Infections complicating cesarean delivery

Clinical Equivalence of Polyglycolic Acid Suture and Polyglactin 910 Suture for Subcutaneous Tissue Closure After Cesarean Delivery: A Single-Blind Randomized Study

Purpose

The global rise in frequency of cesarean delivery raises the concern to minimize the post-operative complications, in order to improve the maternal and neonatal health. Closure of subcutaneous tissue following cesarean section closes dead space, hence reduces the wound complications. No previous study has compared the clinical equivalence of polyglycolic acid suture with polyglactin 910 suture for subcutaneous tissue closure following cesarean section. Therefore, this study compared the incidence of subcutaneous abdominal wound disruptions within the first 6 weeks of subcutaneous tissue closure with either of the sutures.

Patients and Methods

A single-blind, prospective, randomized study was conducted in two centres between February and November, 2021. Primiparous or multiparous women (18-40 years) with a singleton pregnancy requiring cesarean section were randomized to polyglycolic acid suture (Truglyde^®) (n=54) and polyglactin 910 suture (Vicryl^®) (n=54) group. The primary endpoint, incidence of subcutaneous abdominal wound disruptions within 6 weeks of cesarean delivery was evaluated. In addition, the secondary endpoints, incidence of post-operative subcutaneous abdominal wound disruptions for the study period, skin disruption, surgical site infection (SSI), seroma, hematoma, intraoperative handling, operative time, hospital stay, suture removal, microbial deposits on sutures, pain, time taken to resume normal activities, and adverse events were recorded.

Results

Non-significant difference in the incidence of subcutaneous abdominal wound disruptions, skin disruption, SSI, seroma, hematoma, intraoperative handling characteristics, operative time, pain, duration of hospital stay, suture removal, microbial deposits, time taken to return to day-to-day activities, and adverse events were observed between the two treatment groups.

Conclusion

Following cesarean section, subcutaneous tissue closure using polyglycolic acid suture or polyglactin 910 suture was not associated with incidence of subcutaneous abdominal wound disruptions. Additionally, non-significant differences regarding secondary endpoints between the groups suggested the clinical equivalence of the sutures.

CTRI Registration Number

CTRI/2020/12/029737; Registration date: 11/12/2020.

Incidence and predictors of surgical site infection in women who are obese and give birth by elective caesarean section: A secondary analysis

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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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.

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

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

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

Immune Regulation, Maternal Infection, Vaccination, and Pregnancy Outcome

About 12.5% of all maternal deaths in the United States are due to infectious causes. This proportion, although stable during the past three decades, represents an increase in infectious causes of mortality, as the overall mortality rate in U.S. pregnant women had increased steadily during that same period. During healthy pregnancies, a delicate immunological balance-in which a mother's immune system tolerates the semi-allogeneic fetus yet maintains immune competency against infectious agents-is achieved and maintained. This immunological paradigm, however, results in increased susceptibility to infectious diseases during pregnancy, particularly in later stages and during the early postpartum period. The inflammatory process induced by these infectious insults, as well as some noninfectious insults, occurring during pregnancy can disrupt this carefully achieved balance and, in turn, lead to a state of rampant inflammation, immune activation, and dysregulation with deleterious health outcomes for the mother and fetus. Elucidating mechanisms contributing to the disruption of this immunologic homeostasis, and its disruption by infectious pathogens, might offer opportunities for interventions to reduce maternal and fetal morbidity and mortality.

Evaluation of Adjunctive Azithromycin Prophylaxis in Women Undergoing Cesarean Delivery in a Setting With Low Baseline Incidence of Surgical Site Infection

OBJECTIVE

The purpose of this quality improvement study was to determine the effect of adding azithromycin to standard antibiotic prophylaxis on the rates surgical site infection (SSI) in women undergoing both elective and non-elective cesarean deliveries at our centre.

METHODS

A before-and-after quality improvement study was conducted at the Regina General Hospital in Regina, Saskatchewan. Data collected from 989 women who had a caesarean delivery between June 1, 2016 and June 30, 2017 were compared with those from 1033 women who had a caesarean delivery between August 1, 2017 and July 31, 2018, after the introduction of adjunctive azithromycin prophylaxis. The primary outcome measure was the change in the incidence of SSI up to 30 days following surgery. Secondary outcome measures included timing of azithromycin prophylaxis and the number of women who did not receive azithromycin.

RESULTS

Surgical site infection rates decreased from 3.5% to 2.9% after adjunctive azithromycin prophylaxis was introduced. The absolute reduction in SSIs of 0.6% was not statistically significant (P = 0.42). There were no differences in SSI rates between the elective and non-elective subgroups.

CONCLUSION

Adding azithromycin to the standard antibiotic prophylaxis for cesarean delivery showed no statistically significant reduction in SSI rates in a population with low baseline rates of SSI.

A Risk-Stratified Peri-Operative Protocol for Reducing Surgical Site Infection after Cesarean Delivery

Background: Surgical site infections (SSI) are multifaceted. Pre-operative, intra-operative, and post-operative factors influence the risk of developing an infection. Our objective was to evaluate the effectiveness of an infection risk-stratification checklist, utilizing known SSI risk factors, and a tailored surgical protocol for SSI prevention in women undergoing cesarean delivery. Patients and Methods: A prospective project to reduce SSI was conducted for women undergoing cesarean delivery on the resident staff service at a midwestern, urban tertiary care hospital. Patients were categorized according to an SSI risk-stratification checklist as high risk or low risk. The low-risk group received the local standard of care (single prophylactic dose of pre-operative intravenous antibiotics and a standard pressure dressing). In the high-risk group, prophylactic antibiotic agents were given pre-operatively and continued for the first 24 hours post-operatively. Additionally, patients at high risk received an absorbent dressing (Mepilex Ag^®; Mölnlycke Health Care AB, Gothenburg, Sweden) that was applied in the operating room and worn for one week. Results: The overall rate of SSIs decreased from 6.1% (pre-study rate) to 1.4% after initiation of the protocol, a 77% reduction (p < 0.001). The low- and high-risk groups did not differ in infection rate (0% and 1.4%, respectively; p < 0.59). Both deep incisional and organ/space SSIs decreased after initiation of the protocol (91% and 62% decrease, respectively). Conclusion: Stratifying patients into high- and low-risk groups with tailored peri-operative management strategies reduced overall SSIs. The protocol incorporates known risk factors for SSI in a surgical procedure with high rates of SSI. This approach offers a structured method that can be adopted by other hospital systems for SSI prevention in patients undergoing cesarean delivery.

Periodontopathogenic microbiota, infectious mechanisms and preterm birth: analysis with structural equations (cohort-BRISA)

PURPOSE

The association between periodontopathogenic microbiota and preterm birth (PTB) has been overly studied. However, the biological mechanisms involved are little known. The objective is to evaluate the effect of periodontopathogenic bacteria burden (PBB), periodontal disease and other infections during pregnancy on preterm birth (PTB), through Structural Equation Modeling.

METHODS

This was a case-control study nested in a prospective cohort called BRISA, including 330 pregnant women, 110 cases and 220 controls. This study included the following variables: cytokines interleukin-10 (IL-10) and transforming growth factor beta (TGF-β), periodontal disease, PBB, age, socioeconomic status (SES), systemic infections and PTB. The correlations between variables were analyzed using Standardized Coefficient (SC).

RESULTS

Greater PBB interfered positively with the occurrence of periodontal disease (SC: 0.027; p: 0.011), but these were not associated with the cytokines studied, nor with PTB. The lower serum levels of IL-10 (SC - 0.330; p 0.022) and TGF-β (SC - 0.612; p  < 0.001), and the presence of other systemic infections during pregnancy (SC 0.159; 0.049) explained the higher occurrence of PTB.

CONCLUSION

It is possible that only the more severe periodontal disease and other systemic infections are capable of altering the cascade of cytokines regulating the inflammatory process and have an effect on the occurrence of PTB.

Reducing post-caesarean delivery surgical site infections: a narrative review

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.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.