow-up at day 30 will assess superficial and deep infection, and wound dehiscence (grade I-IV) and the core outcome data set for wound complications. This study will collect health-related quality of life (European Quality of Life 5-Dimensions 5-Level Scale), mortality and late complications such as further surgery with a cost analysis conducted. The primary analysis will be by intention-to-treat. This clinical trial protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and the Consolidated Standards of Reporting Trials guidelines.

ETHICS AND DISSEMINATION

Ethics approval was obtained through St John of God Health Care (HREC1409), Western Australia Department of Health King Edward Memorial Hospital (HREC3111). Study findings will be published in peer-reviewed journals and presented at international conferences. We used the SPIRIT checklist when writing our study protocol.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12618002006224p).

Surgical site infection and associated factors among women underwent cesarean delivery in Debretabor General Hospital, Northwest Ethiopia: hospital based cross sectional study

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.

Intra-abdominal infection (IAI) following cesarean section: a retrospective study in a tertiary referral hospital in Egypt

BACKGROUND

The incidence of post cesarean intra-abdominal infection (IAI) and the independent risk factors associated with it were retrospectively studied at a tertiary referral hospital in Egypt.

METHODS

The study targeted the period between January 2014 and December 2017 (4 years) at Minia University Hospital for Obstetrics and Gynecology (a tertiary referral hospital), Minia Governorate, Egypt. All cases that developed IAI following cesarean section (CS) during the study period were included (408 cases, which served as the case group); in addition, 1300 cases that underwent CS during the study period and were not complicated by IAI or surgical site Infection (SSI) were randomly chosen from the records (control group). The records of cases and controls were compared and bivariate analysis and multivariate logistic regression were used to identify risk factors for IAI.

RESULTS

During the studied period, there were 35,500 deliveries in the hospital, and 14200 cases (40%) of these were by cesarean section, producing a rate of 40%. The incidence of IAI post CS was 2.87%, and the mortality rate was 1.2% (due to septicemia). The most identifiable risk factors for IAI were chorioamnionitis (AOR 9.54; 95% CI =6.15-16.2; p ≤ 0.001) and premature rupture of membranes (PROM) (AOR 7.54; 95% CI =5.69-10.24; p ≤ 0.001). Risk factors also included: prolonged duration of CS >  1 h (AOR 3.42; 95% CI =2.45-5.23; p = 0.005), no antenatal care (ANC) visits (AOR 3.14; 95% CI =2.14-4.26; p = 0.003), blood loss > 1000 ml (AOR 2.86; 95% CI =2.04-3.92; p = 0.011), emergency CS (AOR 2.24; 95% CI =1.78-3.29; p = 0.016), prolonged labor ≥24 h. (AOR 1.76; 95% CI =1.26-2.27; p = 0.034) and diabetes mellitus (AOR 1.68; 95% CI =1.11-2.39; p = 0.021).

CONCLUSIONS

The incidence of IAI post CS in our hospital was 2.87%. Identification of predictors and risk factors for IAI is an important preventive measure.

Infections complicating cesarean delivery

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.

Standardising intraoperative irrigation with 0.05% chlorhexidine gluconate in caesarean delivery to reduce surgical site infections: A single institution experience

Background

Surgical site infection is a significant cause of morbidity and mortality following caesarean delivery.

Objective

To determine whether standardising intraoperative irrigation with 0.05% chlorhexidine gluconate during caesarean delivery could decrease infection rates.

Methods

This was a process improvement project involving 742 women, 343 of whom received low-pressured 0.05% chlorhexidine gluconate irrigation during caesarean delivery over a one-year period. Infection rates were compared with a standard-of-care control group (399 women) undergoing caesarean delivery the preceding year.

Results

The treatment group infection rate met the study goal by achieving a lower infection rate than the control group, though this was not statistically significant. A significant interaction effect between irrigation with 0.05% chlorhexidine gluconate and antibiotic administration time existed, such that infection occurrence in the treatment group was not dependent on antibiotic timing, as opposed to the control group infection occurrence, which was dependent on antibiotic timing.

Conclusion

Intraoperative irrigation with 0.05% chlorhexidine gluconate during caesarean delivery did not statistically significantly reduce the rate of infections. It did render the impact of antibiotic administration timing irrelevant in prevention of surgical site infection. This suggests a role for 0.05% chlorhexidine gluconate irrigation in mitigating infection risk whether antibiotic prophylaxis timing is suboptimal or ideal.

Surgical site infection risk following cesarean deliveries covered by Medicaid or private insurance

Objective:

To compare risk of surgical site infection (SSI) following cesarean delivery between women covered by Medicaid and private health insurance.

Study design:

Retrospective cohort.

Study population:

Cesarean deliveries covered by Medicaid or private insurance and reported to the National Healthcare Safety Network (NHSN) and state inpatient discharge databases by hospitals in California (2011–2013).

Methods:

Deliveries reported to NHSN and state inpatient discharge databases were linked to identify SSIs in the 30 days following cesarean delivery, primary payer, and patient and procedure characteristics. Additional hospital-level characteristics were obtained from public databases. Relative risk of SSI by primary payer primary payer was assessed using multivariable logistic regression adjusting for patient, procedure, and hospital characteristics, accounting for facility-level clustering.

Results:

Of 291,757 cesarean deliveries included, 48% were covered by Medicaid. SSIs were detected following 1,055 deliveries covered by Medicaid (0.75%) and 955 deliveries covered by private insurance (0.63%) (unadjusted odds ratio, 1.2; 95% confidence interval [CI], 1.1–1.3; P < .0001). The adjusted odds of SSI following cesarean deliveries covered by Medicaid was 1.4 (95% CI, 1.2–1.6; P < .0001) times the odds of those covered by private insurance.

Conclusions:

In this, the largest and only multicenter study to investigate SSI risk following cesarean delivery by primary payer, Medicaid-insured women had a higher risk of infection than privately insured women. These findings suggest the need to evaluate and better characterize the quality of maternal healthcare for and needs of women covered by Medicaid to inform targeted infection prevention and policy.

Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity

We conducted an observational retrospective cohort study to evaluate the risk factors and the maternal morbidity associated with unintended extensions of the hysterotomy during caesarean delivery. We evaluated 2707 women who underwent low-transverse caesarean deliveries in 2011 at an academic, tertiary-care hospital. Hysterotomy extensions were identified through operative reports. Of the 2707 caesarean deliveries, 392 (14.5%) had an unintended hysterotomy extension. On the multivariable regression modelling, neonatal weight (OR 1.42; 95%CI 1.17-1.73), the arrest of labour [first-stage arrest (2.42; 1.73-3.38); second-stage arrest (5.54; 3.88-7.90)] and a non-reassuring foetal status (1.65; 1.20-2.25) were significantly associated with hysterotomy extensions. Hysterotomy extensions were significantly associated with an increased morbidity including an estimated blood loss >1200 millilitres (2.06; 1.41-3.02), a decline in postoperative haemoglobin ≥3.7 g/dL (2.07; 1.35-3.17), an evaluation for lower urinary tract injury (5.58; 3.17-9.81), and a longer operative time (8.11; 6.33-9.88). Based on these results, we conclude that unintended hysterotomy extensions significantly increase the maternal morbidity of caesarean deliveries. Impact statement What is already known on this subject? Maternal morbidity associated with caesarean delivery (CD) is significantly greater than that in vaginal delivery. Unintended extensions of the hysterotomy occur in approximately 4-8% of CDs and are more common after a prolonged second stage of labour. The morbidity associated with hysterotomy extensions has been incompletely evaluated. What do the results of this study add? We demonstrate a rate of hysterotomy extension in a general obstetric population of approximately 15%, which is higher than previously reported estimates, and represents a potential doubling of the rate of the unintended hysterotomy extensions in recent years. The most significant risk factor for a hysterotomy extension was a second-stage labour arrest with a fourfold increase in the frequency of extensions. A hysterotomy extension is a significant independent risk factor for an intraoperative haemorrhage, a drop in postoperative haemoglobin, an intraoperative evaluation for lower urinary tract injury, and longer CD operative times. What are the implications of these findings for clinical practice and/or further research? A second-stage arrest is a strong independent risk factor for a hysterotomy extension. Recent re-evaluations of the labour curve that extend the second stage of labour will likely increase the frequency of CDs performed after a prolonged second stage. In these scenarios, obstetricians should be prepared for an unintended hysterotomy extension and for the possibility of a longer procedure with the increased risks of blood loss and the need for evaluation of the lower urinary tract.

Caesarean Delivery Surgical Site Infection: What are Expected Rates and Potentially Modifiable Risk Factors?

OBJECTIVE

This study sought to determine baseline Caesarean delivery (CD) surgical site infection (SSI) rates in various patient subgroups and to identify potentially modifiable and non-modifiable risk factors for SSI.

METHODS

This is a secondary analysis of a multicentre CD registry. Women who underwent CD were divided into SSI versus no SSI. SSI was defined as an infection that occurred in the part of the body where the surgery took place, within 30 days of surgery. Clinical characteristics and potential risk factors were compared between groups.

RESULTS

Of 57 182 women, 3696 (6.5%) had SSI. SSI rates were higher in primary versus repeat CD (9.7% vs. 4.2%; P <0.001), and in CD after labour vs. no labour (9.5% vs. 3.8%; P <0.001). After adjustment for confounding factors, low transverse CD (adjusted OR [aOR] 0.7 [0.6-0.9]), CD performed between 7 pm and 7 am (aOR 0.9 [0.83-0.98]), primary CD (aOR 0.5 [0.5-0.6]), and intrapartum antibiotics (aOR 0.3 [0.1-0.4]) were associated with a decreased in the rate of SSI. Black race (aOR 1.9 [1.7-2.1]), tobacco use (aOR 1.4 [1.2-1.6]), increasing American Society of Anesthesiologists category (aOR 1.3 [1.1-1.6]), vertical skin incision (aOR 1.2 [1.1-1.3], emergency CD (aOR 1.3 [1.1-1.5]), and postpartum transfusion (aOR 2.7 [2.1-3.6]) were associated with an increase in the rate of SSI.

CONCLUSION

This study estimates the CD SSI rates in different subgroups and serves as a baseline for future trials designed to develop preventive guidelines and protocols.

Incidence and risk factors for surgical site infections in obstetric and gynecological surgeries from a teaching hospital in rural India

BACKGROUND

Surgical site infections (SSI) are one of the most common healthcare associated infections in the low-middle income countries. Data on incidence and risk factors for SSI following surgeries in general and Obstetric and Gynecological surgeries in particular are scare. This study set out to identify risk factors for SSI in patients undergoing Obstetric and Gynecological surgeries in an Indian rural hospital.

METHODS

Patients who underwent a surgical procedure between September 2010 to February 2013 in the 60-bedded ward of Obstetric and Gynecology department were included. Surveillance for SSI was based on the Centre for Disease Control (CDC) definition and methodology. Incidence and risk factors for SSI, including those for specific procedure, were calculated from data collected on daily ward rounds.

RESULTS

A total of 1173 patients underwent a surgical procedure during the study period. The incidence of SSI in the cohort was 7.84% (95% CI 6.30-9.38). Majority of SSI were superficial. Obstetric surgeries had a lower SSI incidence compared to gynecological surgeries (1.2% versus 10.3% respectively). The risk factors for SSI identified in the multivariate logistic regression model were age (OR 1.03), vaginal examination (OR 1.31); presence of vaginal discharge (OR 4.04); medical disease (OR 5.76); American Society of Anesthesia score greater than 3 (OR 12.8); concurrent surgical procedure (OR 3.26); each increase in hour of surgery, after the first hour, doubled the risk of SSI; inappropriate antibiotic prophylaxis increased the risk of SSI by nearly 5 times. Each day increase in stay in the hospital after the surgery increased the risk of contacting an SSI by 5%.

CONCLUSIONS

Incidence and risk factors from prospective SSI surveillance can be reported simultaneously for the Obstetric and Gynecological surgeries and can be part of routine practice in resource-constrained settings. The incidence of SSI was lower for Obstetric surgeries compared to Gynecological surgeries. Multiple risk factors identified in the present study can be helpful for SSI risk stratification in low-middle income countries.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

PURPOSE

To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution.

METHODS

This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3-6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0-9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05-1.09; p = .02), asthma (OR 1.9; 95%CI 1.1-3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1-3.2; p = .02) were associated with increased SSI.

CONCLUSIONS

Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

Incidence of surgical site infection following caesarean section: a systematic review and meta-analysis protocol

INTRODUCTION

Caesarean section (CS) rates have increased globally during the past three decades. Surgical site infection (SSI) following CS is a common cause of morbidity with reported rates of 3-15%. SSI represents a substantial burden to the health system including increased length of hospitalisation and costs of postdischarge care. The definition of SSI varies with the postoperative follow-up period among different health systems, resulting in differences in the reporting of SSI incidence. We propose to conduct the first systematic review and meta-analysis to determine the pooled estimate for the overall incidence of SSI following CS.

METHODS AND ANALYSIS

We will perform a comprehensive search to identify all potentially relevant published studies on the incidence of SSI following CS reported from 1992 in the English language. Electronic databases including PubMed, CINAHL, EMBASE and Scopus will be searched using a detailed search strategy. Following study selection, full-text paper retrieval, data extraction and synthesis, we will appraise study quality and risk of bias and assess heterogeneity. Incidence data will be combined where feasible in a meta-analysis using Stata software and fixed-effects or random-effects models as appropriate. This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required as this review will use published data. The review will evaluate the overall incidence of SSI following CS and will provide the first quantitative estimate of the magnitude of SSI. It will serve as a benchmark for future studies, identify research gaps and remaining challenges, and emphasise the need for appropriate prevention and control measures for SSI post-CS. A manuscript reporting the results of the systematic review and meta-analysis will be submitted to a peer-reviewed journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

CRD42015024426.