Surgical Site Infections and Antimicrobial Resistance After Cesarean Section Delivery in Rural Rwanda

Abstract

Background: As the volume of surgical cases in low- and middle-income countries (LMICs) increases, surgical-site infections (SSIs) are becoming more prevalent with anecdotal evidence of antimicrobial resistance (AMR), despite a paucity of data on resistance patterns. Objectives: As a primary objective, this prospective study aimed to describe the epidemiology of SSIs and the associated AMR among women who delivered by cesarean at a rural Rwandan hospital. As secondary objectives, this study also assessed patient demographics, pre- and post-operative antibiotic use, and SSI treatment. Methods: Women who underwent cesarean deliveries at Kirehe District Hospital between September 23rd, 2019, and March 16th, 2020, were enrolled prospectively. On postoperative day (POD) 11 (+/– 3 days), their wounds were examined. When an SSI was diagnosed, a wound swab was collected and sent to the Rwandan National Reference Laboratory for culturing and antibiotic susceptibility testing. Findings: Nine hundred thirty women were enrolled, of whom 795 (85.5%) returned for the POD 11 clinic visit. 45 (5.7%) of the 795 were diagnosed with SSI and swabs were collected from 44 of these 45 women. From these 44 swabs, 57 potential pathogens were isolated. The most prevalent bacteria were coagulase-negative staphylococci (n = 12/57, 20.3% of all isolates), and Acinetobacter baumannii complex (n = 9/57, 15.2%). 68.4% (n = 39) of isolates were gram negative; 86.7% if excluding coagulase-negative staphylococci. No gram-negative pathogens isolated were susceptible to ampicillin, and the vast majority demonstrated intermediate susceptibility or resistance to ceftriaxone (92.1%) and cefepime (84.6%). Conclusions: Bacterial isolates from SSI swab cultures in rural Rwanda predominantly consisted of gram-negative pathogens and were largely resistant to commonly used antibiotics. This raises concerns about the effectiveness of antibiotics currently used for surgical prophylaxis and treatment and may guide the appropriate selection of treatment of SSIs in rural Rwanda and comparable settings.

Medical-Grade Honey Enhances the Healing of Caesarean Section Wounds and Is Similarly Effective to Antibiotics Combined with Povidone-Iodine in the Prevention of Infections—A Prospective Cohort Study

“…In developing countries, there is a high risk of antimicrobial resistance, due to the misuse of antimicrobials, over-the-counter availability, non-compliance, and unregulated supply chains [33]. To illustrate this, a previous study in Rwanda found that 84.6-100% of the infected CS cases were resistant to commonly used antibiotics (ampicillin, ceftriaxone, and cefepime) [34]. Infections arose despite 88.8% of the cohort receiving pre-operative antibiotics (94% ampicillin) and 95.9% receiving postoperative antibiotics (52.3% ampicillin, 48.1% gentamicin, 46.3% metronidazole, and 41.3% ceftriaxone) [34].…”

“…To illustrate this, a previous study in Rwanda found that 84.6-100% of the infected CS cases were resistant to commonly used antibiotics (ampicillin, ceftriaxone, and cefepime) [34]. Infections arose despite 88.8% of the cohort receiving pre-operative antibiotics (94% ampicillin) and 95.9% receiving postoperative antibiotics (52.3% ampicillin, 48.1% gentamicin, 46.3% metronidazole, and 41.3% ceftriaxone) [34]. Another advantage of MGH over antibiotics is that MGH will not end up in the circulation of the patient, and subsequently, in the milk of breastfeeding women.…”

mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda

“…A third limitation is that the gold standard for SSI diagnosis is a GP physical examination, without isolating pathological organisms through swab or fluid culture. Due to lack of infrastructure for pathology confirmations, this is the main means of SSI diagnosis in this rural hospital, similar to many other rural SSA settings 48 49. Since we are interested in identifying strategies that imitate a facility visit without the burden of travel, the GP diagnosis is a suitable gold standard in this context.…”

Image-based surgical site infection algorithms to support home-based post-cesarean monitoring: Lessons from Rwanda

“…However, many rural health facilities in LMICs do not have access to bacteriology labs and we found establishing such capacity incredibly challenging [12]. Further, even when available, non-pathogenic bacteria can be misdetected on wound swabs, adding uncertainty to diagnoses [13]. In rural Rwanda, SSI by clinical diagnosis is standard of care and for our algorithm development, we used this clinical diagnosis as the gold standard, as this replicates what the patient would have received if she returned to the facility for wound monitoring.…”