Cesarean Surgical Site Infection Research Articles

Impact of antimicrobial stewardship interventions on peripartum antibiotic prescribing in patients with penicillin allergy

Beta-lactam antibiotics (eg, penicillins, cephalosporins, and carbapenems) are preferred for group B streptococcus prophylaxis, intra-amniotic infection, and cesarean surgical site infection prophylaxis. Non-beta-lactam alternatives are associated with inferior efficacy and contribute to higher rates of surgical site infection and longer lengths of stay. Most patients who report a penicillin allergy can tolerate penicillins without any adverse reaction. There are low rates of cross-reactivity between penicillins and other beta-lactams, including cephalosporins and carbapenems. Efforts to evaluate penicillin allergy and promote the use of beta-lactams are needed. This study aimed to evaluate whether an antimicrobial stewardship intervention improved the use of first-line antibiotics for peripartum indications in patients with a reported penicillin allergy, following updates to institutional guidelines. This was a retrospective study of adult patients presenting for vaginal or cesarean delivery at 2 hospitals within a healthcare system. Patients received at least 1 dose of antibiotics for a peripartum indication between May 1, 2018, and October 31, 2018 (preintervention group) and May 1, 2020, to October 31, 2020 (postintervention group). The stewardship intervention bundle, which was implemented between March 2019 and April 2020, included updates to institutional antibiotic guidelines, reclassification of severe penicillin allergy, development of obstetrical prophylaxis and treatment order sets, promotion of allergy referral services, and establishment of a physician champion. The primary outcome was the composite rates of patients with reported penicillin allergy who received a preferred antibiotic for a peripartum indication. The secondary measures included maternal and neonatal outcomes. A total of 192 patients with a history of documented penicillin allergy were evaluated (96 patients in the preintervention group and 96 patients in the postintervention group). Hives were the most commonly reported index symptom in both groups (40/96 [41.7%] vs 39/96 [40.6%]; P=.883). After stewardship interventions, there was a significant increase in the rate of preferred antibiotic use (33/96 [34.3%] vs 81/96 [84.3%]; P<.001). The effect was the greatest in patients with nonsevere allergy (14/76 [18.4%] vs 68/82 [82.9%]; P<.001). There was no difference in the rates of postpartum endometritis, 30-day readmission, 90-day surgical site infection, or neonatal early-onset sepsis between the pre- and postintervention groups. Of note, 1 patient in the postintervention group experienced itching, and another patient developed a rash, both of which resolved with medical management. A comprehensive antibiotic stewardship intervention was associated with a 50% increase in the use of preferred antibiotics for peripartum indications in patients with penicillin allergy. Allergic reactions with first-line beta-lactams were minimal and manageable.

Evaluation of a cesarean surgical site infection (SSI) prevention protocol on SSI and neonatal hypoglycemia

Evaluation of a cesarean surgical site infection (SSI) prevention protocol on SSI and neonatal hypoglycemia

INCIDENCE AND RISK FACTORS OF SURGICAL SITE INFECTION FOLLOWING CESAREAN SECTION IN A TERTIARY CARE CENTRE IN NORTH KERALA, INDIA

Objectives: To objectives of the study were to study 1) the incidence and maternal determinants (host related) risk factors on post cesarean surgical site infection (SSI) and 2) the influence of labor related and procedure related risk factors on post cesarean SSI. Methods: This study was conducted in the Department of Obstetrics and Gynaecology, KMCT Medical College, Kozhikode from April 1 to August 31 2021 after clearance from ethical committee in which 153 cases of SSI post cesarean were included in the study. Results: Educational status of patients had statistically significant association with the development of SSI incidence of SSI (44.4%) and is highest among overweight women. Patients with diabetes and hypertension had increased risk of developing SSI. 72.2% with SSI had duration of ruptured membrane for &gt;8 h and duration of rupture of membrane were significantly associated with development of wound infection. Significant linear association was found between number of prior cesarean and risk of development of SSI (p=0.019). Cesarean with mean operative time &gt;45 min had statistically significant risk of developing SSI. Intraoperative complication like adhesions was a predictor of SSI (p=0.001) Conclusions: Medical morbidities and increased body mass index being predictors along with prolonged operative time can be properly identified and awareness ensured to prevent and identify post cesarean SSI.

Documented β-Lactam Allergy and Risk for Cesarean Surgical Site Infection.

Objective To examine the relationship between documented β-lactam allergy and cesarean delivery (CD) surgical site infection (SSI). Study Design. We conducted a retrospective cohort analysis of women who underwent CD at Ben Taub Hospital and Texas Children's Pavilion for Women (Houston, TX) from August 1, 2011, to December 31, 2019. The primary exposure was a documented β-lactam allergy, and the second exposure of interest was the type of perioperative antibiotic received. The primary outcome was the prevalence of SSI. Maternal characteristics were stratified by the presence or absence of a documented β-lactam allergy, and significance was evaluated using Pearson's chi-squared test for categorical variables and t-test for continuous variables. A logistic regression model estimated odds of SSI after adjusting for possible confounders. Results Of the 12,954 women included, 929 (7.2%) had a documented β-lactam allergy while 12,025 (92.8%) did not. Among the 929 women with a β-lactam allergy, 495 (53.3%) received non-β-lactam perioperative prophylaxis. SSI occurred in 38 (4.1%) of women who had a β-lactam allergy versus 238 (2.0%) who did not (p ≤ 0.001). β-Lactam allergy was associated with higher odds of SSI compared to no allergy (adjusted odds ratio (aOR) = 1.97; 95%confidence interval (CI) = 1.24-3.14; p = 0.004) after controlling for age, race, ethnicity, insurance status, delivery body mass index (BMI), tobacco use, intra-amniotic infection in labor, duration of membrane rupture, preterm delivery, delivery indication, diabetes, hypertension, group B Streptococcus colonization, and type of perioperative antibiotic received. Conclusion The presence of a β-lactam allergy is associated with increased odds of developing a CD SSI after controlling for possible confounders, including the type of perioperative antibiotic received.

Comparison of Cesarean Surgical Site Infection in Patients Treated with Cefazolin and Cefazolin-Azithromycin Regimes: A Quasi-experimental Study in a Developing Country

Background: Prophylactic antibiotics effectively reduce the incidence of infection associated with cesarean section after labor. The use of a first-generation cephalosporin for antibiotic prophylaxis has been suggested in these patients, but in some studies, increasing the spectrum of antibiotic prophylaxis by adding another antibiotic to standard cephalosporin may provide greater protection against post-cesarean wound infections. Objectives: The present study aimed to compare the effects of conventional prophylaxis with cefazolin with a combination of cefazolin and azithromycin in reducing wound infection. Methods: In this quasi-experimental study, 200 cesarean section candidates admitted to Ali Ibn Abi Taleb Hospital in Zahedan, Iran, in 2019 - 2020 were divided into two groups of 100 patients. The control group received cefazolin alone, and the intervention group received cefazolin and azithromycin. Finally, in addition to demographic factors, various underlying diseases, causes of cesarean section, non-infectious wound complications, and post-surgery wound infection were investigated. Results: The two groups were homogenized in terms of age and BMI of patients. Surgical wound infection occurred after cesarean section in 3% of patients in the control group. Only 1% of infections were observed in patients in the intervention group, and the two groups had a statistically significant difference (P = 0.01). Conclusions: Compared with cefazolin alone, the combination of cefazolin and azithromycin was more effective in preventing cesarean section wound infection. Therefore, the combined use of these two antibiotics instead of cefazolin alone is recommended for this desirable clinical outcome.

142. Impact of an Antimicrobial Stewardship Intervention on Antibiotic Prescribing in Patients with Obstetric Infection and Penicillin Allergy

BackgroundAntibiotics are commonly administered in the peripartum period and most patients with penicillin allergy can tolerate beta lactams, which are preferred for the prophylaxis and treatment of several common obstetric infections. The purpose of this study was to evaluate the impact of a stewardship intervention bundle (including updates to institutional antibiotic guidelines, reclassification of severe penicillin allergy, development of order sets, and a physician champion) on the management of obstetric infections in patients with reported penicillin allergy. MethodsThis was a multicenter, retrospective study of adult patients presenting for labor and delivery who received at least one dose of antibiotics for an infectious indication May 1, 2018 to October 31, 2018 (pre-intervention) and May 1 2020 to October 31, 2020 (post-intervention). The primary outcome was the composite rates of patients with a reported penicillin allergy who received a preferred agent for Group B Streptococcus (GBS) prophylaxis, intraamniotic infection, or cesarean surgical site infection (SSI) prophylaxis. ResultsA total of 192 patients with a documented penicillin allergy were evaluated (96 patients each in pre- and post-intervention groups). Hives were the most commonly reported allergy in both groups (40% vs 39%, P=0.883). Following stewardship interventions, there was a significant increase in the rate of preferred antibiotics prescribed to patients with penicillin allergy (34.3% vs 84.3%, P< 0.001), driven mainly by patients with non-severe allergy (18.4% vs 82.9%, P< 0.001). There were non-statistically significant trends toward lower rates of postpartum endometritis, 30-day readmission, 90-day SSI, and neonatal early onset sepsis. Allergic reactions in the post-intervention group were limited to itching and rash in one patient each; both resolved with medical management. ConclusionA comprehensive antibiotic stewardship intervention increased preferred antibiotic prescribing for treatment and prophylaxis of obstetric infections. Pregnant patients with non-severe penicillin allergies, even those reporting hives, can tolerate beta-lactam antibiotics. The potential positive impact on clinical outcomes warrants additional investigation. Disclosures Neil Seligman, MD, Natera (Consultant)UpToDate (Other Financial or Material Support, Author)

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle.

Reduction in the incidence of surgical site infection (SSI) serves as a measure of patient safety and quality improvement. Cesarean birth (CB) accounts for 31.9% of all childbirths in the United States. However, our understanding of SSI prevention bundles predominantly stems from gynecological and colorectal surgeries. This study aimed to determine the efficacy of a standardized perioperative bundle designed to reduce SSI in CBs. All CB patients at Flushing Hospital Medical Center from 2017 to 2019 were included in a retrospective analysis. Patients were divided into three groups based on the timing of intervention: prebundle/control, transition, and postbundle. Baseline demographics and clinical characteristics were summarized using descriptive statistics. Multiple logistic regression was performed to determine the association between bundle group and SSI, considering variables different between groups at baseline (P<0.10). Two thousand eight hundred and seventy-five CBs were performed: 1086 in prebundle, 812 in transition, and 977 in postbundle phase. In the prebundle phase, 25 CBs (2.3%) were complicated by SSIs; in the transition phase, 10 (1.2%) had SSIs; and in the postbundle phase, 7 (0.7%; P=0.009) had SSIs. In a logistic regression model, only use of the CB bundle (OR 0.26 [95% CI 0.07-0.94]; P=0.04), rupture of membranes (0.29 [0.09-0.87]; P=0.03), and operating room time (1.02 [1.01-1.04]; P=0.01) were significant in prediction of SSI. SSI postbundle was significantly reduced from prebundle (0.04). Thus, introduction of a hospital-wide perioperative bundle significantly reduced SSI rates, and should be developed as a mainstay of CB surgical care.

Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda.

The World Health Organization (WHO) recommends adherence to its surgical safety checklist (SSC) to optimize patient safety and reduce cesarean surgical site infection (SSI). Educational interventions combined with audit and feedback mechanisms on the checklist use by clinicians have the potential to improve adherence and clinical outcomes. Despite the increase in cesarean delivery rates, there is a paucity of data on how such interventions can improve adherence in resource-limited settings. We performed a quality improvement project to measure the impact of an educational intervention with daily audit and feedback procedures on rates of WHO SSC adherence, including pre-operative antibiotic administration and SSI at Mbarara Regional Referral Hospital maternity ward in Uganda. The study involved chart abstraction of WHO SSC and pre-operative antibiotic use during cesarean deliveries and signs of subsequent SSI in three phases. First, we conducted a retrospective review of all charts from May to June 2018 (pre-intervention phase). Second, we instituted an educational intervention on the WHO SSC and pre-operative antibiotics use, followed by a daily audit of charts and feedback to clinicians from July to August 2018 (the intervention phase). Third, we reviewed charts from September to October 2018 (the post-intervention phase). The WHO SSC adherence, pre-operative antibiotic administration and SSI rates were measured as the proportion of the total cesarean deliveries per study phase and then compared across the three phases. We reviewed 678 patients' charts (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). The mean patient age was 25 years. The use of the WHO SSC was 7% in the pre-intervention phase compared to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (P < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (P < 0.001) and 84% in the post-intervention phase (P < 0.001). The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (P = 0.02) and 11% in the post-intervention phase (P = 0.20). An educational intervention, daily audit and feedback to clinicians increased the use of the WHO SSC and prophylactic antibiotics for cesarean delivery-although the rates waned with time. Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.

Surgical site infection risk in cesarean delivery patients with obesity after negative pressure wound therapy: A retrospective cohort study

BackgroundThere are conflicting reports of postoperative efficacy of negative pressure wound therapy in patients with obesity after cesarean delivery. MethodsRetrospective cohort study for patients with obesity and negative pressure wound therapy or abdominal dressing after cesarean delivery between April 1, 2014 and January 31, 2018. Postoperative surgical site infection was defined from medical record charting or positive wound culture and confirmed by the hospital’s Infection Prevention team. Multivariable logistic regression model for surgical site infection was conducted including additional potential confounding variables. Mantel-Haenszel tests were conducted to stratify by body mass index class and operative time, and we performed quasi-Poisson regression to determine which factors were associated with an increased operative time. ResultsWe included 4,391 Black or White patients with obesity, 696 (15.9%) underwent negative pressure wound therapy and 3,695 (84.1%) abdominal dressing after cesarean delivery. Incidence of surgical site infection after negative pressure wound therapy and abdominal dressing were 6.1% and 3.4%, respectively (2-sample test of proportions P < .001). The multivariable logistic regression (covariates: race, diabetes, body mass index category, insurance, scheduled/emergency, artificial rupture, previous c-section, operative time, age, closure type) found negative pressure wound therapy dressing was associated with an increased risk of surgical site infection (adjusted odds ratio 1.54; 95% confidence interval, 1.01–2.34), as did a Mantel-Haenszel test which was stratified by body mass index (odds ratio 1.62; 95% confidence interval, 1.08–2.43) and a Mantel-Haenszel test stratified by operative time (odds ratio 1.85; 95% confidence interval, 1.28–2.65). Negative pressure wound therapy dressing also led to an increase in operative time in the Quasi-Poisson regression, which was the primary predictor of infection. ConclusionNegative pressure wound therapy was associated with an increased the risk of postoperative surgical site infection after cesarean delivery in our obstetric patients with obesity. Future prospective studies are needed to determine a dressing type and other intervention to decrease postoperative cesarean surgical site infection in women with obesity.

Incidence, risk factors and Microorganisms for post caesarean Surgical Site Infection In A Tertiary Care Centre in Bangladesh

Background: Surgical site infection (SSI) is a common complication following caesarean section (C-section) and mainly responsible for increased maternal morbidity and higher treatment costs. This study will determine the incidence and risk factors of surgical site infections following caesarean section in Dhaka Medical College Hospital (DMCH).&#x0D; Materials and Methods: This is a retrospective observational study which was conducted among patients having post caesarean surgical site infections attending post-natal outdoor clinic of DMCH from January, 2019 to December, 2019. Data were collected in structured questionnaire. Culturebased microbiological methods were used to identify causal agents in postoperative wounds.&#x0D; Results: Overall SSI rate following caesarian section was 4.44%.Patient related risk factors were inadequate antenatal check-up, emergency procedures, malnutrition (22.44%), anaemia (21.46%) associated comorbidity (59.46%), history of rupture membrane &gt;12 hours (40.98%) and had history of prolonged labour pain &gt;12 hours (16.10%).Surgery related risk factors were repeated per vaginal examinations by untrained birth attendant (21.95%) &amp; duration of surgery&gt;1 hour (62.93%). The most common organisms responsible for SSI were Staphylococcus aureus 44(21.46%) and Escherichia coli 31(15.12%). The most sensitive antibiotics were aminoglycosides, cephalosporin &amp; cloxacillin.&#x0D; Conclusion: Most of the risk factors for surgical site infection following caesarean section identified in this study can be modified through intervention. However the microorganisms detected from our patient showed a high degree of resistance for commonly prescribed antimicrobials in our set-up.&#x0D; J Dhaka Medical College, Vol. 28, No.2, October, 2019, Page 136-141

The Power of Teamwork in Preventing Cesarean Surgical Site Infections

The Power of Teamwork in Preventing Cesarean Surgical Site Infections

The Use of Silver in Cesarean Wound Bandages: A New Way to Decrease Infection and Healthcare Costs [36P

INTRODUCTION: Post-cesarean surgical site infection (SSI) occurs after 3.7–9.8% of cesarean deliveries and is associated with significant morbidity and healthcare costs. Silver has antimicrobial properties and bandages impregnated with it are associated with decreased rates of SSI in non-obstetric surgery. Our objective was to compare the rates of deep and superficial cesarean SSI before and after the institution of silver-impregnated bandages and to analyze related healthcare costs. METHODS: This was a retrospective cohort study comparing the rates of cesarean-related SSI five months before and after the institution of silver-impregnated bandages and associated healthcare costs. Data was analyzed using chi-square and Fisher's exact test. RESULTS: There were 1,044 cesarean deliveries and 33 wound-related emergency department (ED) presentations during the study period. The demographics of the standard-of-care (n=538) and silver-bandage (n=506) groups were similar. The overall rates of deep and superficial SSI were 0.8% (n=8) and 0.6% (n=6) respectively. The use of silver-bandages was associated with a decrease in the rate of deep SSI (0.6% (n=3) vs 0.9% (n=5), P=.2) and superficial SSI (0.4% (n=2) vs 0.7% (n=4), P=.3). There were 24% fewer ED presentations in the silver-bandage group (13 vs 17) and one wound dehiscence requiring re-operation and negative-pressure wound-therapy, which was in the standard-of-care group. Healthcare costs related to SSI, ED presentations and long-term wound care were 29% less in the silver-bandage group. CONCLUSION: The use of silver-impregnated bandages was associated with a decreased rate of cesarean SSI and decreased healthcare costs. Longer-term studies will likely yield statistically significant decreases in SSI and healthcare costs, as post-cesarean SSI is a rare outcome.

The Prevalence, Risk Factors, and Bacterial Profile of Cesarean Surgical Site Infections at a University Teaching Hospital in South Western Uganda

Introduction: The single most important risk factor for post-partum maternal infection is Cesarean section (C/S) with a 5-20-fold greater risk for infection compared to a vaginal delivery. Post Cesarean wound infection is diagnosed in 2.5 to 16 percent of patients. Early wound infections (in the first 24 to 48 hours) are usually due to group A or B beta-hemolytic streptococcus and are characterized by high fever and cellulitis while later infections are likely due to Staphylococcus epidermises or aureus, Escherichia coli, or Proteus species. Objectives: To determine the prevalence, risk factors and bacterial profile of wound sepsis following Cesarean at Mbarara Regional Referral Hospital (MRRH). Methods: A cross sectional study of mothers who delivered by Cesarean at MRRH was conducted. Mothers were recruited consecutively until the sample size was achieved. The main dependent variable was wound sepsis confirmed by a positive culture for microorganisms. Results: Of the 359 mothers recruited in the study, 54 (15.5%) developed Cesarean wound sepsis. The risk factors associated with post Cesarean wound sepsis were severe anemia, lack of preoperative antibiotics use, poor antenatal attendance, mothers referred from peripheral health facilities, abnormal Body Mass Index (BMI), diabetes mellitus, more than five vaginal examinations, prolonged rupture of membranes before C/S, and prolonged labour. Staphylococcus aureus was isolated in 48.2% of all the septic cases and most of the bacterial isolates were susceptible to ceftriaxone, ceftazidime, ciprofloxacin and nalidixic acid and resistant to penicillin. Conclusion: The prevalence of post Cesarean wound sepsis is high with staphylococcus aureus being the most common bacteria isolated in infected wounds. Most of the bacteria were susceptible to third generation cephalosporins and quinolones. Antibiotics use was protective against developing wound sepsis.

879: Antimicrobial prophylaxis within 30 versus 30-60 minutes before cesarean delivery and surgical site infection rate

879: Antimicrobial prophylaxis within 30 versus 30-60 minutes before cesarean delivery and surgical site infection rate

Preoperative cefazolin rather than clindamycin or metronidazole is associated with lower postpartum infection among women with chorioamnionitis delivering by cesarean delivery

The optimal antibiotic regimen to prevent maternal postpartum infection among high-risk women treated for chorioamnionitis delivering by cesarean delivery remains to be defined. Emerging data suggest that cefazolin decreases the risk of cesarean surgical site infection. To investigate whether intrapartum antibiotic therapy with cefazolin versus the current standard clindamycin or metronidazole decreases the risk of postpartum infectious morbidity among women delivering by cesarean delivery who were receiving a base regimen of ampicillin or penicillin with gentamicin for chorioamnionitis. A secondary analysis from the Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry. We included women who delivered by cesarean delivery with presumptive chorioamnionitis (intrapartum fever >100.4°F and receipt of intrapartum antibiotics). All women received a base regimen of penicillin or ampicillin with gentamicin. We compared antibiotic therapy with cefazolin versus clindamycin or metronidazole. The primary outcome was a composite of postpartum maternal infection, including endometritis and surgical site infection. Multivariable logistic regression was used, adjusting for age, parity, race/ethnicity, insurance, body mass index at delivery, tobacco use, pregestational diabetes, American Society of Anesthesiologists classification, trial of labor prior to cesarean delivery, and postpartum antibiotics. Among 1105 women with presumptive chorioamnionitis who delivered by cesarean delivery, 22.0% (n= 244) received cefazolin and 77.9% (n= 861) received clindamycin or metronidazole. Most women were in labor prior to cesarean delivery (93.8%) and received postpartum antibiotics (88.4%). Almost one-tenth (9.5%) were diagnosed with a postpartum infection, most commonly endometritis (80.9%), followed by surgical site infection (20.9%) (not mutually exclusive). Women treated with cefazolin rather than clindamycin or metronidazole had lower odds of postpartum infectious morbidity (adjusted odds ratio, 0.49; 95% confidence interval, 0.26-0.90). This association held when the outcome was restricted to surgical site infection (adjusted odds ratio, 0.11; 95% confidence interval, 0.01-0.92) but not endometritis. Similar results were observed with propensity score analysis. Among women delivering by cesarean delivery who were treated for chorioamnionitis, additional antibiotic therapy with cefazolin decreased the risk of postpartum infection, primarily surgical site infection, compared to the current standard clindamycin or metronidazole.

Prevalence and indicators of post cesarean surgical site infection in Minia maternity university hospital

Prevalence and indicators of post cesarean surgical site infection in Minia maternity university hospital

Bundled Prevention of Cesarean Surgical Site Infections: The Down and Dirty [20Q

INTRODUCTION: Surgical site infections (SSI) following cesarean delivery (CD) are a major cause of morbidity and economic burden. Our tertiary-care hospital implemented a multidisciplinary SSI surveillance system and preventative bundles to reduce rate of SSI after CD. Our objective was to measure the effect of 3 bundles on post-CD SSI. METHODS: A retrospective single-center cohort study of all CD July 2012 to December 2017 was performed. Infections were identified via 30-day active surveillance using CDC definitions by one infection preventionist and reviewed by one physician. Patient demographics and procedural details were stored for submission to CDC. Unadjusted and adjusted risk factors were identified using logistic regression. Bundle 1 (2014) included enhanced surgical instrument sterilization, bandage removal POD2, preoperative sage cloth, 3 grams Cefazolin for women &gt;120 kg, recommended patient warming, staples removal POD7, and provided silver dressings. Bundle 2 (2015) included nurses prepping with prolonged prep time using two chlorhexidine applicators. Bundle 3 (2016) included preoperative vaginal prep and 500 mg Azithromycin in unscheduled CD in labor and encouraged post-placental glove change. RESULTS: Over 5.5 years, 2.2% (176/8150) of women developed post-CD SSI. 79% (138/176) were superficial incisional primary SSI. The first bundle had no significant effect on the odds of post-CD SSI (odds ratio [OR] 0.48, confidence interval [95% CI] 0.15 - 1.61). We observed decreased odd of post-CD SSI for both bundle 2 (OR 0.63, 95% CI 0.45 - 0.87) and bundle 3 (OR 0.61, 95% CI 0.42 - 0.88). CONCLUSION: Evidence-based bundles should be considered at institutions experiencing high post-CD SSI rates.

Improving Detection of Surgical Site Infections After Cesarean Delivery: What Are Diagnosis Codes Missing? [28Q

INTRODUCTION: Surveillance for surgical site infections (SSI) following cesarean can be challenging. We sought to identify cases of SSI over two years and describe our methods of case ascertainment. METHODS: We queried our hospital's data warehouse for cesareans deliveries from 2016-2017 among women >18 years of age. Three methods for case finding were used: i) ICD-10 diagnoses codes, ii) reporting complications in postoperative notes, and iii) infection control surveillance activities. For ICD-10 codes, we sought endometritis following delivery and infection of obstetrical surgical wound, infection following procedure, cellulitis, and/or peritoneal abscess. We included endometritis as an organ/space SSI by CDC definitions. Chart review was performed for all cases identified by any of the 3 methods to confirm SSI diagnosis as per CDC criteria. RESULTS: Among 3,507 cesareans, ICD-10 codes identified 76 confirmed cases of endometritis and 31 SSI. The positive predictive value for endometritis was 88.0% (95% CI 80.2-93.1) and for SSI codes, 53.5% (95% CI 43.0-63.6). Adding puerperal sepsis produced one additional SSI case, and searching the postoperative note yielded another 26 cases of endometritis and one wound infection. Six SSI were identified by infection control not identified by other methods. In total, we identified 141 SSI, including 98 endometritis-only cases. The incidence of all SSI, endometritis, and SSI excluding endometritis was 4.02%, 2.79%, and 1.23%. CONCLUSION: Improved ascertainment methods are needed to inform and assess performance improvement efforts for cesarean SSI. Reliance on diagnosis codes may miss a significant number of cases and is poorly predictive of SSI other than endometritis.

The efficacy of ampicillin compared with ceftriaxone on preventing cesarean surgical site infections: an observational prospective cohort study

BackgroundCesarean surgical site infections (SSIs) can be prevented by proper preoperative antibiotic prophylaxis. Differences in antibiotic selection in clinical practice exist according to obstetricians’ preferences despite clear guidelines on preoperative antibiotic prophylaxis. This study aimed to compare the efficacy of ampicillin and ceftriaxone in preventing cesarean SSIs.MethodsThe observational prospective cohort study was conducted at a tertiary hospital in Thailand from 1 January 2007 to 31 December 2012. Propensity scores for ceftriaxone prophylaxis were calculated from potential influencing confounders. The cesarean SSI rates of the ceftriaxone group vs. those of the ampicillin prophylactic group were estimated by multilevel mixed-effects Poisson regression nested by propensity score.ResultsData of 4149 cesarean patients were collected. Among these, 911 patients received ceftriaxone whereas 3238 patients received ampicillin as preoperative antibiotic prophylaxis. The incidence of incisional SSIs was (0.1% vs. 1.2%; p = 0.001) and organ space SSIs was (1.2% vs. 2.9%; p = 0.003) in the ceftriaxone group compared with the ampicillin group. After adjusting for confounders, the rate ratios of incisional and organ/space SSIs in the ceftriaxone compared with the ampicillin group did not differ (RR, 0.23; 95% CI 0.03–1.78), and (RR, 1.62; 95% CI 0.83–3.18), respectively.ConclusionThese data indicate no difference exists between ampicillin and ceftriaxone to prevent SSIs after cesarean section. Ampicillin may be used as antibiotic prophylaxis in cesarean section.

Risk factors for post caesarean surgical site infection at a tertiary care center in Eastern Nepal

Background &amp; Objectives:Post cesarean surgical site infection (SSI) is one of the commonly encountered complications which considerably increase the burden to health care. It is caused due to the interplay of various patient related, procedure related and iatrogenic factors. This study aims at identifying common risk factors for post cesarean SSI at our centre.Materials &amp; Methods:This was a prospective observational study conducted from July 2015 to December 2015, in which all patients who were admitted with post cesarean SSI or developed SSI during their stay were included and their risk factors were studied.Results:Emergency procedures (82.97%) were more likely to develop SSI as compared to elective cesarean (17%). Among the patient related risk factors most of them were nulliparous (48.9%), term gestation (42.6%), malnourished (53.1%) and had history of prolonged leaking (44.68%) The mean age was 24.04±4.6years.Most of the patients who developed SSI were operated for repeat cesarean and fetal indications. Most patients who had SSI had at three to five per vaginal examinations (2.72±2). 66% of patient who had SSI had duration of surgery more than one hour. 68% of the surgeries which developed SSI were done by residents as compared to 32% of those done by consultantsConclusion:The commonly associated risk factors linked with post cesarean SSI are maternal age, emergency procedures, prolonged membrane rupture, multiple vaginal examinations, malnutrition and the experience of surgeon.