Caesarean Section Surgical Site Infections Research Articles

Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India.

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates. To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India. A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity. The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%). The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Evaluation of development of cesarean section scar niche in Patients with post cesarean section surgical site infection by 2 Dimension saline infusion sonohysterography:prospective study at Minia Maternity University Hospital

Evaluation of development of cesarean section scar niche in Patients with post cesarean section surgical site infection by 2 Dimension saline infusion sonohysterography:prospective study at Minia Maternity University Hospital

Implementation of enhanced recovery after cesarean section reduces surgical site infection

The cesarean section surgical site infection (SSI) rate for Barnes Jewish Hospital in 2019 rose to 2.2 infections per 100 procedures, the highest since achieving an average rate of 1.1 infections per 100. A multidisciplinary team was convened to create a cesarean section SSI bundle. Several studies demonstrated that implementing an Enhanced recovery after surgery, an evidenced-based protocol, could improve maternal outcomes and decrease SSI rates. This group implemented the Enhanced recovery after cesarean section with closure tray and glove change at the fascia closure to decrease the SSI rate.

The influence of home environment and wound care practice on surgical site infection among post cesarean section women in Dodoma- Tanzania

BackgroundPost caesarean section surgical site infections continue to be the problem of wound management that contribute to high maternal morbidity. This study assessed the prevalence of post caesarean section surgical site infections and the influence of home environment and wound care practices at home on surgical site infections among post cesarean section women in Dodoma region-Tanzania. MethodsThis was a hospital-based analytical cross-sectional study involved 183 randomly selected post caesarean section women during postnatal clinic visit within two weeks post discharge. Wound assessment and isolation of microbes were used to confirm the infection, while questionnaire was used to assess the wound care practices and characteristics of home environment. Logistic regression models were employed, and the level of significance was set at p ≤ 0.05. ResultsThe prevalence of post caesarean surgical site infections was 20.8 %, and the common isolated microbes were Staphylococcus aureus (52.6 %). Most isolates were sensitive to ciprofloxacin (81.5 %). Women with poor wound care practices had 6 times greater odds of developing surgical site infections (AOR = 5.95; p-value 0.004). The home environment condition did not influence the development of surgical site infections but it was related with good wound care practices. ConclusionThe post cesarean section surgical site infections rate after being discharged is high in Dodoma and it is directly influenced by the poor wound care practices and indirectly by the unconducive home environment. Efforts need to be directed to ensure women adhere to infection prevention measures when caring for their wound at home while taking into consideration their physical home environment they are living in.

Effectiveness of preoperative bath using chloroxylenol antiseptic soap on the incidence of post emergency cesarean section surgical site infection at Mbarara Regional Referral hospital, Uganda: a randomized controlled trial.

IntroductionSurgical Site Infections (SSIs) constitute 15%-45% of hospital acquired infections in sub-Saharan Africa. Cesarean section (CS) increases the risk of developing sepsis by 5-20 times and is highest when the operation is emergency. Therefore, the purpose of this study was to measure the effect of chloroxylenol in reducing the incidence of post cesarean SSIs at Mbarara Regional Referral Hospital (MRRH).Methodsa randomized controlled trial was conducted at MRRH maternity ward and mothers were randomized into either control or intervention arms. The intervention was a complete body bath with chloroxylenol antiseptic soap before the operation, while the control arm participants received a standard ward pre-operative preparation procedures. All participants were followed up for 30 days and assessed using an SSI screening tool.Resultsninety-six women were randomized, and 48 were assigned to each arm. The overall incidence of SSI was 30.21%. The incidence of SSI was significantly lower in the intervention compared to the control arm (6.25% in the intervention arm versus 54.17% in the control arm) (p-value <0.001). Chloroxylenol bath was protective of SSI with a 90% risk reduction for SSI (95% confidence interval of 67%–97%).Conclusiona preoperative bath with chloroxylenol for pregnant mothers is associated with a significantly lower risk of post cesarean section surgical site infections. Health facilities with a high burden of post SSI should consider adding this simple and effective intervention to the existing infection prevention measures. Clinical Trials.gov registration (NCT03544710).

A guide to caesarean wound healing

A guide to caesarean wound healing

Meconium Stained Amniotic Fluid and Risk of Post Cesarean Section Surgical Site Infection

Meconium Stained Amniotic Fluid and Risk of Post Cesarean Section Surgical Site Infection

Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: A hospital-based analytic cross-sectional study.

Cesarean section (CS) is often complicated by surgical site infection (SSI) that may happen to a woman within 30 days after the operation. This study was conducted to estimate the prevalence of SSI and identify the factors associated with SSI. A hospital-based analytic cross-sectional study was conducted based on the review of medical records of 1069 women who underwent CS in two public hospitals in Harar city. The post-CS SSI is defined when it occurred within 30 days after the CS procedure. Factors associated with SSI were identified using a multivariable binary logistic regression analysis. The analysis outputs are presented using an adjusted odds ratio (aOR) with a corresponding 95% confidence interval (CI). All statistical tests are defined as statistically significant at P-values<0.05. The prevalence of SSI was 12.3% (95% confidence interval (CI): 10.4, 14.4). Emergency-CS was conducted for 75.9% (95% CI: 73.2, 78.3) of the women and 13.2% (95% CI: 11.3, 15.4) had at least one co-morbid condition. On presentation, 21.7% (95% CI: 19.3, 24.3) of women had rupture of membrane (ROM). Factors significantly and positively associated with post-CS SSI include general anesthesia (aOR = 2.0, 95%CI: 1.10, 2.90), ROM (aOR = 2.27, 95%CI: 1.02, 3.52), hospital stay for over 7 days after operation (aOR = 3.57, 95%CI: 1.91, 5.21), and blood transfusion (aOR = 4.2, 95%CI: 2.35, 6.08). The prevalence of post-CS SSI was relatively high in the study settings. Screening for preoperative anemia and appropriate correction before surgery, selection of the type of anesthesia, close follow-up to avoid unnecessary prolonged hospitalization, and careful assessment of membrane status should be considered to avoid preventable SSI and maternal morbidity.

Factors Related To The Incidence of Cesarean Section Surgical Site Infection (CS SSI) At Harapan Jayakarta Hospital In 2019

Chi square test results showed that there was a relationship between age and the incidence of CS SSI (p = 0.011), there was no relationship between parity and the incidence of CS SSI (p = 0.237), there was a relationship between education and the incidence of CS SSI (p = 0,000), there was a relationship between BMI with the incidence of CS SSI (p = 0.006), there was a relationship between DM and the incidence of CS SSI (p = 0,000), there was a relationship between anemia with the incidence of CS SSI (p = 0,000), and there was a relationship between prophylaxis antibiotic and the incidence CS SSI (p = 0.01). There was a relationship between age, education, BMI, DM, anemia and prophylactic antibiotics with the incidence of CS SSI. There was no relationship between parity and CS SSI.

Determinants of post cesarean section surgical site infection at public hospitals in Dire Dawa administration, Eastern Ethiopia: Case control study.

IntroductionPost 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.MethodFacility-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.ResultAge 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.ConclusionIncreased 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.

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

This study aims to evaluate the effectiveness of HealthTracker, a surgical site infection surveillance system that aims to improve the notification of surgical site infection for women after giving birth by caesarean section. This protocol is an intervention study to evaluate the effectiveness of the surveillance system called "HealthTracker" in monitoring surgical site infections post caesarean section. This study will use a mobile web application to automatically send a text message inviting all women who give birth to a live baby by caesarean section over six months during 2020-2021, at an Australian tertiary referral hospital. The text message invites women to complete a web-based validated Wound Healing Questionnaire. The estimated number of eligible women in six months is 700 (caesarean section rate: 34% of 4,000 births annually). the proposed "HealthTracker" surveillance system facilitates active patient-reported surgical site infection identification through an automated mobile text message linking women to an individualized online Wound Healing Questionnaire. This project aims to provide a consistent, reliable and cost effective surgical site infection surveillance tool to improve post caesarean section surgical site infection reporting, can be scaled for broader utilization and will provide valuable information to decision makers regarding surgical site infection prevention. Study findings will provide insights into whether HealthTracker is an efficient and cost effective platform for a systematic and consistent approach to surgical site infection surveillance that can be adopted more broadly, across the local health organization, the State and across other surgical specialty areas. This information will equip hospitals and clinicians with knowledge to better identify patient outcomes related to SSI post discharge from hospital and inform decision making related to preventative strategies, providing the necessary momentum to introduce practice change initiatives aimed at reducing surgical site infection rates. ACTRN12620001233910.

A midwifery-led prevalence programme for caesarean section surgical site infections

Caesarean section (CS) is a common procedure accounting for 29% of all deliveries. Surgical site infections (SSI) are a risk with any surgical procedure. A CS SSI prevalence programme led by a midwife, who is also an infection prevention and control matron, was implemented to determine the rate of CS SSI within the trust. The initial CS SSI rate was 26% over a 3-month period (June-August 2012). Targeted interventions were put in place to reduce the CS SSI rate, and by 2019, it had decreased to 8%. Hospitals should consider implementing CS SSI surveillance and prevention programmes. Real benefits can be realized with minimal resources.

Risk Factors for Cesarean Section Surgical Site Infections: A Systematic Review

Background: According to the CDC NHSN, surgical site infections (SSI) are wound infections that develop within 30 days postoperatively for nonimplanted surgeries such as cesarean sections. SSIs is shown to manifest in a continuum of a purulent discharge from surgical site to severe sepsis. It contributes to rising morbidity, mortality and prolonged length of stay. Objective: To describe risk factors to the development of SSI in cesarean section in descriptive studies. Methods: The Preferred Reporting Items for Systematic Reviews (PRISMA) reporting guidelines is used as method for this systematic review. A PubMed literature search was conducted, limited to published articles in English from 1998 to 2016 using the broad key terms “cesarean section,” “surgical site infection,” and “risk factor.” The following inclusion criteria were applied to all reviews: (1) peer-reviewed journal, (2) computed risk factor for SSI development, and (3) calculated SSI rate. Reviews of references of the include studies were conducted, and 7 studies were appraised, with only 1 accepted. Results: After extracting data from 52 article reviews, 23 were finally accepted based on the inclusion criteria. Most studies were multivariate studies (n = 8) followed by cohort studies (n = 6). Unique numerators and denominators for SSI reviews were mentioned in all 23 studies, of which 22 studies followed the CDC NHSN definitions for SSI. Within the 23 studies, most studies showed that obesity (11.46%) is a common maternal risk factor for the development of postoperative cesarean section SSI. Conclusions: Identifying that obesity is a major contributor of surgical site infection in postoperative cesarean section women is a topic that warrants exploration. The relationship of cesarean section SSI to obesity should be investigated, specifically highlighting the level of obesity based on the WHO international body mass index (BMI) classification and the development of SSI. A correlation between increasing wound infection rates and increasing body mass index should be studied further. Published recommendations for preventing SSIs in this population should be reviewed.Funding: NoneDisclosures: None

Reducing Caesarean Section Surgical Site Infection (SSI) by 50%: A Collaborative Approach.

Caesarean section surgical site infection (SSI) is a surgical wound site infection occurring within 30 days of surgery with a reported incidence of 3-15%. This quality improvement (QI) project aimed to reduce caesarean section SSI by 50% in a tertiary maternity center. Using multidisciplinary team approach, the project was designed with evidence-based interventions. The Royal College of Physicians of Ireland/Royal College of Surgeons in Ireland "Preventing Surgical Site Infections Key Recommendations for Practice" guideline was used as standard perioperative care. A care bundle was designed targeting preoperative personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique, all measured using a patient survey. The rate of SSI was followed for 14 months. The Model for Improvement methodology was used to implement change. Surgical site infection rate decreased from 6.7% (n = 684 caesarean sections, n = 46 SSI) to 3.45% (n = 3,206 caesarean sections, n = 110 SSI), p = .0006. Reduction occurred in both elective (4.4%-2.7%) and emergency (9.1%-4.1%) caesarean section groups. There was excellent adherence to all three elements of the care bundle. The 50% reduction in caesarean section SSI was sustained over the 14-month period, significantly reducing maternal morbidity. The success of this QI project is attributable to frontline ownership and empowerment of patients and staff.

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

BackgroundSurgical 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.MethodsThe 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.ResultsTotal 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.ConclusionsFurther 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.

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.

Best Practice Operative Strategies and Surgical Techniques for Preventing Caesarean Section Surgical Site Infections: A Systematic Review of Reviews and Meta-Analyses

(BJOG. 2018;125:956–964) The risk of surgical site infection (SSI) following cesarean section has been estimated to be as high as 9%. This is a problem for both women and health service providers and may lead to pain, depression, persistent seroma, and delay returning to normal activities. Currently, available evidence for perioperative strategies and surgical techniques have been reported individually. One recent systematic review has already become outdated due to new evidence. This study aimed to identify a suite of perioperative strategies and surgical techniques to reduce SSI risk after cesarean section, while including guidance for decision-making clinicians.

Antibiotic Prescription Review Improves Cesarean Section Surgical Site Infection Surveillance

BACKGROUND Post cesarean section (CS) surgical site infections (SSI) surveillance may be challenging due to short postoperative hospital stays and time and resource intensive post discharge surveillance methods. At our obstetrical/gynecological facility, which is housed within a large pediatric hospital, surveillance was limited to inpatient readmissions and patients who presented to an urgent care center. Our purpose was to expand CS SSI surveillance to include outpatient clinics in our system by creating and implementing the use of a custom surveillance tool in October 2018. METHODS Reports of patients who underwent CS within the past 30?days were generated from the electronic data warehouse. Of these, patients who presented to our outpatient clinics and were prescribed antibiotics were considered. After chart review, two infectious diseases physicians further refined the list of antibiotics based on local prescribing patterns for wound infections. Patients queried through this tool received an additional full medical chart review by an infection preventionist to determine the possibility of SSI following CS. RESULTS After two months of implementation, 4 of 8 (50%) of CS SSI were identified through the use of this surveillance method. Compared to the previous year, enhanced surveillance resulted in a 1.7 fold increase in the CS SSI rate. CONCLUSIONS CS SSI surveillance using antibiotic prescription data in the outpatient setting is an efficient method to enhance traditional SSI surveillance. In our facility, implementation of this tool has improved the identification of CS SSI. Accurate case identification will aid in identifying trends and guide targeted interventions.

A Quality Improvement Study Project to Improve Post Cesarean Section Surgical Site Infection Surveillance in a District Hospital in Kigali City

Post-caesarean surgical site infection (PCSI) is one of the most common cesarean section-related complications. In low- and middle-income countries (LMIC), PCSI prevalence is often under-reported and inaccurate because LMIC surveillance systems are often unable to detect PCSIs developed after discharge; this can ultimately wrongly inform the decision-making related to reducing PCSIs.This paper describes the establishment of a post-discharge PCSI surveillance system for identification of PCSI rate in a district hospital in Rwanda.A total of 540 women underwent CS in the hospital from November 2017 to February 2018, and 536 (99.3%) consented to participate in the surveillance. Among those consented, 22 had no telephone and 174 could not be reached by telephone despite multiple attempts. At the end of this study, a total of 340 women completed the entire surveillance period. The total PCSI rate was 11.5%.Out of all PCSIs, 21% were detected during hospitalization period and 79% were detected during the post-discharge period.The PCSI surveillance system developed in this project covered the 30-day period after surgery and provided a more accurate estimate of PCSI rate. The system was able to track PCSIs developed after a patient was discharged from the hospital. Long term sustainability of the project must be evaluated.

Exploring an optimal risk adjustment model for public reporting of cesarean section surgical site infections.

Public report of surgical site infections (SSI) rates has been an important component of SSI reduction strategies, and risk adjustment is needed before SSI rates are publicly reported. Improving the risk adjustment model facilitates meaningful comparison in the public reporting of SSIs. This research aimed to explore an optimal risk adjustment model for the public reporting of cesarean section (CS) SSI. Information on 2506 cases of CS performed at T hospital, a tertiary general hospital located in the W City of H Province in China, from 01 January 2013 to 31 December 2014 was collected. The data were used to construct the multivariate risk adjustment models of CS SSI through logistic and Poisson stepwise regression. The c-index was used to compare the predictive power between the new logistic regression and the National Nosocomial Infections Surveillance (NNIS) risk index model. Pearson goodness-of-fit was determined to compare the goodness-of-fit between the new Poisson regression and the NNIS risk index model. The two new regression models were also compared. The logistic and Poisson regression models included two patient-related risk factors, namely, BMI (OR=1.085, P=0.006; RR=1.081, P=0.006) and ASA score (OR=1.522, P=0.044; RR=1.501, P=0.047). The c-index of the logistic regression model (0.628) was higher than that of the NNIS risk index model (0.600). The goodness-of-fit of the Poisson regression model (0.946) was better than that of the NNIS risk index model (0.851). The logistic and Poisson regression risk models are better than the NNIS risk index model, implying that a multifactorial risk adjustment model is needed for the public reporting of CS SSI. The advantage of logistic regression model is that the predictive power of model can be evaluated by c-index, however, Poisson regression may offer more advantages on model accuracy than logistic regression does when the infection rate decreases.