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

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.

Impact of Azithromycin-Based Extended-Spectrum Antibiotic Prophylaxis on Noninfectious Cesarean Wound Complications

“…[2][3][4][5][6][7][8] This includes both infectious and noninfectious wound complications, either of which can result in longer hospital stays, increased visits to healthcare providers, hospital readmissions, and higher medical costs. [9][10][11][12][13] Despite research showing promising interventions at the time of cesarean, such as skin preparation with chlorhexidine, 3,12,[14][15][16][17] closure of the subcutaneous fat layer, 12,15 and skin closure with suture as opposed to staples, 12,15,18,19 wound complications remain a common postoperative complication. The frequency of postcesarean wound complications, both infectious and noninfectious, has been reported to occur in approximately 10 to 15% of women.…”

Obesity: Unique Challenges at the Time of Cesarean Delivery

“…The addition of azithromycin to standard antibiotic prophylaxis in women of all weight groups undergoing non-elective cesarean delivery has been proven to reduce wound infection [79]. Given the high chance of wound infection in obese patients, it may be reasonable to add azithromycin to standard antibiotic prophylaxis, even in women undergoing elective scheduled cesarean delivery [71]. In our institution, the addition of azithromycin has reduced surgical site infections in a longitudinal cohort quality improvement project (unpublished data).…”

“…Evidence suggests that closure of the subcutaneous tissue (if over 2-3 cm in depth) and avoidance of subcutaneous drains decrease the chance of wound complications in obese patients [70][71][72].…”

“…On a large multicenter randomized trial, obese women with subcutaneous drains had similar rates of wound complications as those with subcutaneous fat closure only [85]. However, more recent studies suggest that the subcutaneous tissue should be closed if more than 2-3 cm deep, and subcutaneous drains should be avoided to prevent surgical site infections [70][71][72].…”

Does a Care Bundle Reduce Racial Disparities in Postcesarean Surgical Site Infections?

“…As reported previously, an evidence-based care bundle was developed and implemented as a quality improvement initiative. 17 The postcesarean surgical site infection reduction bundle included cefazolin and azithromycin administration to all women prior to skin incision, 3,18,19 2% chlorhexidine gluconate with 70% isopropyl alcohol skin preparation, 20 use of clippers, 21 vaginal cleansing with 10% povidone-iodine, 4,22 placenta removal by umbilical cord traction, 23 suture closure of subcutaneous tissue if wound thickness !2 cm, 24 suture skin closure using 4-0 poliglecaprone 25, 6 dressing removal between 24 and 48 hours, 25 and daily use of 4% chlorhexidine gluconate shower for 1 week. [26][27][28] Postpartum nurses reviewed proper wound care prior to discharge.…”