Surgical site infections after cesarean delivery: epidemiology, prevention and treatment

Tetsuya Kawakita,Helain J. Landy

doi:10.1186/s40748-017-0051-3

Abstract

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system. SSIs complicate a significant number of patients who undergo CD – 2-7% will experience sound infections and 2-16% will develop endometritis. Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples. Implementation of surgical bundles in non-obstetric patients has been promising., Creating a similar patient care bundle comprised evidence-based elements in patients who undergo CD may decrease the incidence of this major complication. Each hospital has the opportunity to create its own CD surgical bundle to decrease surgical site infection.

Highlights

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries [1]
A metaanalysis of randomized controlled trials showed that the use of first generation cephalosporin compared with no antibiotics decreased the risks for development of wound infections (Relative Risk [RR] 0.38; 95% confidence interval [Confidence interval (CI)] 0.28, 0.53) and endometritis (RR 0.42; 95% CI 0.33, 0.54) [35]
In 2016, this same author reported that adding intravenous azithromycin 500 mg to standard preoperative antibiotic prophylaxis was associated with lower risks of endometritis (3.8% vs. 6.1%; RR 0.62; 95% CI 0.42, 0.92; P = .02) and wound infection (2.4% vs. 6.6%; RR 0.35; 95% CI 0.22, 0.56; P < .001) in women undergoing non-elective CD compared with placebo

Summary

Introduction

Cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries [1]. Rupture of mambranes (each hour) 1.02 maternal comorbidities (American Society of Anesthesiologists class of 3 or greater) [22], tobacco use in pregnancy [23], incision length > 16.6 cm [25], limited prenatal care (fewer than 7 visits) [26], body mass index >30 or 35 kg/m2 [22, 24, 25, 27,28,29] corticosteroid use [25], subcutaneous tissue thickness > 3 cm [30], prolonged second stage (compared with first stage) [31], teaching service [8], no antibiotic prophylaxis [26], pregestational diabetes [27, 29, 32], operating time ≥ 38 min [28], hypertensive disease/preeclampsia [22, 29], duration of labor >12 h [24], nulliparity [22], twin gestations [29], premature rupture of membranes [29], gestational diabetes [33], blood loss (increased for every increase in blood loss of 100 mL) [22], previous cesarean delivery [33], emergency delivery [29], and rupture of membranes (increased risk for every additional hour) [26].

Results

Conclusion