Incidence of postcesarean infections in relation to HIV status in a setting with limited resources

Risk Factors for Postcesarean Wound Infection in a Tertiary Hospital in Lagos, Nigeria

Background:

There has been a global increase in cesarean section rates. While this has improved perinatal outcome, it is associated with complications such as wound infection. We determined risk factors for cesarean section wound infection in a tertiary hospital in Lagos, Nigeria.

Materials and Methods:

We prospectively studied a cohort of 906 women who had cesarean section at the Obstetrics Unit of the Lagos State University Teaching Hospital between January 1, 2011, and December 31, 2011. A comparison was made between 176 women who had wound infection and 730 women who did not using logistic regression.

Results:

Of the 2134 deliveries during the study, 906 (42.5%) had cesarean section and of which 176 (19.4%) had wound infection. Independent risk factors for wound infection were: preoperative anemia (adjusted odds ratio [aOR] = 1.88; 95% confidence intervals [CI] = 1.03–3.41; P = 0.0396), presence of diabetes mellitus (aOR = 7.94; 95% CI = 1.60–39.27; P = 0.0111), HIV infection (aOR = 6.34; 95% CI = 1.74–23.06; P = 0.0051), prolonged operation time (aOR = 2.30; 95% CI = 1.19–4.42; P = 0.0127), excessive blood loss at surgery (aOR = 5.05; 95% CI = 2.18–11.66; P = 0.0002), and chorioamnionitis (aOR = 9.00; 95% CI = 1.37–59.32; P = 0.0224).

Conclusions:

Patients with HIV infection, diabetes mellitus, preoperative anemia and chorioamnionitis have an increased risk of postcesarean wound infection as is when surgical time exceeds 1 h or when associated with blood loss >11.

Burden of surgical site infection following cesarean section in sub-Saharan Africa: a narrative review

Cesarean section (CS) is the most common operative procedure performed in sub-Saharan Africa (SSA), accounting for as much as 80% of the surgical workload. In contrast to CSs performed in high-income countries, CSs performed in SSA are accompanied by high morbidity and mortality rates. This operation is the most important known variable associated with an increased probability of postpartum bacterial infection. The objective of this review was to assess surgical outcomes related to CS in SSA. PubMed (including Medline), CINAHL, Embase, and the World Health Organization’s Global Health Library were searched without date or language restrictions. A total of 26 studies reporting surgical site–infection rates after CS were identified, representing 14,063 women from 14 countries. The vast majority (76.7%) of CSs performed were emergency operations. The overall CS rate for women included in this review was 12.4% (range: 1.0%–41.9%). Only 17 of 26 total studies reported a significant proportion of women receiving antimicrobials of any kind. The surgical site–infection rate was 15.6% and the wound-infection rate 10.3%.

Risk factors for surgical site infection following cesarean section in a Brazilian Women's Hospital: a case-control study

The present study evaluated patients with diagnosis of surgical site infection (SSI) following cesarean section and their controls to determinate risk factors and impact of antibiotic prophylaxis on this condition.

Methods

All cesareans performed from January 2009 to December 2012 were evaluated for SSI, based on criteria established by CDC/NHSN. Control patients were determined after inclusion of case patients. Medical records of case and control patients were reviewed and compared regarding sociodemographic and clinical characteristics.

Results

Our study demonstrated an association following univariate analysis between post-cesarean SSI and number of internal vaginal examinations, time of membrane rupture, emergency cesarean and improper use of antibiotic prophylaxis. This same situation did not repeat itself in multivariate analysis with adjustment for risk factors, especially with regard to antibiotic prophylaxis, considering the emergency cesarean factor only.

Conclusion

The authors of the present study not only question surgical antimicrobial prophylaxis use based on data presented here and in literature, but suggest that the prophylaxis is perhaps indicated primarily in selected groups of patients undergoing cesarean section. Further research with greater number of patients and evaluated risk factors are fundamental for better understanding of the causes and evolution of surgical site infection after cesarean delivery.

HIV and maternal mortality

The majority of the 17 million women globally that are estimated to be infected with HIV live in Sub-Saharan Africa. Worldwide, HIV-related causes contributed to 19 000-56 000 maternal deaths in 2011 (6%-20% of maternal deaths). HIV-infected pregnant women have two to 10 times the risk of dying during pregnancy and the postpartum period compared with uninfected pregnant women. Many of these deaths can be prevented with the implementation of high-quality obstetric care, prevention and treatment of common co-infections, and treatment of HIV with ART. The paper summarizes what is known about HIV disease progression in pregnancy, specific causes of HIV-related maternal deaths, and the potential impact of treatment with antiretroviral therapy on maternal mortality. Recommendations are proposed for improving maternal health and decreasing maternal mortality among HIV-infected women based on existing evidence.

Postpartum Endometritis Leading to Decidual Abscess

Postpartum Endometritis (PPE) is one of the common causes of postpartum fever. PPE leading to decidual abscess has not been reported previously in the literature. Risk factors for PPE range from invasive fetal monitoring to maternal diabetes mellitus and anemia. Our patient had several risk factors for the development of PPE. Commonly PPE is a polymicrobial infection but in our case it was monobacterial. Ultrasonography, tissue histopathology and culture sensitivity are helpful in diagnosing PPE, as well as tailoring the antimicrobial therapy. PPE is a common etiology for postpartum fever and acute infection of decidua which may progress and lead to decidual abscess formation. Endometritis can be monobacterial from the genital tract organisms. Uterine curettage and endometrial tissue culture and sensitivity will guide in tailoring the antimicrobial therapy.

Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa

This paper draws on two reviews commissioned by the UK Department for International Development in 2006-2007 that explore progress in linking HIV prevention and maternity services in sub-Saharan Africa. Although pilot and demonstration projects have been successful, progress in scaling up PMTCT has been slow, reaching just 11% of pregnant HIV positive women in much of Africa, less than half the percentage of coverage achieved by antiretroviral treatment programmes for adults in need. Despite ongoing efforts to promote comprehensive approaches, significant policy, financing and institutional barriers, and weak co-ordination and leadership, continue to hamper progress. Maternal health services face human and financial resource shortages which affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account. However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programming that will have an impact on HIV, including certain maternity services. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternal and newborn care to address HIV.

Update: preventing mother-to-child transmission of HIV

The success of antiretroviral therapies for prevention of mother-to-child transmission of HIV in the developed world has prompted a wide array of research efforts, from improved implementation of voluntary counseling and testing programs to innovative approaches for short-course peripartum prophylaxis to understanding the dynamics of HIV transmission via breastfeeding. Clinical trials of modified short-course peripartum regimens which are applicable to resource-limited areas are demonstrating much lower transmission rates and preliminary data are emerging on limiting transmission via breastfeeding. Some of the most recent data on these topics are reviewed. Primary prevention of HIV in women of childbearing age combined with efforts to prevent mother-to-child transmission of HIV offer the best hope for addressing the burden of HIV in women and children.