Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania

Preoperative anemia: impact on short- and long-term outcomes following curative-intent resection of gastroenteropancreatic neuroendocrine tumors

BACKGROUND

The effect of preoperative anemia on clinical outcomes of patients undergoing resection of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) has not been previously investigated. This study aimed to characterize how preoperative anemia affected short- and long-term outcomes of patients undergoing curative-intent resection of GEP-NETs.

METHODS

Patients who underwent curative-intent resection for GEP-NETs between January 1990 and December 2020 were identified from 8 major institutions. The last preoperative hemoglobin level was recorded; anemia was defined as <13.5 g/dL in males or <12.0 g/dL in females based on the guides of the American Society of Hematology. The effect of anemia on postoperative outcomes was assessed on uni- and multivariate analyses.

RESULTS

Among 1559 patients, the median age was 58 years (IQR, 48-66), and roughly one-half of the cohort was male (796 [51.1%]). Most patients had a pancreatic tumor (1040 [66.7%]), followed by small bowel (259 [16.6%]), duodenum (103 [6.6%]), stomach (66 [4.2%]), appendix (53 [3.4%]), and other locations (38 [2.6%]). The median preoperative hemoglobin level was 13.4 g/dL (IQR, 12.2-14.5). Overall, 101 (6.7%) and 119 (8.5%) patients received an intra- or postoperative packed red blood cell (pRBC) transfusion, respectively. A total of 972 patients (44.5%) experienced a postoperative complication. Although the overall incidence of complications was no different among patients who did (anemic: 48.7%) vs patients who did not (nonanemic: 47.3%) have anemia (P = .597), patients with preoperative anemia were more likely to develop a major (Clavien-Dindo grade ≥IIIa: 48.9% [anemic] vs 38.0% [nonanemic]; P = .006) and multiple (≥3 types of complications: 32.2% [anemic] vs 19.7% [anemic]; P < .001) complications. Of note, 1-, 3-, and 5-year overall survival (OS) rates were 96.7%, 90.5%, and 86.6%, respectively. On multivariable analysis, anemia (hazard ratio, 2.0; 95% CI, 1.2-3.2; P = .006) remained associated with worse OS; postoperative pRBC transfusion was associated with an OS (5-year OS: 75.0% vs 87.7%; P = .017) and recurrence-free survival (RFS; 5-year RFS: 66.9% vs 76.5%; P = .047).

CONCLUSION

Preoperative anemia was commonly identified in roughly 1 in 3 patients who underwent curative-intent resection for GEP-NETs. Preoperative anemia was strongly associated with a higher risk of postoperative morbidity and worse long-term outcomes.

Burden of Antimicrobial Resistance Among Women with Post-Partum Infections in Low-Middle Income Countries: A Systematic Review

BACKGROUND

Due to the rising incidence of multidrug-resistant (MDR) pathogens, especially in Low-Middle-Income Countries (LMIC), post-partum infections represent a significant treatment challenge.

METHODS

We performed a systematic review of the literature from January 2005 to February 2023 to quantify the frequency of maternal post-partum infections due to MDR pathogens in LMICs, focusing on methicillin-resistant Staphylococcus aureus (MRSA) and/or extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales.

SECONDARY OBJECTIVES

description of antimicrobials' prescriptions.

FINDINGS

We included 22 studies with 14,804 total bacterial isolates from 12 countries, mostly from WHO African-Region. Twelve papers described wound- and 10 puerperal-infections. Seven were high-quality articles. Seventeen studies reported data on MRSA, and 18 on ESBL-producing Enterobacterales. Among high-quality studies, MRSA ranged from 9.8% in Ghana to 91.2% in Uganda; ESBL-producing Enterobacterales ranged from 22.8% in Ukraine to 95.2% in Uganda. Nine articles, mostly on C-sections, described different protocols for antibiotic prophylaxis and/or post-partum treatment.

INTERPRETATION

We described a high burden of post-partum infections caused by MRSA and/or ESBL-producing Enterobacterales in LMICs, but only a few studies met quality standards. There is an urgent need for high-quality studies to better describe the real burden of antimicrobial resistance in low-resource settings and inform policies to contain the spread of multidrug-resistant organisms.

Prevalence, risk factors, and antimicrobial resistance of endemic healthcare-associated infections in Africa: a systematic review and meta-analysis

BACKGROUND

Healthcare-associated infections (HCAI) place a significant burden on healthcare systems globally. This systematic review and meta-analysis aimed to investigate the prevalence, risk factors, and aetiologic agents of endemic HCAI in Africa.

METHODS

MEDLINE/PubMed, CINAHL, and Global Health databases (EBSCOhost interface) were searched for studies published in English and French describing HCAI in Africa from 2010 to 2022. We extracted data on prevalence of HCAI, risk factors, aetiologic agents, and associated antimicrobial resistance patterns. We used random-effects models to estimate parameter values with 95% confidence intervals for risk factors associated with HCAI. This study was registered in PROSPERO (CRD42022374559) and followed PRISMA 2020 guidelines.

RESULTS

Of 2541 records screened, 92 were included, comprising data from 81,968 patients. Prevalence of HCAI varied between 1.6 and 90.2% with a median of 15% across studies. Heterogeneity (I2) varied from 93 to 99%. Contaminated wound (OR: 1.75, 95% CI: 1.31-2.19), long hospital stay (OR: 1.39, 95% CI: 0.92-1.80), urinary catheter (OR: 1.57, 95% CI: 0.35-2.78), intubation and ventilation (OR: 1.53, 95% CI: 0.85-2.22), vascular catheters (OR: 1.49, 95% CI: 0.52-2.45) were among risk factors associated with HCAI. Bacteria reported from included studies comprised 6463 isolates, with E. coli (18.3%, n = 1182), S. aureus (17.3%, n = 1118), Klebsiella spp. (17.2%, n = 1115), Pseudomonas spp. (10.3%, n = 671), and Acinetobacter spp. (6.8%, n = 438) being most common. Resistance to multiple antibiotics was common; 70.3% (IQR: 50-100) of Enterobacterales were 3rd -generation cephalosporin resistant, 70.5% (IQR: 58.8-80.3) of S. aureus were methicillin resistant and 55% (IQR: 27.3-81.3) Pseudomonas spp. were resistant to all agents tested.

CONCLUSIONS

HCAI is a greater problem in Africa than other regions, however, there remains a paucity of data to guide local action. There is a clear need to develop and validate sustainable HCAI definitions in Africa to support the implementation of routine HCAI surveillance and inform implementation of context appropriate infection prevention and control strategies.

Patterns and outcomes of health-care associated infections in the medical wards at Bugando medical centre: a longitudinal cohort study

BACKGROUND

The burden of healthcare associated infections (HCAIs) in low- and middle-income countries (LMICs) remains underestimated due to diagnostic complexity and lack of quality surveillance systems. We designed this study to determine clinical diagnosis, laboratory-confirmed, associated factors and risks of HCAIs.

METHODS

This hospital-based longitudinal cohort study was conducted between March and June 2022 among adults (≥ 18 years) admitted in medical wards at BMC in Mwanza, Tanzania. Patients who were negative for HCAIs by clinical evaluations and laboratory investigations during admission were enrolled and followed-up until discharge or death. Clinical samples were collected from patients with clinical diagnosis of HCAIs for conventional culture and antimicrobial sensitivity testing.

RESULTS

A total of 350 adult patients with a median [IQR] age of 54 [38-68] years were enrolled in the study. Males accounted for 54.6% (n = 191). The prevalence of clinically diagnosed HCAIs was 8.6% (30/350) of which 26.7% (8/30) had laboratory-confirmed HCAIs by a positive culture. Central-line-associated bloodstream infection (43.3%; 13/30) and catheter-associated urinary tract infection (36.7%; 11/30) were the most common HCAIs. Older age was the only factor associated with development of HCAIs [mean (± SD); [95%CI]: 58.9(± 12.5); [54.2-63.5] vs. 51.5(± 19.1); [49.4-53.6] years; p = 0.0391) and HCAIs increased the length of hospital stay [mean (± SD); [95%CI]: 13.8 (± 3.4); [12.5-15.1] vs. 4.5 (± 1.7); [4.3-4.7] days; p < 0.0001].

CONCLUSION

We observed a low prevalence of HCAIs among adult patients admitted to medical wards in our setting. Central-line-associated bloodstream infections and catheter-associated urinary tract infections are common HCAIs. Significantly, older patients are at higher risk of acquiring HCAIs as well as patients with HCAIs had long duration of hospital stays.

The effect of forced-air warming in the cesarean section on maternal hypothermia, shivering, and thermal comfort: A randomized controlled trial

This trial was carried out to investigate the effect of forced air warming in various body areas of women on hypothermia during cesarean delivery. The patients in the study groups (n = 76) were assigned to the full-body warming group, upper-extremity warming group, lower-extremity warming group, and control groups. The intervention groups received forced-air warming 30 min before the surgery and continued until 30 min after surgery. The incidence of hypothermia was significantly higher in the control group than in the other groups at the 60th minute of the operation (p < 0.01). The intervention and control groups showed significant differences in the frequency of shivering at the entrance to the PACU (p = 0.001). Thermal comfort scores have significant difference between the control group and all of the intervention groups (p<.001). It is said that the full-body forced-air warming technique prevents hypothermia, shivering, and thermal discomfort in women Cesarean Section (CS).

Incidence and outcomes of surgical site infection following emergency laparotomy during the COVID-19 pandemic in a low resource setting: A retrospective cohort

Introduction

Surgical site infection (SSI) is the commonest form of hospital acquired infection in sub-Saharan Africa, associated with increased morbidity and mortality. This study was aimed at determining the incidence and outcomes of surgical site infection following emergency laparotomy during the COVID -19 pandemic in a low resource setting.

Methods

This was a retrospective single Centre cohort of patients that had emergency laparotomy between July 2021-June 2022 (COVID period) and July 2018-June 2019 (pre-COVID period). Analysis was done using SPSS version 22 in which SSI rates were compared between the two periods using the chi squared test. Mortality, re-operation rates and length of hospital stay were also compared.

Results

Of the 453 patient files included in analysis, 244 (53.9%) were for the COVID period, while 209 (46.1%) were for the pre COVID period. The incidence of SSI was insignificantly higher in the COVID period (17.6% versus 16.7%; P = 0.901). Mortality was also insignificantly higher in the SSI group (3.8% versus 3.5%; P = 0.745). Presence of surgical site infection increased the risk for re-operation (P < 0.001) and prolonged hospital stay (P < 0.001).

Conclusion

Since the incidence and outcomes of surgical site infection appear not to have changed following the pandemic, the same measures that were previously used to prevent SSI could still be effective even during the pandemic if followed appropriately and combined with the COVID specific peri-operative care recommendations.

Characterisation of genes encoding for extended spectrum β-lactamase in Gram-negative bacteria causing healthcare-associated infections in Mwanza, Tanzania

Healthcare-associated infections (HCAIs) caused by extended spectrum β-lactamase-producing Gram-negative bacteria (ESBL-GNB) increase morbidity and mortality. This cross-sectional study characterised ESBL genes (bla _CTX-M, bla _TEM and bla _SHV) among 30 ceftriaxone-resistant GNB causing HCAIs between January 2022 and July 2022 by multiplex polymerase chain reaction assay at the zonal referral hospital in Mwanza, Tanzania. Twenty-five (83.3%) had at least one ESBL gene, of which 23/25 (92.0%) carried the bla _CTX-M gene. Seventy-two percent (18/25) of the GNB-ESBL isolates carried more than one ESBL gene, of which the majority (88.8%; n = 16/25) carried the bla _CTX-M and bla _TEM genes. Extended spectrum β-lactamase genes, particularly bla _CTX-M, are common among ceftriaxone-resistant GNB causing HCAIs.

What this study adds

This study revealed the distribution of genes (bla _CTX-M, bla _TEM and bla _SHV) coding for ESBL production among ceftriaxone resistant GNB causing HCAIs However, all ESBL producing GNB were susceptible towards ceftriaxone-sulbactam indicating that ceftriaxone-sulbactam may be empirically prescribed for treating patients with HCAIs.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial

Background

The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings.

Objective

This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district.

Methods

A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care.

Results

The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively).

Conclusions

Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy.

Trial Registration

ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399

Telemedicine for Surgical Site Infection Diagnosis in Rural Rwanda: Concordance and Accuracy of Image Reviews

BACKGROUND

In rural Africa where access to medical personnel is limited, telemedicine can be leveraged to empower community health workers (CHWs) to support effective postpartum home-based care after cesarean section (c-section). As a first step toward telemedicine, we assessed the sensitivity, specificity, and interrater reliability of image-based diagnosis of surgical site infections (SSIs) among women delivering via c-section at a rural Rwandan Hospital.

METHODS

Women ≥18 years who underwent c-section from March to October 2017 at Kirehe District Hospital (KDH) were enrolled. On postoperative day 10 at KDH, participants underwent a physical examination by a general practitioner, who provided a diagnosis of SSI or no SSI. Trained CHWs photographed patients' incisions and the collected images were shown to six physicians, who upon review, assigned one of the following diagnoses to each image: definite SSI, suspected SSI, suspected no SSI, and definite no SSI, which were compared with the diagnoses based on physical exam. We report the sensitivity and specificity and assessed reviewer agreement using Gwet's AC1.

RESULTS

569 images were included, with 61 women (10.7%) diagnosed with an SSI. Of the 3414 image-reviews, 49 (1.4%) could not be assigned diagnoses due to image quality. The median sensitivity and specificity were 0.83 and 0.69, respectively. The Gwet's AC1 estimate for binary classification was 0.46.

CONCLUSIONS

We demonstrate decent accuracy but only moderate consistency for photograph-based SSI diagnosis. Strategies to improve overall agreement include providing clinical information to accompany photographs, providing a baseline photograph for comparison, and implementing photograph-taking processes aimed at improving image quality.

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.

Discharge instructions given to women following delivery by cesarean section in Sub-Saharan Africa: A scoping review

OBJECTIVE

A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA).

METHOD

Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system.

RESULTS

We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity.

CONCLUSION

Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

Predictors of Surgical Site Infections among Patients Undergoing Open Urological Surgery at a Tertiary Hospital, Tanzania: A Cross Sectional Study

BACKGROUND

Surgical Site Infection (SSI) is one of the major hospital acquired infections, highly associated with prolonged hospitalisation, morbidity and mortality. In open urological surgeries, little is known on magnitude and factors associated with development of SSI.

METHODS AND MATERIALS

The intervention was a cross-sectional prospective observational study performed between August 2015 and March 2016 at Muhimbili National hospital (MNH), Dar es Salaam, Tanzania. Patients who underwent open urological surgery at MNH during the study period and met inclusion criteria were consecutively enrolled, and followed up for 30 days. Patients' and operative characteristics were recorded using standard structured questionnaires. Wound/pus swabs were collected from patients with clinical evidence of SSI for bacteriological processing. Data analysis was performed using SPSS version 20.

RESULTS

Of 182 patients who underwent open urological surgery, 22% (40/182) developed SSI. Pre-operative urinary tract infection (aOR 9.73, 95%CI 3.93-24.09, p<.001) and contaminated wound class (aOR 24.997, 95%CI 2.58-242.42, p = .005) were independent predictors for development of SSI. Shaving within 30 hrs before surgical procedure was found to be protective for developing SSI (aOR 0.26, 95%CI 0.09-0.79, p=.02). Escherichia coli (20/40) was the most predominant pathogen in SSI followed by Klebsiella pneumoniae (7/40) and S. aureus (6/40). Gram-negative bacteria were highly resistant to ceftriaxone, gentamicin, amoxicillin-clavulanic acid and trimethoprimsulfamethoxazole.

CONCLUSION

Surgical Site Infection was high in open urological interventions. Pre-operative urinary tract infection and contaminated wound class predicted SSI. Bacteria causing SSI were highly resistant to commonly used antibiotics.

Post-cesarean section surgical site infection and associated factors in East Gojjam zone primary hospitals, Amhara region, North West Ethiopia, 2020

PURPOSE

Maternal surgical site infection after cesarean delivery is a clinical problem which contributes to significant morbidity and mortality. In Ethiopia admissions following cesarean section due to surgical site infection have been routine activities of health care institutions but there is limited scientific evidence on both the magnitude of the problem and factors associated with it making prevention mechanisms less effective. Therefore, this study aimed to assess magnitude and risk factors of post-cesarean section surgical site infection at primary hospitals of East Gojjam Zone, Northwest Ethiopia.

METHODS

Institution-based cross sectional study with retrospective chart review was conducted from September 10-30 /2020 at 3 randomly selected primary hospitals of east Gojjam zone. The data were entered in Epi data version 3.1 and exported to Statistical Package for Social Science Software version 26. Post-cesarean section surgical site infection was measured based on disease classification and definition of the term by Center for Disease Control and Prevention. After checking for presence of multicollinarity, presence and degree of association of factors with outcome variable were computed through logistic regression analysis. Factors with P value ≤ 0.2 in bi-variable logistic regression analysis were included in the multivariable logistic regression analysis and those variables with P-value of <0.05 in multivariable analysis were considered statistically significant.

RESULT

From 622 medical records of women who underwent cesarean section, 77 (12.4%) of them developed surgical site infection. Rural residence [(AOR = 2.30, 95%CI: (1.29, 4.09)], duration of labor greater than 24hrs [(AOR = 3.48, 95%CI: (1.49, 8.09)], rupture of membrane>12hrs[(AOR = 4.61,95%CI:(2.34,9.09)], hypertension[(AOR = 3.14,95%CI:(1.29,7.59)] and preoperative Hematocrit ≤30%[(AOR = 3.22,95%CI:(1.25,8.31)] were factors significantly associated with post-cesarean section surgical site infections.

CONCLUSION

Magnitude of post-cesarean section surgical site infection was a significant problem in primary hospitals. Minimizing prolonged labor; minimize early rupture of membrane, properly managing patients with comorbidities like hypertension, strengthen prophylaxis and treatment for anemia during antenatal care and raising awareness for rural residents can reduce the problem. Zonal police makers should give emphasis to reduce its burden.

Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention

INTRODUCTION

Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs).

METHODS

We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15.

RESULTS

The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions.

CONCLUSION

Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs.

Comparison of hand hygiene compliance self-assessment and microbiological hand contamination among healthcare workers in Mwanza region, Tanzania

Background

Compliance with hand hygiene (HH) practices remains a major challenge in preventing healthcare-associated infections (HCAI). Little is known whether self-reported HH compliance reflects the level of hand contamination microbiologically as a guide for specific infection prevention and control (IPC) measures.

Methods

A cross-sectional study was conducted between July and September 2019 involving 18 healthcare facilities (HCF) in Mwanza region, Tanzania. It assessed HH using astructured questionnaire and microbiological analysis of hand samples for culture (n=212), and the WHO Hand Hygiene Self-Assessment Framework (2010) (n=74).

Results

The overall median HH score (interquartile range) was 212.5 (190–245) and designated at basic level in the WHO framework. The scores progressively increased from basic level in health centres to intermediate level in a tertiary hospital. Self-reported HH compliance using the WHO recommended cut-off value of ≥81.0% was 10.8% (8/74). A total of 56 (26.4%) healthcare workers (HCWs) hands had bacterial contamination; 17.9% (n=38) by Gram negative bacteria (including coliforms, Acinetobacter spp and Pseudomonas aeruginosa), 8.0% (n=17) by meticillin-resistant Staphylococcus aureus (MRSA) and 0.5% (n=1) by both. Hand contamination was significantly higher in district hospitals (P-value=0.0437), and among HCWs residing in the rural areas (P-value=0.017).

Conclusion

The median HH score amongst HCF in Mwanza region was at basic level. A quarter of HCWs hands were contaminated by bacteria which mismatched self-reported HH. A need to incorporate HH microbiological paramaters to the WHO HH assessment tool is needed, and future IPC interventional measures should be tailored to the HCF tier and in rural areas.

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).

Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study

BACKGROUND

Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority.

OBJECTIVE

To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection.

METHODS

We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact.

RESULTS

Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs.

CONCLUSION

Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.

Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania's Lake Zone

BACKGROUND

Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality.

METHODS

We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method.

RESULTS

In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period.

CONCLUSIONS

Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.

Magnitude and factors associated with surgical site infection among mothers underwent cesarean delivery in Nekemte town public hospitals, western Ethiopia

Background

Surgical site infection (SSI) is a serious public health problem due to its impacts on maternal morbidity and mortality and it can have a significant effect on quality of life for the patient. However, little has been studied regarding the magnitude and factors associated with SSI among women underwent cesarean delivery (CD) in study area. Therefore, the aim of this study was to assess the magnitude and factors associated with SSI among women underwent cesarean delivery in Nekemte Town Public Hospitals 2020.

Methods

An institution based cross-sectional study was conducted from January 1/2018 to January 1/2020. A simple random sampling technique was employed to select 401 patient cards from all records women underwent CD from January 1/2018 to January 1/2020. Epidata version 3.2 was used for data entry, and STATA version 14 was used for analysis. A logistic regression model was used to determine the association of independent variables with the outcome variable and adjusted odds ratios (AOR) with 95% confidence interval was used to estimate the strength of the association.

Results

Three hundred eight two (382) cards of women were selected for analysis making a response rate of 95.2%. The mean (±SD) age of the mothers was 25.9 (±4.8) years. The prevalence of SSIs was 8.9% (95% CI: 6.03, 11.76). Age > 35 years (AOR = 5.03, 95% CI:1.69, 14.95), pregnancy-induced hypertension (AOR = 5.63, 95%CI:1.88, 16.79), prolonged labor (AOR = 4.12, 95% CI:1.01, 32.19), receiving general anesthesia (AOR = 3.96 95% CI:1.02, 15.29), and post-operative hemoglobin less than 11 g/dl (AOR = 4.51 95% CI:1.84, 11.07) were significantly associated with the occurrence of SSI after cesarean delivery.

Conclusions and recommendations

The magnitude of post CD SSI in this study was comparable with the sphere standards of CDC guidelines for SSI after CD. Concerned bodies should give due attention the proper utilization of partograph to prevent prolonged labor, and provision of iron folate to increase the hemoglobin level of pregnant mothers in all health institution. In addition, we would recommend the use of spinal anesthesia over general anesthesia.

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.

Whole Genome Sequencing and Antimicrobial Resistance of Staphylococcus aureus from Surgical Site Infections in Ghana

Staphylococcus aureus (S. aureus) is a common cause of surgical site infections (SSIs) globally. Data on the occurrence of methicillin-susceptible S. aureus (MSSA) as well as methicillin-resistant S. aureus (MRSA) among patients with surgical site infections (SSIs) in sub-Saharan African are scarce. We characterized S. aureus from SSIs in Ghana using molecular methods and antimicrobial susceptibility testing (AST). Wound swabs or aspirate samples were collected from subjects with SSIs. S. aureus was identified by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF-MS); AST was performed by Kirby-Bauer disk diffusion, and results were interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guideline. Detection of spa, mecA, and pvl genes was performed by polymerase chain reaction (PCR). Whole-genome sequencing (WGS) was done using the Illumina MiSeq platform. Samples were collected from 112 subjects, with 13 S. aureus isolates recovered. Of these, 92% were sensitive to co-trimoxazole, 77% to clindamycin, and 54% to erythromycin. Multi-drug resistance was detected in 5 (38%) isolates. The four mecA gene-positive MRSA isolates detected belonged to ST152 (n = 3) and ST5 (n = 1). In total, 62% of the isolates were positive for the Panton-Valentine leukocidin (pvl) toxin gene. This study reports, for the first time, a pvl-positive ST152-t355 MRSA clone from SSIs in Ghana. The occurrence of multi-drug-resistant S. aureus epidemic clones suggests that continuous surveillance is required to monitor the spread and resistance trends of S. aureus in hospital settings in the country.

Preoperative vaginal cleansing with chlorhexidine solution in preventing post-cesarean section infections in a low resource setting: A randomized controlled trial

INTRODUCTION

Infection is one of the most common causes of maternal morbidities and mortality and has been reported to be responsible for about 15% of maternal deaths. Any woman is at risk of infection during childbirth, but women undergoing cesarean section are at higher risk. Improvement in surgical procedures with asepsis and the use of antibiotics have helped reduce postoperative infectious morbidities. However, ascending infection from the lower to the upper genital tract is a common but often neglected source of infection. Cleaning the vagina with chlorhexidine antiseptic solution before cesarean section can be a cheap and affordable source of infection control. This study is aimed at evaluating the efficacy of preoperative vaginal cleansing using 1.0% chlorhexidine in the reduction of post-cesarean section infectious morbidities.

MATERIAL AND METHODS

This prospective randomized control trial was conducted among 322 pregnant women who underwent an emergency cesarean section at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AE-FUTHA). The women were randomized into two groups. The interventional group received vaginal cleansing with three standard gauzes soaked in 30 mL 1.0% chlorhexidine gluconate solution preoperatively in addition to surgical skin cleaning with chlorhexidine-alcohol. The women in the control group only had surgical skin cleaning with chlorhexidine-alcohol. All the women received pre- and postoperative antibiotics. The primary outcomes were endometritis and wound infections.

RESULTS

Infectious morbidity was significantly reduced from 36.8% in the control group to 12.0% in the intervention group (P = .001). Endometritis occurred significantly less frequently in the intervention group than the control group (respectively 6.6% compared with 27.6%: relative risk [RR] 0.29, 95% confidence interval [CI] 0.16-0.53; P < .05). Foul-smelling vaginal discharge was significantly more common in the control group than in the intervention group (11.8% vs 1.3%, respectively) but the CI was wide (RR 8.5, 95% CI 1.30-64.55; P < .001). Fever and wound infection were more common in the control group (5.9% vs 3.3% and 9.2% vs 5.3%) but the difference was not significant. The hospital stay was significantly shorter among the intervention group (5.54 ± 1.04 days compared with 6.01 ± 1.55 days, P < 0.05). The most common microbial isolate implicated in endocervical colonization was Staphylococcus aureus followed by Klebsiella species.

CONCLUSIONS

Vaginal cleansing with 1.0% chlorhexidine gluconate solution before emergency cesarean section appears to be effective in reducing rates of post-cesarean section infectious morbidity in the study area. We recommend its use among women undergoing cesarean section to help reduce the contribution of infections to a poor obstetrics outcome.

Surgical site infection and its association with rupture of membrane following cesarean section in Africa: a systematic review and meta-analysis of published studies

Introduction

Surgical site infection occurs within 30 days after a surgical procedure and involves the skin, subcutaneous tissue, and soft tissue. Surgical site infection following cesarean section is a common postoperative complication and is associated with maternal morbidity and mortality in resource-limited settings. Even though the proportion of surgical site infection and some risk factors were reported by kinds of literature, varying results were stated across studies. There is also limited knowledge on the association between postpartum surgical site infection and the rupture of membrane. Hence, this systematic review and meta-analysis was designed to estimate the pooled proportion of surgical site infection and its association with rupture of membrane following cesarean section in Africa.

Methods

Studies published from January 01, 2000 to January 30, 2020 were searched from MEDLINE via PubMed, Scopus, Medscape, Web-science and CINAHL databases to search relevant published articles. We also performed a manual search of reference lists of key articles to retrieve additional relevant articles. Initially, 559 records were identified and 15 studies included in the analysis. The statistical analysis was performed using STATA 11. Heterogeneity between-study was explored by forest plot and inconsistency index (I²). The publication bias was checked by a funnel plot and Egger’s test. Pooled estimates of proportion and odds ratio were calculated by a random-effects model with a 95% confidence interval (CI).

Results

The overall pooled proportion of surgical site infection following cesarean section was 10.21% (I² = 86.8, p < 0.000; 95% CI = 8.36, 12.06). The odds of developing surgical site infection among women who had the rupture of membrane before delivery were nearly 6 times higher than those who had not a rupture of the membrane (AOR = 5.65, 95% CI: 3.95–8.07).

Conclusions

The proportion of surgical site infections following the cesarean section is relatively high. Women who had rupture of the membrane before delivery were more likely to develop surgical site infections following the cesarean section. Due attention should be given to the provision of prophylactic antibiotics that can reduce surgical site infection after cesarean delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-020-00122-2.

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.

Incidence and predictors of surgical site infection following cesarean section in North-west Ethiopia: a prospective cohort study

BACKGROUND

Following delivery by caesarean section, surgical site infection is the most common infectious complication. Despite a large number of caesarean sections performed at Debre Markos Referral Hospital, there was no study documenting the incidence of surgical site infection after caesarean section. Therefore, this study aimed to estimate the incidence of surgical site infection following caesarean section at Debre-Markos Referral Hospital in Amhara region, North-west Ethiopia.

METHODS

A prospective cohort study was conducted among 520 pregnant women who had a caesarean section between March 28, 2019 and August 31, 2019. Preoperative, intraoperative, and postoperative data were collected using a standardized questionnaire. Data was entered using EpiData™ Entry Version 4.1 software and analyzed using R Version 3.6.1 software. A descriptive analysis was conducted using tables, interquartile ranges and median. The time to development of surgical site infection was estimated using Kaplan-Meier method. The Cox regression model for bivariable and multivariable analyses was done. Adjusted Hazard Ratio (AHR) with 95% Confidence Interval (CI) was reported to show the strength of association.

RESULT

The mean age of the study cohort was 27.4 ± 4.8 years. The overall cumulative incidence of surgical site infection was 25.4% with an incidence of 11.7 (95% CI:9.8,13.9) per 1000 person/days. Not able to read and write (AHR = 1.30,95% CI:1.19,2.11), no antenatal care (AHR = 2.16, 95%CI:1.05,4.53), previous history of CS (AHR = 1.21, 95% CI:1.11,2.31), HIV positive (AHR = 1.39, 95% CI:1.21,2.57), emergency procedure (AHR = 1.13, 95% CI:1.11,2.43), vertical type of incision (AHR = 2.60, 95% CI:1.05,6.44), rupture of membrane (AHR = 1.50, 95% CI:1.31,1.64), multiple vaginal examination (AHR = 1.88, 95% CI: 1.71, 3.20) were significant predictors of surgical site infection in this study.

CONCLUSION

This study concluded that the incidence of surgical site infection following caesarean section was relatively high compared to previous studies. Not able to read and write, have no ante natal care, previous history of caesarean section, HIV, emergency surgery, vertical type of incision, rupture of membranes before caesarean section, and multiple vaginal examinations were significant predictors of surgical site infection in this study. Therefore, intervention programs should focus on and address the identified factors to minimize and prevent the infection rate after caesarean section.

Communication practices of healthcare professionals when caring for overweight/obese pregnant women: A scoping review

OBJECTIVE

To synthesize existing research on communication practices between healthcare professionals and overweight and obese pregnant women.

METHODS

Following PRISMA guidance on conducting scoping reviews, we included original research addressing communication/counseling practices of healthcare professionals with overweight and/or obese pregnant women, published between 2008-2018, and available in English. Fourteen articles are included in this review.

RESULTS

Study findings were organized into three themes: (a) topics addressed during encounters, (b) providers' comfort/confidence, knowledge and methods in communicating with overweight/obese pregnant women, and (c) overweight/obese pregnant women's experiences in communicating with healthcare providers. The most prevalent topics addressed were gestational weight gain, physical activity, and nutrition. Healthcare professionals experience discomfort and are reluctant to address weight status with overweight/obese pregnant patients, use vague statements about weight gain and weight-related obstetric risks, and report low confidence when counseling obese pregnant women. Overweight/obese pregnant women perceive weight stigma when interacting with providers.

CONCLUSION

Weight-related counseling in obstetric care is suboptimal. Providers may benefit from training to more confidently and effectively counsel overweight and obese pregnant women about gestational weight gain, physical activity, and nutrition.

PRACTICE IMPLICATIONS

Patients perceive weight stigma in the obstetric setting, which may be prevented by effective, patient-centered communication.

Overview of risk factor and bacterial pattern in patient with surgical site infection after caesarean section in Ciptomangunkusumo Hospital from 2016 to 2018

Background

Caesarean section is one of the most commonly performed surgeries both in the hospital. The incidence of infections in cesarean section varies greatly around the world at 3–15%. SSI on is a multifactorial process that starts from the perioperative preparation, the patient, the type of surgery, the type of germ and other factors.

Aims

To determine the characteristics of patients, bacterial patterns, and risk factors for the incidence of SSI in Cipto Mangunkusumo National General Hospital in 2016–2018.

Method

This study was an observational study using a retrospective cohort method. The subject of this study were patients undergoing cesarean section in Cipto Mangunkusumo National General Hospital in 2016–2018 recruited using consecutive sampling method. Based on the data obtained, bivariate and multivariate analysis were conducted to determine the factors affecting post-caesarean SSI.

Results

A total of 2052 subjects were included in the study. There were 85 cases of surgical site infection (SSI) out of 2052 operations (4.14 %). A total of 85 SSI cases and 1967 control groups were included in the risk factor analysis. The most common bacteria found in surgical site infection culture were Staphylococcus aureus (16,5%), Klebsiella pneumoniae (12,9%), Escherichia coli (9,4%), Enterococcus faecalis (9,4%), and others (21,2%). Variables associated with SSI in this study is fetal distress (p=0,002; AOR = 2,265 CI 95 % 1,350–3,801) and BMI ≥30 kg/m² (p=0,028; AOR 1,824 CI 95% 1,066–3,121).

Conclusion

Factors influencing the incidence of SSI post cesarean section was fetal distress (p=0,002; AOR = 2,265 CI 95 % 1,350–3,801) and BMI ≥30 kg/m² (p=0,028; AOR 1,824 CI 95% 1,066–3,121).

Short versus Long-Term Antibiotic Prophylaxis in Cesarean Section: A Randomized Clinical Trial

Objective:

The objective of the present study was to compare the efficacy of intravenous (IV) 48 h course of cefuroxime/metronidazole with long-term course using 48 h cefuroxime/metronidazole plus 5 days oral regimen of cefuroxime and metronidazole for the prevention of post cesarean section wound infection.

Methods:

Two hundred and forty-eight women were randomized into two equal groups. Women in each arm of the study received IV cefuroxime 750 mg twelve hourly and IV metronidazole 400 mg eight hourly for 48 h. Those in the long-term arm received additional tablets of cefuroxime 500 mg twelve hourly and Tabs 400 mg of metronidazole eight hourly for 5 days. After the surgery, surgical site infections were evaluated. Length of hospital stay and the cost of antibiotics were also assessed.

Results:

The wound infection rate was not statistically significantly different between the 2 groups (1.3% vs. 3.3%, P = 0.136). The incidence of endometritis was 2.1%, with no statistically significant difference seen between the two groups (0.4% vs. 1.6%, P = 0.213). Escherichia coli was the most common isolate seen in 36.4% of infected wounds. The short arm group stayed for significantly shorter days in the hospital (2.9 ± 1.0 vs. 3.8 ± 1.1 days,P < 0.001), and the cost of antibiotics was also significantly less in the short arm group (P < 0.001). Organisms associated with nosocomial infections were seen only in the long arm that stayed in the hospital for longer days.

Conclusions:

Short-term prophylactic antibiotics are as effective as long-term prophylaxis and have other benefits such as shorter duration of hospital stay, reduced cost of antibiotics, and reduction of nosocomial infections.

Impact of hand hygiene intervention: a comparative study in health care facilities in Dodoma region, Tanzania using WHO methodology

Background

Compliance with guidelines on hand hygiene (HH) is pivotal to prevent and control health-care associated infections and contributes to mitigating antimicrobial resistance. A baseline assessment in Dodoma region, Tanzania in March 2018 showed inadequate HH levels across health care facilities. We evaluated the impact of training in HH as part of a water, sanitation and hygiene (WASH) interventions of “Maji kwa Afya ya Jamii” (MKAJI) project.

Methods

A comparative HH assessment was conducted in June 2019 involving health care facilities under MKAJI project (n = 87 from which 98 units were assessed) vs non-MKAJI facilities (n = 85 from which 99 units were assessed). Irrespective of MKAJI interventional status, baseline assessment in March 2018 were compared to re-assessment in June 2019 in all health care facility units (unpaired comparison: 261 vs 236 units, respectively), and in facilities assessed in both surveys (paired comparison: 191 versus 191 units, respectively). The ‘WHO HH Self-Assessment Framework Tool, 2010’ with five indicators each counting 100 points was used. The cumulative scores stratified each health facility’s unit into inadequate (0–125), basic (126–250), intermediate (251–375) or advanced (376–500) HH level (score). The HH compliance rates were also assessed and compared.

Results

The overall post-intervention median HH score [interquartile range (IQR)] was 187.5 (112.5–260). MKAJI health facilities had significantly higher median HH scores (IQR) [190 (120–262.5)] compared with non-MKAJI facilities [165 (95–230); p = 0.038]. Similarly, the HH compliance rate of ≥51% was significantly higher in MKAJI than non-MKAJI facilities [56.1% versus 30.3%; chi2 = 13.39, p < 0.001]. However, the recommended WHO compliance rate of ≥81% was only reached by 6.1 and 3.0% units of MKAJI and non-MKAJI facilities, respectively. Both paired and unpaired comparisons during baseline and re-assessment surveys showed increase in HH level from inadequate to basic level.

Conclusion

The overall HH level after the combined WASH and training intervention was at basic level. Higher median HH scores (IQR) and HH compliance rates were evident in health facilities of the MKAJI project, underscoring the impact of the intervention and the potential value of a national roll-out.

Implementing a combined infection prevention and control with antimicrobial stewardship joint program to prevent caesarean section surgical site infections and antimicrobial resistance: a Tanzanian tertiary hospital experience

Background

Surgical site infections are a leading cause of morbidity and mortality after caesarean section, especially in Low and Middle Income Countries. We hypothesized that a combined infection prevention and control with antimicrobial stewardship joint program would decrease the rate of post- caesarean section surgical site infections at the Obstetrics & Gynaecology Department of a Tanzanian tertiary hospital.

Methods

The intervention included: 1. formal and on-job trainings on infection prevention and control; 2. evidence-based education on antimicrobial resistance and good antimicrobial prescribing practice. A second survey was performed to determine the impact of the intervention. The primary outcome of the study was post-caesarean section surgical site infections prevalence and secondary outcome the determinant factors of surgical site infections before/after the intervention and overall. The microbiological characteristics and patterns of antimicrobial resistance were ascertained.

Results

Total 464 and 573 women were surveyed before and after the intervention, respectively. After the intervention, the antibiotic prophylaxis was administered to a significantly higher number of patients (98% vs 2%, p < 0.001), caesarean sections were performed by more qualified operators (40% vs 28%, p = 0.001), with higher rates of Pfannenstiel skin incisions (29% vs 18%, p < 0.001) and of absorbable continuous intradermic sutures (30% vs 19%, p < 0.001). The total number of post-caesarean section surgical site infections was 225 (48%) in the pre-intervention and 95 (17%) in the post intervention group (p < 0.001). A low prevalence of gram-positive isolates and of methicillin-resistant Staphylococus aureus was detected in the post-intervention survey.

Conclusions

Further researches are needed to better understand the potential of a hospital-based multidisciplinary approach to surgical site infections and antimicrobial resistance prevention in resource-constrained settings.

Incidence of Surgical Site Infection and Factors Associated among Cesarean Deliveries in Selected Government Hospitals in Addis Ababa, Ethiopia, 2019

Background

One-third to two-thirds of operated patients in low-income countries acquire surgical site infection, which is nine times higher when compared to high-resource countries. Identifying the incidence and risk factors that contribute to surgical site infection following cesarean delivery is a step ahead for preventing and reducing the problem. Nonetheless, the distribution of the problem in Addis Ababa, where the rate of cesarean delivery is relatively high compared to other parts of the country, is under investigation.

Objective

The aim of this study is to assess the incidence of surgical site infection among cesarean deliveries and factors associated with it in selected governmental hospitals found in Addis Ababa, Ethiopia, in 2019.

Method

A hospital-based prospective cohort study design was employed to follow 175 women, who gave birth by cesarean delivery in selected government hospitals in Addis Ababa, from March 11 to April 9, 2019. Convenience sampling method was used to select study units from the randomly selected hospitals. Descriptive statistics were run for determining the rate of cesarean delivery surgical site infection. Presence and degree of association between outcome and independent variables were computed through bivariate logistic regression analysis and factors that had p < 0.2 significance level in the bivariate logistic regression analysis were considered in the multivariable logistic regression analysis.

Result

From 166 participants who completed 30-day follow-up, 25 (15%) of the participants developed surgical site infection. Age, gestational age, duration of operation, and ≥5 vaginal examinations showed a significant association with the outcome variable with AOR (95% CI) of ((AOR = 1.504, 95% CI: (1.170 – 1.933, p < 0.2 significance level in the bivariate logistic regression analysis were considered in the multivariable logistic regression analysis. p < 0.2 significance level in the bivariate logistic regression analysis were considered in the multivariable logistic regression analysis. p < 0.2 significance level in the bivariate logistic regression analysis were considered in the multivariable logistic regression analysis. p < 0.2 significance level in the bivariate logistic regression analysis were considered in the multivariable logistic regression analysis. Conclusion and recommendation. Surgical site infection rate is higher and certain associations lost due to small sample size. Further interventional studies with vast sample size are recommended.

Ceftriaxone- and ceftazidime-resistant Klebsiella species, Escherichia coli, and methicillin-resistant Staphylococcus aureus dominate caesarean surgical site infections at Mulago Hospital, Kampala, Uganda

Objectives:

The aim of this study was to determine the proportion and mechanism of resistance to ceftriaxone and ceftazidime among Klebsiella species and Escherichia coli and examine the burden of methicillin-resistant Staphylococcus aureus from caesarean section surgical site infections in Uganda.

Methods:

Wound swabs from 109 caesarean section surgical site infections were cultured for pathogenic bacteria following standard microbiological procedures. The Kirby–Bauer disc diffusion technique was used for antimicrobial susceptibility testing. Methicillin-resistant S. aureus diagnosis was based on polymerase chain reaction testing for the mecA gene. Data were analysed using SPSS-IBM Statistics v.20.

Results:

A total of 118 pathogens were recovered from 93 (85%) of 109 surgical site infections swabs. Of the 118 pathogens, gram-negative bacteria were 69 (58.5%), including 44 (37.3%) Klebsiella species, 11 (9.3%) E. coli, 6 (5.1%) Citrobacter species, and 8 (6.8%) other gram-negative bacteria. In total, 49 of the 118 pathogens were gram-positive bacteria, including 34 (28.8%) S. aureus and 15 (12.7%) Enterococci species. Resistance to ceftriaxone was detected in all 11 (100%) of the E. coli and in 43 (97.7%) of the 44 Klebsiella species and to ceftazidime in all 11 (100%) of the E. coli and 40 (91%) of the 44 Klebsiella species. Extended-spectrum beta-lactamase explained resistance to ceftazidime in 10 (91%) of the 11 E. coli and 19 (48%) of the 40 Klebsiella species. Carbapenemase production explained 15 (38%) of the 40 ceftazidime-resistant Klebsiella species. Methicillin-resistant S. aureus was detected in 91% of S. aureus.

Conclusion:

Klebsiella species, E. coli, and S. aureus–majority methicillin-resistant S. aureus dominated the pathogens in caesarean section surgical site infections. Almost all of the E. coli and Klebsiella species were resistant to ceftriaxone or ceftazidime. Extended-spectrum beta-lactamase was the underlying resistance mechanism among almost all of the ceftriaxone- or ceftazidime-resistant E. coli. However, this mechanism accounted for less than half of ceftriaxone- or ceftazidime-resistant Klebsiella species, where carbapenemases accounted for 40% of the resistance, a finding previously unreported in Uganda.

Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs

Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

Effectiveness of a multicomponent safe surgery intervention on improving surgical quality in Tanzania's Lake Zone: protocol for a quasi-experimental study

INTRODUCTION

Effective, scalable strategies for improving surgical quality are urgently needed in low-income and middle-income countries; however, there is a dearth of evidence about what strategies are most effective. This study aims to evaluate the effectiveness of Safe Surgery 2020, a multicomponent intervention focused on strengthening five areas: leadership and teamwork, safe surgical and anaesthesia practices, sterilisation, data quality and infrastructure to improve surgical quality in Tanzania. We hypothesise that Safe Surgery 2020 will (1) increase adherence to surgical quality processes around safety, teamwork and communication and data quality in the short term and (2) reduce complications from surgical site infections, postoperative sepsis and maternal sepsis in the medium term.

METHODS AND ANALYSIS

Our design is a prospective, longitudinal, quasi-experimental study with 10 intervention and 10 control facilities in Tanzania's Lake Zone. Participants will be surgical providers, surgical patients and postnatal inpatients at study facilities. Trained Tanzanian medical data collectors will collect data over a 3-month preintervention and postintervention period. Adherence to safety as well as teamwork and communication processes will be measured through direct observation in the operating room. Surgical site infections, postoperative sepsis and maternal sepsis will be identified prospectively through daily surveillance and completeness of their patient files, retrospectively, through the chart review. We will use difference-in-differences to analyse the impact of the Safe Surgery 2020 intervention on surgical quality processes and complications. We will use interviews with leadership and surgical team members in intervention facilities to illuminate the factors that facilitate higher performance.

ETHICS AND DISSEMINATION

The study has received ethical approval from Harvard Medical School and Tanzania's National Institute for Medical Research. We will report results in peer-reviewed publications and conference presentations. If effective, the Safe Surgery 2020 intervention could be a promising approach to improve surgical quality in Tanzania's Lake Zone region and other similar contexts.

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.

The prevalence and root causes of surgical site infections in public versus private hospitals in Ethiopia: a retrospective observational cohort study

Background

Healthcare-associated illnesses, of which surgical site infection is the most common are significant causes of morbidity and mortality. Therefore, this study aimed to determine the prevalence and root causes of surgical site infections in public versus private hospitals in Ethiopia.

Methods

An institution based retrospective observational cohort study was conducted among patients who underwent surgical procedures at public and private health facilities from March 15 to April 15, 2018. Samples were selected by the simple random sampling technique, and data extracted from the patient’s medical chart, operation, and anesthesia notes. Data were entered using Epi info version 7 and analyzed using STATA 14. Binary logistic regression was fitted to identify factors associated with surgical site infections in private and public hospitals. Crude and adjusted odds ratios (OR) with a 95% confidence interval (CI) were computed to assess the strength of associations. Variables with a p-value less than 0.05 in the multivariable logistic regression model considered as significant predictors of surgical site infections.

Result

The overall prevalence of surgical site infections was 9.9% (95%CI: 7.8, 12.5). The prevalence of the infections was higher in procedures performed in public hospitals (13.4%) compared to private hospitals (6.5%). Rural residence (AOR = 0.13, 95%CI: 0.034 0.55), clean-contaminated and dirty wound (AOR = 12.81, 95%CI: 4.42 37.08) were significant predictors of the infections in private hospitals. Similarly, clean-contaminated and dirty wounds (AOR = 4.37, 95%CI: 1.88 10.14), length of hospital stay≥6 days (AOR = 2.86, 95%CI: 1.11 7.33), and surgical operation time of over 1 h (AOR = 15.24, 95%CI: 4.48 51.83) were such factors in public hospitals.

Conclusion

The prevalence of surgical site infections was high, and significant differences were also observed between public and private hospitals. Clean-contaminated and dirty wounds, prolonged operation, and length of hospital stay were predictors of surgical site infections among patients in public hospitals, whereas clean-contaminated wound and rural dwellings were predicted the infections among patients operated in the private hospital.

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.

The role of patients and healthcare workers Staphylococcus aureus nasal colonization in occurrence of surgical site infection among patients admitted in two centers in Tanzania

Background

Colonization with Staphylococcus aureus has been identified as a risk for subsequent occurrence of infection. This study investigated the relationship between S. aureus colonization of patients and healthcare workers (HCWs), and subsequent surgical site infections (SSI).

Methods

Between December 2014 and September 2015, a total of 930 patients and 143 HCWs were enrolled from the Bugando Medical Centre and Sekou Toure hospital in Mwanza, Tanzania. On admission and discharge nasal swabs, with an additional of wound swab for those who developed SSI were collected from patients whereas HCWs were swabbed once. Identification and antimicrobial susceptibility testing were done by VITEK-MS and VITEK-2, respectively. Detection of Panton Valentine leukocidin (PVL) and mecA genes was done by PCR. S. aureus isolates were further characterized by spa typing and Multi-Locus Sequence Typing (MLST).

Results

Among 930 patients screened for S. aureus on admission, 129 (13.9%) were positive of which 5.4% (7/129) were methicillin-resistant S. aureus (MRSA). Amongst 363 patients rescreened on discharge, 301 patients had been tested negative on admission of whom 29 (9.6%) turned positive after their hospital stay. Three (10.3%) of the 29 acquired S. aureus were MRSA. Inducible Clindamycin resistance occurred more often among acquired S. aureus isolates than among isolates from admission [34.5% (10/29) vs. 17.1% (22/129), P = 0.018]. S. aureus contributed to 21.1% (n = 12) of the 57 cases of investigated SSIs among 536 patients followed. Seven out of eight S. aureus carriage/infection pairs had the same spa and sequence types. The previously reported dominant PVL-positive ST88 MRSA strain with spa type t690 was detected in patients and HCW.

Conclusion

A significant proportion of patients acquired S. aureus during hospitalization. The finding of more than 90% of S. aureus SSI to be of endogenous source underscores the need of improving infection prevention and control measures including screening and decolonization of high risk patients.

[Parietal suppurations after cesarean section at the Yalgado Ouédraogo University Hospital, Burkina Faso: epidemiological clinical, therapeutic and prognostic aspects]

Les infections des sites opératoires sont fréquemment rencontrées dans les pays en développement. La césarienne étant l'une des interventions chirurgicales la plus pratiquée chez les femmes dans le monde, nous avons initié cette étude sur les aspects épidémiologiques, cliniques, thérapeutiques et pronostiques des suppurations pariétales post-césariennes dans le département de gynécologie-obstétrique du CHU Yalgado Ouédraogo en vue de réduire leur survenue. Il s'est agi d'une étude transversale à visée descriptive menée du 1^er avril 2015 au 30 septembre 2015 soit une période de 6 mois. Soixante-dix cas de suppurations pariétales ont été notés sur 1998 cas de césariennes soit une incidence de 3,5%. L'âge moyen des patientes était de 26,2 ans ± 6,1. Les patientes étaient majoritairement des femmes au foyer (77%). La césarienne a été réalisée en urgence chez toutes les patientes. La suppuration a été diagnostiquée surtout à la 1^èresemaine (60%). Le germe identifié était le staphylocoque aureus dans 37,8% des cas. Une reprise chirurgicale de la paroi abdominale a été nécessaire dans 34,3% des cas. L'évolution a été favorable chez toutes les patientes. La suppuration pariétale post césarienne reste fréquente. La prise en charge nécessite parfois une reprise chirurgicale. Une meilleure identification des facteurs favorisant cette affection par d'étude plus poussée pourrait permettre de réduire de façon significative leur incidence et par conséquent améliorer le pronostic maternel.

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%.

Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda

Background

There are few prospective studies of outcomes following surgery in rural district hospitals in sub-Saharan Africa. This study aimed to estimate the prevalence and predictors of surgical-site infection (SSI) following caesarean section at Kirehe District Hospital in rural Rwanda.

Methods

Adult women who underwent caesarean section between March and October 2017 were given a voucher to return to the hospital on postoperative day (POD) 10 (±3 days). At the visit, a physician evaluated the patient for an SSI. A multivariable logistic regression model was used to identify risk factors for SSI, built using backward stepwise selection.

Results

Of 729 women who had a caesarean section, 620 were eligible for follow-up, of whom 550 (88·7 per cent) returned for assessment. The prevalence of SSI on POD 10 was 10·9 per cent (60 women). In the multivariable analysis, the following factors were significantly associated with SSI: bodyweight more than 75 kg (odds ratio (OR) 5·98, 1·56 to 22·96; P = 0·009); spending more than €1·1 on travel to the health centre (OR 2·42, 1·31 to 4·49; P = 0·005); being a housewife compared with a farmer (OR 2·93, 1·08 to 7·97; P = 0·035); and skin preparation with a single antiseptic compared with a combination of two antiseptics (OR 4·42, 1·05 to 18·57; P = 0·043). Receiving either preoperative or postoperative antibiotics was not associated with SSI.

Conclusion

The prevalence of SSI after caesarean section is consistent with rates reported at tertiary facilities in sub-Saharan Africa. Combining antiseptic solutions for skin preparation could reduce the risk of SSI.

[Incidence and risk factors of surgical site infection following caesarean section in a Tunisian maternity unit]

INTRODUCTION

Surgical site infection (SSI) is a major health concern and is one of the most common complications following caesarean section, with an incidence of 3%-15%. With the worldwide increase in caesarean section rates, the incidence of SSI is expected to increase in parallel. This study was designed to estimate the incidence and determine the risk factors of SSI after caesarean section in an Obstetrics and Gynaecology department in the Kairouan region in Tunisia.

METHODS

A prospective cohort study of all patients who delivered by caesarean section between December 2015 and February 2016 was conducted in the Kairouan Obstetrics and Gynaecology department. The clinical status of these women was monitored during the 30-day postoperative period (in the outpatients department, emergency room or they were contacted by phone). A multivariate logistic regression model was used to identify risk factors.

RESULTS

Of the 714 patients admitted for caesarean delivery, 636 (89%) were monitored for 30 days. Thirty-two of these women were diagnosed with SSI, corresponding to an incidence of 5% (95% CI = 3.3%; 6.6%). 87.5% (n = 28) of SSI were superficial and 12.5% (n = 4) were complex (deep and organ/space). Multivariate logistic regression analysis identified the woman's age as a risk factor of SSI (RR = 1.07 for every year increment, 95% CI = 1.007; 1.17), whereas drainage was identified as a protective factor (RR = 0.16, 95% CI = 0.05; 0.48).

CONCLUSION

This study identified the incidence and risk factors of postoperative infection following caesarean section. Prevention of these infections should be a public health priority.

Risk factors for surgical site infection after cesarean delivery: A case-control study

BACKGROUND

The cesarean delivery (CD) rate is increasing worldwide. Surgical site infection (SSI) incidence is likely to follow an upward trajectory. We examined the incidence and risk factors for SSI after CD.

METHODS

A case-control study of women who had a lower-segment CD during the study period was performed at Ireland's Cork University Maternity Hospital. Cases were patients who presented to the hospital with SSI and who met the criteria of the U.S. Centers for Disease Control and Prevention. Controls were randomly selected from the discharge register of CDs at a ratio of 2:1. Data were extracted from the medical records. A multivariable stepwise logistic regression model approach was used, and the results were expressed as adjusted odds ratios (aORs).

RESULTS

The SSI rate was 2%. The greatest contribution to risk of SSI was associated with maternal obesity (aOR, 4.76; 95% confidence interval [CI], 2.00-11.32) and hypertensive disorders (aOR, 6.67; 95% CI, 1.54-28.99]. There was also an increased risk for women who underwent an emergency CD (aOR, 3.50; 95% CI, 1.09-11.30), for women who had ≥5 vaginal examinations (aOR, 3.24; 95% CI, 0.92-11.41), and for women without hypertensive disorders who delivered a baby weighing <3,500 g (aOR, 2.18; 95% CI, 1.08-4.37).

CONCLUSIONS

Obesity, hypertensive disorders, emergency CD, and multiple vaginal examinations were independent risk factors for SSI after CD.

Magnitude and determinants of surgical site infecion among women underwent cesarean section in Ayder comprehensive specialized hospital Mekelle City, Tigray region, Northern Ethiopia, 2016

Background

Surgical site infection (SSI) is an infection that occurs after surgery within 30 days in the part of the body where the surgery took place. Some of the common symptoms are: drainage of cloudy fluid from the surgical wound, pain or tenderness, localized swelling, redness, and raised body temperature. Lack of data on surgical site infection among women who underwent cesarean section (C/S) initiated us to undertake this paper which is targeted to assess the magnitude and determinants of SSI among women who underwent cesarean section.

Methods

Retrospective document review study design was conducted among mothers who underwent cesarean section in Ayder Comprehensive, Specialized Hospital (ACSH) from September 2014 –January 2016. Mother’s charts were selected using systematic random sampling technique. Data were cleaned using EPI info version 3.5.1 and analyzed using SPSS version 20. Descriptive statistics, Bivariate, and multivariable logistic regression were conducted to summarize the data.

Result

A total of 206 medical records of women who underwent C/S in ACSH comprehensive specialized hospital were reviewed. The mean age was 27 years (+ 5 year). The magnitude of surgical site infection was 11.7%. Premature rupture of membrane (PROM), prolonged labor, rural setting, human immune deficiency Virus, chorioaminities and blood loss showed significant association [(AOR = 8.818 95%CI (21.71–35.816)], [AOR = 16.17, 95%CI (2.850–91.819), [AOR = 5.666,95%CI (1.568–20.483)], [AOR = 6.982,95%CI (1.382–35.269), [AOR = 16.17,95%CI (2.850–91.819)] and [AOR = 0.097,9%CI (0.017–0.569)] respectively.

Conclusion

The magnitude of post C/S infection in this study 11.7%. PROM, prolonged labor, residence, HIV, Chorioaminities and blood loss are considered to be an independent risk factor.

Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time

OBJECTIVES

To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing.

DESIGN

Nationally representative, repeated cross-sectional surveys of women and health facilities.

SETTING

Tanzania.

PARTICIPANTS

Women of reproductive age and health facility staff.

MAIN OUTCOME MEASURES

Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment.

RESULTS

The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals).

CONCLUSIONS

Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania.

Magnitude and Determinant Factors of Surgical Site Infection in Suhul Hospital Tigrai, Northern Ethiopia: A Cross-Sectional Study

BACKGROUND

Surgical site infections (SSIs) are the most common hospital-acquired infection among surgical patients and remains a major clinical issue. In Ethiopia, despite many studies, the magnitude and associated factors of SSIs are not well documented and differ among regions. The aim of this study was to identify the magnitude and associated factors of SSIs in Suhul Hospital, Northern Ethiopia.

METHODS

An institution-based cross-sectional study was conducted from February 2-March 31, 2016, in Shire Suhul Hospital. A total of 280 post-operative patients were included and were selected using simple random sampling. A pre-tested interviewer administrated the questionnaire used to collect relevant information. Data were cleaned, entered, and analyzed using SPSS Version 20. Bivariable and multivariable logistic regression was employed to identify the predictors at p < 0.05.

RESULTS

Of the 281 potential study subjects, 280 participated. The mean age of the study subjects was 34.5 years (standard deviation [SD} ±15.6). The prevalence of SSI was 11.1% (95% confidence interval [CI] 7.34-14.67), and in the multivariable logistic regression analysis, four independent determinants emerged as associated with SSI: post-operative hospital stay from 8-14 days (odds ratio [OR] 7.97; 95% CI 1.70-37.38); history of alcohol use (OR 0.04; 95% CI 0.004-0.43); use of local anesthesia (OR 8; CI 1.010-63.398); and dirty incision classification (OR 17; CI 1.249-232.362).

CONCLUSION

The magnitude of SSI was high. A hospital stay for more than a week, a history of alcohol consumption, use of local anesthesia, and dirty incision classification were associated independently with a higher risk of SSI. Due attention should be given to infection prevention control methods; and more has to be done to manage dirty and contaminated sites, maintain a strict sterile environment and aseptic surgical techniques, and implement the World Health Organization surgical safety protocol. Efforts should be made to improve appropriate and timely discharge among surgical clients. Prospective longitudinal studies ought to be conducted considering SSI after hospital discharge.

Pattern of antibiotics use, incidence and predictors of surgical site infections in a Tertiary Care Teaching Hospital

Objective

Surgical site infections (SSIs) were the most common healthcare-associated infection mainly in developing countries. Inappropriate use of surgical antibiotic prophylaxis, in terms of antibiotic choice, timing, and duration, can lead to the selection of resistant microorganisms and high costs. The aim of this study was to investigate the pattern of antibiotic use, incidence and predictors of SSIs at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Results

From 131 patients, 55.7% were male study participants. Ninety (68.7%) patients received preoperative prophylaxis. Ceftriaxone was the most 76 (84.5%) prescribed agent for prophylaxis. Twenty-seven (20.6%) patients developed surgical site infection. Previous surgery AOR = 3.22 (95% CI [1.14–9.13]) and alcohol use AOR = 7.04 (95% CI [2.56–23.12, p = 0.000]) were independent predictors of SSIs in multivariate logistic regression analysis.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3643-8) contains supplementary material, which is available to authorized users.