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

The incidence of surgical site infection and its predictors among women delivered via cesarean sections in Ethiopia: a systematic review and meta-analysis

Background

Although surgical wound infection remains a serious issue worldwide, the disease burden is greater in developing countries, including Ethiopia. Even though there were primary studies conducted at district levels in Ethiopia, there is little evidence about the pooled incidence of surgical site infections at the national level. Thus, this systematic review and meta-analysis determined the pooled incidence of surgical site infection and its associated factors among cesarean-delivered women in Ethiopia.

Methods

We searched PubMed, CINAHL, African Journals Online, Google Scholar, and higher educational institutional repositories. A random-effects model was used to estimate the pooled effect size with 95% confidence intervals (CIs). Funnel plot and egger tests were computed to determine the existence of publication bias. A subgroup analysis was carried out.

Results

Twenty-three studies were included in the final analysis. The pooled incidence of surgical site infection among women delivered via cesarean section was 12.32% (95% CI: 8.96-16.11%). Rural residence (AOR = 2.51, 95% CI: 1.15-3.87), membrane rupture (AOR = 2.04, 95% CI: 1.24-2.85), chorioammionitis (AOR = 4.13, 95% CI: 1.45-6.8), general anesthesia (AOR = 1.99, 95% CI: 1.22-2.75), post-operative Hgb level less than 11 mg/dL (AOR = 3.25, 95% CI: 1.54-4.96) and membrane rupture greater or equal to 12 h (AOR = 3.93, 95% CI: 1.93-5.92) were independent risk factors for surgical site infections.

Conclusion

More than one in 10 women delivered via cesarean section developed surgical site infections in Ethiopia. Women living in rural areas and those with a membrane rupture, chorioammionitis, or anemia should be given special attention. General anesthesia should not be a mandatory procedure.

Medical-Grade Honey as a Potential New Therapy for Bacterial Vaginosis

The prevalence of bacterial vaginosis (BV) among women of reproductive age is 29%. BV arises from a vaginal imbalance marked by reduced levels of lactic acid-producing lactobacilli and an overgrowth of pathogenic anaerobes. The multifactorial nature of BV's pathogenesis complicates its treatment. Current antibiotic therapy exhibits a recurrence rate of about 60% within a year. Recurrence can be caused by antibiotic treatment failure (e.g., due to antimicrobial resistance), the persistence of residual infections (e.g., due to biofilm formation), and re-infection. Because of the high recurrence rates, alternative therapies are required. Medical-grade honey (MGH), known for its antimicrobial and wound healing properties in wound care, emerges as a potential novel therapy for BV. MGH exerts broad-spectrum antimicrobial activity, employing multiple mechanisms to eliminate the risk of resistance. For example, the low pH of MGH and the production of hydrogen peroxide benefit the microbiota and helps restore the natural vaginal balance. This is supported by in vitro studies demonstrating that MGH has an antibacterial effect on several pathogenic bacteria involved in the pathophysiology of BV, while lactobacilli and the vaginal microenvironment can be positively affected. In contrast to antibiotics, MGH exerts anti-biofilm activity, affects the microbiome as pre- and probiotic, and modulates the vaginal microenvironment through its anti-inflammatory, anti-oxidative, physicochemical, and immunomodulatory properties. More clinical research is required to confirm the positive effect of MGH on BV and to investigate the long-term cure rate.

Impact of prior use of topical hemostatic agents on trial of labor after cesarean: Insights from a multicenter cohort study

OBJECTIVE

To evaluate the association between a topical hemostatic agent used at the time of cesarean delivery and uterine scar disruption (rupture or dehiscence) at the subsequent trial of labor after cesarean (TOLAC).

METHODS

A multicenter retrospective cohort study was conducted (2005-2021). Parturients with a singleton pregnancy in whom a topical hemostatic agent was placed during the primary cesarean delivery were compared with patients in whom no such agent was placed. We assessed the uterine scar disruption rate after the subsequent TOLAC and the rate of adverse maternal outcomes. Univariate analyses were followed by multivariate analysis (adjusted odds ratio [aOR]; 95% confidence interval [CI]).

RESULTS

During the study period, 7199 women underwent a trial of labor and were eligible for the study; 430 (6.0%) had prior use of a hemostatic agent, 6769 (94.0%) did not. In univariate analysis, a history of topical hemostatic agent use was not found to be significantly associated with uterine scar rupture, dehiscence, or failed trial of labor. This was also confirmed on multivariate analysis for uterine rupture (aOR 1.91, 95% CI 0.66-5.54; P = 0.23), dehiscence of uterine scar (aOR 1.62, 95% CI 0.56-4.68; P = 0.37), and TOLAC failure (aOR 1.08, 95% CI 0.79-1.48; P = 0.61).

CONCLUSION

A history of hemostatic agent use is not associated with an increased risk for uterine scar disruption after subsequent TOLAC. Further prospective studies in other settings are needed to strengthen these findings.

Surgical site infection following cesarean section and its predictors in Ethiopia: A systematic review and meta-analysis

INTRODUCTION

Worldwide, surgery related deaths within 30 days of the procedure accounts the third contributor among all causes of deaths, with an estimated 4.2 million people annually and half of these deaths occur in low and middle income countries.

OBJECTIVE

To determine the pooled prevalence of surgical site infection following cesarean section and its predictors in Ethiopia.

METHODS

A systematic review and meta-analysis were conducted by using PRISMA guideline. An appropriate and comprehensive search of PubMed, MEDLINE, EMBASE, CINAHL, Google Scholar, HINARI and Scopus was done. This SRMA included all articles conducted in all regional state of Ethiopia reporting the prevalence/proportion/incidence of SSI after cesarean section and/or associated factors. All observational study designs were included in this SRMA. Articles which lack our outcome of interest: SSI following cesarean section and its predictors were excluded from this SRMA. The I2 statistic was used to quantify heterogeneity across studies. Funnel plot asymmetry and Egger's tests were used to check for publication bias. A random effect model was used to estimate the pooled prevalence of SSI. Adjusted Odds Ratio (OR) with 95% Confidence Interval (CI) was also considered to determine the association of identified variables with SSI. Statistical analysis was conducted using STATA version 17 software.

RESULT

Initially 6334 studies were identified and finally 19 studies were found eligible for the analysis. Studies with a score of 7 and above were included for the final systematic review and meta-analysis. The review was comprised of 14 cross sectional studies, 4 cohort and one case control studies. The pooled estimate of SSI in Ethiopia was 11.13% (95%CI, 9.29-12.97%). Prolonged labor (AOR = 3.16, 95% CI; (2.14-4.68)), chorioamnionitis (AOR = 4.26, 95% CI; (1.99-8.91)), prolonged PROM (AOR = 3.80, 95% CI; (2.51-5.62)), repeated vaginal examination (AOR = 3.80, 95% CI; (2.45-5.88)), decreased hemoglobin level (AOR = 4.57, 95%CI; (3.16-6.60)), vertical skin incision (AOR = 3.09, 95% CI; (2.04-4.67)) and general anesthesia (AOR = 1.82, 95% CI (1.21-2.75)) are significantly associated with SSI after cesarean section in Ethiopia.

CONCLUSION

SSI after cesarean section in Ethiopia is high. Prolonged labor, chorioamnionits, prolonged PROM, repeated vaginal examination, decreased Hgb level, vertical skin incision and general anesthesia were positively associated. Thus, evidence based intra-partum care should be practiced.

A comprehensive study on the risk factors and pathogen analysis of postoperative wound infections following caesarean section procedures

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.

Antimicrobial approach of abdominal post-surgical infections

Abdominal surgical site infections (SSIs) are infections that occur after abdominal surgery. They can be superficial, involving the skin tissue only, or more profound, involving deeper skin tissues including organs and implanted materials. Currently, SSIs are large global health problem with an incidence that varies significantly depending on the United Nations' Human Development Index. The purpose of this review is to provide a practical update on the latest available literature on SSIs, focusing on causative pathogens and treatment with an overview of the ongoing studies of new therapeutic strategies.

The Impact of Cefepime and Ampicillin/Sulbactam on Preventing Post-Cesarean Surgical Site Infections, Randomized Controlled Trail

Over the previous three decades, the rate of caesarean sections performed worldwide has grown exponentially. In comparison to a vaginal birth, the risk of all postpartum infections is higher with a cesarean section. One of the key factors contributing to maternal morbidity is the development of infectious complications in the surgical site after a caesarean section. The primary goal of the research was to compare the efficiency of using ampicillin/sulbactam (AMS) and cefepime (CEF) to reduce the incidence of surgical site infections (SSI) following caesarean delivery. This prospective randomized study was conducted among 200 pregnant women scheduled for elective cesarean section. They were collected from the Obstetrics and Gynecology department of Beni-Suef University Hospital, and then they were randomly assigned into two groups. Group (A) received cefepime 30 min before and 12 h after cesarean delivery, while group (B) received ampicillin/sulbactam 30 min before and 12 h after cesarean delivery. The groups were matched regarding the baseline women characteristics. Comparing the cefepime to the ampicillin/sulbactam revealed that the cefepime significantly decreased superficial SSI from 27% to 14% (0.023). A significant decrease was observed in deep SSI with cefepime compared to ampicillin/sulbactam from 24% to 13% (p-value 0.045). Interestingly, when the cefepime was compared to the ampicillin/sulbactam, we noted that the incidence of endometritis significantly decreased from 13% to 5% (p = 0.048). A noted decrease in post-operative fever in cefepime as compared to ampicillin/sulbactam from 18% to 13% (p-value = 0.329). Receiving prophylactic cefepime pre- and post-cesarean delivery significantly decreases post-operative wound infection and endometritis.

Sonographic Detection of Surgical Site Fluid Collections and Postoperative Maternal Morbidity Following Cesarean Section

INTRODUCTION

 Surgical site infection (SSI) is one of the most common complications after cesarean and causes much burden on the mother as well as the health care system. SSIs are defined as infections of a surgical site up to 30 days after surgery. Ultrasonography of the surgical site may be a helpful tool to detect its complication. With this background, the following study was planned to evaluate the clinical significance of sonographically detected fluid collections and post-operative maternal morbidity following cesarean section (CS) and identify risk factors associated with their formation.

METHODS

This prospective observational study was conducted at the Department of Obstetrics and Gynecology, Lala Lajpat Rai Memorial Medical College, Meerut. A total of 1000 women, who had undergone CS were included. Sonographic examination of the cesarean site was done on the 3^rd or 4^th postoperative day to look for any fluid collection in the parities or pelvis. All cases were followed on the 8^th postoperative day and finally on the 30^th postoperative day to look for any SSIs i.e. surgical wound problems like wound infection, induration, and discharge from a surgical wound, or even wound dehiscence and postoperative morbidity.  Results: Out of the total cases (1000), abdominal wound fluid collection was noted in 490 (49%) women after CS. Thirty-two patients were lost to follow-up, so 458 patients were followed, of which collection was septated or loculated in 62 (13.6%) and diffused in 396 (86.5%). Out of 62 loculated and 396 diffused cases, 21 (33.87%) and 20 (5.05%) cases reported surgical site abdominal wound infection and needed resuturing, respectively and it was found to be highly significant (p<0.001).

CONCLUSION

Post-operative fluid collections are common after CS. But it is the pattern of the fluid collection that determines post-operative wound infection and morbidity. Thus ultrasound of the cesarean site may be an important tool to detect surgical site wound complications earlier and to decrease postoperative morbidity.

Medical-Grade Honey Enhances the Healing of Caesarean Section Wounds and Is Similarly Effective to Antibiotics Combined with Povidone-Iodine in the Prevention of Infections-A Prospective Cohort Study

Caesarean sections (CS) are becoming increasingly popular. The antibiotic resistance crisis and relentless risk of infections, especially in developing countries, demand alternative treatment options. Medical-grade honey (MGH) exerts antimicrobial and healing properties. This study aims to evaluate the effect of MGH treatment on CS wound healing and postoperative complications when compared to conventional treatment (antibiotics in combination with povidone-iodine). In this prospective cohort study, 766 CS patients were included and evenly divided into two groups. The treatment group (n = 383) received an MGH-based formulation (L-Mesitran Soft) and the control group (n = 383) received antibiotics (Amoxicillin) combined with povidone-iodine. The wound healing time and complication rate were determined for both groups, and subsequently, predisposing factors for complications among the baseline characteristics and non-patient-related parameters were determined. The baseline characteristics were similar for both study groups, supporting a homogenous distribution. Postoperative complications were experienced by 19.3% of the patients in the control group and 18.8% in the treatment (MGH) group. The treatment group experienced significantly more superficial pus discharge than the control group, while the latter experienced significantly more deeper pus discharge. BMI, age, duration of hospitalization, anesthesia, and duration of CS could affect the complication risk. MGH significantly enhanced wound healing until day 42. On average, the healing time with MGH was 19.12 ± 7.760 days versus 24.54 ± 8.168 days in the control group. MGH is a potent alternative treatment to antibiotics and povidone-iodine because while the complication risk is similar, MGH has additional benefits. MGH promotes wound healing and does not bear the risk of resistance.