Reducing Surgical Site Infections Post-Caesarean Section

Background

Surgical Site Infections (SSI) are one of the most common complications after a caesarean with significant morbidity. Evidence suggests that SSI rates can be reduced post caesarean by using a Leukomed® Sorbact® (Essity) bacteria binding wound dressing, thereby reducing bacterial wound colonisation. Barking, Havering & Redbridge University Hospitals NHS Trust, London, UK (BHRUT) maternity unit sought change their clinical practice by using Leukomed Sorbact and evaluate if this reduced their SSI rate, SSI readmission rate, antibiotic usage and evaluate any associated cost savings.

Methods

From January 1st 2022, Mepore® (Molnlycke) wound dressings were replaced with Leukomed Sorbact for all caesareans. Retrospective and prospective audits were undertaken to compare SSI incidence pre- and post- implementation of the dressing. No changes were made to wound cleaning products, prophylactic antibiotic use or surgical technique. Wound closure technique remained the choice of the individual surgeon.

Results

Prior to this practice change, the baseline SSI rate between January-December 2021 was 6.1% and the SSI readmission rate was 1.27%. Comparative data for January-December 2022 showed a 38% reduction in SSI rates (overall SSI rate = 3.8%), a 31% reduction in readmission rate for SSI (overall rate = 0.88%), a 38% reduction in readmission bed days and a 30% reduction in antibiotic use. There was a reduction in SSI rates in all body mass index (BMI) categories. Total savings due to the reduction in SSI rates over twelve months were £234,784. The cost savings to BHRUT solely attributable to the reduction in readmissions was £49,750 or £21 per Caesarean, which will be an ongoing saving.

Conclusion

The use of Leukomed Sorbact dressings after Caesarean resulted in improved clinical outcomes with reduced SSI and readmission rates. Investment in the new dressing was cost effective when considering bed days freed, the reduction in antibiotic usage, reduced morbidity and improved patient experience.

Prevalence, Risk Factors and Microbial Profile of Surgical Site Infection after Cesarean Section in a Tertiary Care Center in Western India

Surgical site infection (SSI) was the predominant complication following cesarean delivery. Risk factors like increased Body Mass Index (BMI), emergency cesarean section (CS), prolonged hospital stay, previous CS, anemia, pre-existing chronic diseases, and failure to use preoperative antibiotic prophylaxis associated with SSI. Surgical site infections are responsible for cost burden, longer hospital stay increased maternal morbidity and mortality. Despite the advance, aseptic measures & control practice SSI was the most common nosocomial infection. To determine the prevalence, risk factors, bacterial profile, and antimicrobial resistance pattern of SSI in women following Cesarean section at tertiary care center western India. Women who developed SSI underwent cesarean delivery enrolled in the present study. Data were collected from patient records. Collection of swab samples, identification of microorganisms, and antimicrobial susceptibility testing was done by standard CLSI guidelines Results: Prevalence of SSI was 14.7% in this study. The risk factors significantly associated with SSI were emergency cesarean delivery, severe anemia, lack of preoperative antibiotics use, high Body Mass Index (BMI), preexisting disease, and previous history of CS, Klebsiella Pneumoniae & Staphylococcus aureus was the most predominant isolates. Imipenem was the most susceptible and Amoxycilline-Clavulanate was the most Resistance antibiotic. Prompt identification of risk factors, microbial agents, and susceptibility patterns of SSIs are beneficial for the selection of appropriate antimicrobial therapy to prevent the emergence of drug resistance, planning to make infection control & antibiotic policy, and taking appropriate steps to prevent risk factors.

What gets measured gets noticed. Tracking surgical site infection post caesarean section through community surveillance: A post intervention study protocol

AIM

This study aims to evaluate the effectiveness of HealthTracker, a surgical site infection surveillance system that aims to improve the notification of surgical site infection for women after giving birth by caesarean section.

DESIGN

This protocol is an intervention study to evaluate the effectiveness of the surveillance system called "HealthTracker" in monitoring surgical site infections post caesarean section.

METHODS

This study will use a mobile web application to automatically send a text message inviting all women who give birth to a live baby by caesarean section over six months during 2020-2021, at an Australian tertiary referral hospital. The text message invites women to complete a web-based validated Wound Healing Questionnaire. The estimated number of eligible women in six months is 700 (caesarean section rate: 34% of 4,000 births annually).

INTERVENTION

the proposed "HealthTracker" surveillance system facilitates active patient-reported surgical site infection identification through an automated mobile text message linking women to an individualized online Wound Healing Questionnaire.

DISCUSSION

This project aims to provide a consistent, reliable and cost effective surgical site infection surveillance tool to improve post caesarean section surgical site infection reporting, can be scaled for broader utilization and will provide valuable information to decision makers regarding surgical site infection prevention.

IMPACT

Study findings will provide insights into whether HealthTracker is an efficient and cost effective platform for a systematic and consistent approach to surgical site infection surveillance that can be adopted more broadly, across the local health organization, the State and across other surgical specialty areas. This information will equip hospitals and clinicians with knowledge to better identify patient outcomes related to SSI post discharge from hospital and inform decision making related to preventative strategies, providing the necessary momentum to introduce practice change initiatives aimed at reducing surgical site infection rates.

TRIAL REGISTRATION

ACTRN12620001233910.

Incidence and Risk Factors of Wound Infection in Women Who Underwent Cesarean Section in 2014 at King Abdulaziz Medical City, Jeddah

Introduction

Cesarean section (C/S) is considered one of the most commonly performed procedures among women. The maternal morbidity due to infection post-C/S reaches eight-fold higher than that of vaginal delivery. Our aim is to identify the incidence and risk factors of surgical site infection (SSI) among patients at King Abdul Aziz Medical City (KAMC), Jeddah, Saudi Arabia, in order to develop a strong strategy to reduce its occurrence.

Methods

This retrospective cohort study was conducted at KAMC, Jeddah. The study included a total of 387 women who underwent cesarean sections from January 2014 to December 2014. The data were collected consecutively by reviewing medical records of pregnant patients who underwent elective or emergency C/S. The risk factors studied included age, presence of underlying diseases, BMI, hemoglobin level, prophylactic antibiotics, pre-labor rupture of membrane, duration of induction of labor, type of C/S, type of uterine incision, duration of operation, type of anesthesia, estimated blood loss, type of organism, and the duration of hospital stay postoperatively. 

Results

The incidence rate of wound infections (WI) was 3.4% (13/387). The mean age score was 31.1±5.6 years, and the mean score of BMI was 32.7±6.2, where the majority were obese (255, 65.9%). More than half of the participants (205, 53.0%) had elective C/S, with mean hospitalization duration 2.5±1.3 days, and operation duration mean score 59.5±22.0 minutes. The majority (378, 97.7%) received antibiotics before the operation, where cefazolin was the main antibiotic (376, 97.2%). Only 38 (10%) cases had intra-operative complications, where the main complication was postpartum hemorrhage (18, 44.0%). The majority of WI were superficial (11 cases), the main organism was E. coli in four (36.4%) cases, followed by Staphylococcus aureus in three (27.3%) cases. There was a significant association between WI post-C/S and BMI, type of uterine incision, and induction of labor (P=006, P=0.003, respectively). 

Conclusions

This study showed that WI post-C/S is associated with high BMI, prolonged induction of labor, and Pfannenstiel incision. Reducing the rate of SSI will help to reduce its morbidity by identifying the risk factors pre-pregnancy and encouraging the implementation of preconception counseling clinics and antenatal classes to educate and increase awareness among patients.

Abdominal Cutaneous Thermography and Perfusion Mapping after Caesarean Section: A Scoping Review

Introduction: Caesarean section (CS) is the most prevalent surgical procedure in women. The incidence of surgical site infection (SSI) after CS remains high but recent observations of CS wounds using infrared thermography has shown promise for the technique in SSI prognosis. Although thermography is recognised as a 'surrogate' of skin perfusion, little is known of the relationship between skin temperature and skin perfusion in the context of wound healing. Aim: To assess the extent of literature regarding the application of infrared thermography and mapping of abdominal cutaneous perfusion after CS. Methods: Wide eligibility criteria were used to capture all relevant studies of any design, published in English, and addressing thermal imaging or skin perfusion mapping of the abdominal wall. The CINAHL and MEDLINE databases were searched, with two independent reviewers screening the title and abstracts of all identified citations, followed by full-text screening of relevant studies. Data extraction from included studies was undertaken using a pre-specified data extraction chart. Data were tabulated and synthesised in narrative format. Results: From 83 citations identified, 18 studies were considered relevant. With three additional studies identified from the reference lists, 21 studies were screened via full text. None of the studies reported thermal imaging and cutaneous perfusion patterns of the anterior abdominal wall. However, two observational studies partially met the inclusion criteria. The first explored analysis methodologies to 'interrogate' the abdominal thermal map. A specific thermal signature ('cold spots') was identified as an early 'flag' for SSI risk. A second study, by the same authors, focusing on obesity (a known risk factor for SSI after CS) showed that a 1 °C lower abdominal skin temperature led to a 3-fold odds of SSI. Conclusion: There is a significant gap in knowledge on how to forewarn of wound complications after CS. By utilising the known association between skin temperature and blood flow, thermographic assessment of the wound and adjacent thermal territories has potential as a non-invasive, independent, imaging option with which to identify tissue 'at risk'. By identifying skin 'hot' or 'cold' spots, commensurate with high or low blood flow regions, there is potential to shed light on the underlying mechanisms leading to infective and non-infective wound complications.

A randomised trial of caesarean wound coverage: exposed versus dressed

OBJECTIVE

To evaluate the superficial surgical site infection (SSI) rate to 28 days and patient satisfaction with wound coverage management when their transverse suprapubic caesarean wound is left exposed compared with dressed after skin closure.

DESIGN

Randomised trial.

SETTING

University Hospital, Malaysia: April 2016-October 2016.

POPULATION

331 women delivered by caesarean section.

METHOD

Participants were randomised to leaving their wound entirely exposed (n = 165) or dressed (n = 166) with a low adhesive dressing (next day removal).

MAIN OUTCOME MEASURES

Primary outcomes were superficial SSI rate (assessed by provider inspection up to hospital discharge and telephone questionnaires on days 14 and 28) and patient satisfaction with wound coverage management before hospital discharge.

RESULTS

The superficial SSI rates were 2/153 (1.3%) versus 5/157 (3.2%) (relative risk [RR] 0.4, 95% CI 0.1-2.1; P = 0.45) and patient satisfaction with wound management was 7 [5-8] versus 7 [5-8] (P = 0.81) in exposed compared with dressed study groups, respectively. In the wound-exposed patients, stated preference for wound exposure significantly increased from 35.5 to 57.5%, whereas in the wound-dressed patients, the stated preference for a dressed wound fell from 48.5 to 34.4% when assessed at recruitment (pre-randomisation) to day 28. There were no significant differences in inpatient additional dressing or gauze use for wound care, post-hospital discharge self-reported wound issues of infection, antibiotics, redness and inflammation, swollen, painful, and fluid leakage to day 28 across trial groups.

CONCLUSION

The trial is underpowered as SSI rates were lower than expected. Nevertheless, leaving caesarean wounds exposed does not appear to have detrimental effects, provided patient counselling to manage expectations is undertaken.

TWEETABLE ABSTRACT

An exposed compared with a dressed caesarean wound has a similar superficial surgical site infection rate, patient satisfaction and appearance.

The surgical wound in infrared: thermographic profiles and early stage test-accuracy to predict surgical site infection in obese women during the first 30 days after caesarean section

Background

Prophylactic antibiotics are commonly prescribed intra-operatively after caesarean section birth, often at high doses. Even so, wound infections are not uncommon and obesity increases the risk. Currently, no independent wound assessment technology is available to stratify women to low or high risk of surgical site infection (SSI).Study Aim: to investigate the potential of non-invasive infrared thermography (IRT), performed at short times after surgery, to predict later SSI.

Methods

IRT was undertaken in hospital on day 2 with community follow up (days 7, 15, 30) after surgery. Thermal maps of wound site and abdomen were accompanied by digital photographs, the latter used for wound assessment by six experienced healthcare professionals. Confirmatory diagnosis of SSI was made on the basis of antibiotic prescribing by the woman's community physician with logistic regression models derived to model dichotomous outcomes.

Results

Fifty-three women aged 21-44 years with BMI 30.1-43.9 Kg.m- 2 were recruited. SSI rate (within 30 days) was 28%. Inter-rater variability for 'professional' opinion of wound appearance showed poor levels of agreement. Two regions of interest were interrogated; wound site and abdomen. Wound site temperature was consistently elevated (1.5 °C) above abdominal temperature with similar values at days 2,7,15 in those who did and did not, develop SSI. Mean abdominal temperature was lower in women who subsequently developed SSI; significantly so at day 7. A unit (1 °C) reduction in abdominal temperature was associated with a 3-fold raised odds of infection. The difference between the sites (wound minus abdomen temperature) was significantly associated with odds of infection; with a 1 °C widening in temperature associated with an odds ratio for SSI of 2.25 (day 2) and 2.5 (day 7). Correct predictions for wound outcome using logistic regression models ranged from 70 to 79%.

Conclusions

IRT imaging of wound and abdomen in obese women undergoing c-section improves upon visual (subjective) wound assessment. The proportion of cases correctly classified using the wound-abdominal temperature differences holds promise for precision and performance of IRT as an independent SSI prognostic tool and future technology to aid decision making in antibiotic prescribing.