Cost-benefit analysis of surveillance for surgical site infection following caesarean section

A Systematic Review and Meta-analysis of Two Negative Pressure Wound Therapy Devices to Manage Cesarean Section Incisions

This paper aims to evaluate whether there is a device-dependent effect on the reduction of surgical site complications in obese patients (body mass index [BMI] ≥ 30 kg/m2) undergoing cesarean section (C-section). PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for the period, January 2011 to September 2021. English language articles describing a randomized controlled trial (RCT) that compared either a -80 or -125 mm Hg single-use negative pressure wound therapy (sNPWT) device to standard dressings in obese (BMI ≥ 30 kg/m2) patients undergoing C-section were included. Conference abstracts and "terminated" RCTs with published results were deemed eligible for inclusion. The primary outcome of interest was surgical site infection (SSI), classified as composite, superficial, or deep. Secondary outcomes assessed included seroma, dehiscence, hematoma, bleeding, reoperation, readmission, blistering, and (composite) wound complications. A total of 223 titles were identified, of which 129 were screened by full-text review. Eleven RCTs encompassing 5,847 patients met the inclusion criteria and were considered eligible for further analysis (-80 mm Hg: six studies; -125 mm Hg: five studies). A statistically significant improvement in the composite SSI (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.54-0.89) and superficial SSI (OR: 0.66; 95% CI: 0.50-0.86) outcomes was observed with the -80 mm Hg device, compared with standard dressings. The same effect on SSI outcomes was not observed with the -125 mm Hg device (composite SSI-OR: 0.91; 95% CI: 0.64-1.28; superficial SSI-OR: 1.12; 95% CI: 0.70-1.78). There were no statistically significant differences in any of the other assessed outcomes. sNPWT devices may differ in their ability to reduce composite or superficial SSI after C-section. KEY POINTS: · Negative pressure benefits obese patients undergoing C-section.. · Negative pressure devices may differ in performance.. · A head-to-head clinical trial is needed..

Effect of participation in a surgical site infection surveillance programme on hospital performance in Japan: a retrospective study

BACKGROUND

The effect of hospital participation in the Japan Nosocomial Infection Surveillance (JANIS) programme on surgical site infection (SSI) prevention is unknown.

AIM

To determine if participation in the JANIS programme improved hospital performance in SSI prevention.

METHODS

This retrospective before-after study analysed Japanese acute care hospitals that joined the SSI component of the JANIS programme in 2013 or 2014. The study participants comprised patients who had undergone surgeries targeted for SSI surveillance at JANIS hospitals between 2012 and 2017. Exposure was defined as the receipt of an annual feedback report 1 year after participation in the JANIS programme. The changes in standardized infection ratio (SIR) from 1 year before to 3 years after exposure were calculated for 12 operative procedures: appendectomy, liver resection, cardiac surgery, cholecystectomy, colon surgery, caesarean section, spinal fusion, open reduction of long bone fracture, distal gastrectomy, total gastrectomy, rectal surgery, and small bowel surgery. Logistic regression models were used to analyse the association of each post-exposure year with the occurrence of SSI.

FINDINGS

In total, 157,343 surgeries at 319 hospitals were analysed. SIR values declined after participation in the JANIS programme for procedures such as liver resection and cardiac surgery. Participation in the JANIS programme was significantly associated with reduced SIR for several procedures, especially after 3 years. The odds ratios in the third post-exposure year (reference: pre-exposure year) were 0.86 [95% confidence interval (CI) 0.79-0.84] for colon surgery, 0.72 (95% CI 0.56-0.92) for distal gastrectomy, and 0.77 (95% CI 0.59-0.99) for total gastrectomy.

CONCLUSION

Participation in the JANIS programme was associated with improved SSI prevention performance in several procedures in Japanese hospitals after 3 years.

Reducing Surgical Site Infections Post-Caesarean Section

Background

Surgical Site Infections (SSI) are one of the most common complications after a caesarean with significant morbidity. Evidence suggests that SSI rates can be reduced post caesarean by using a Leukomed® Sorbact® (Essity) bacteria binding wound dressing, thereby reducing bacterial wound colonisation. Barking, Havering & Redbridge University Hospitals NHS Trust, London, UK (BHRUT) maternity unit sought change their clinical practice by using Leukomed Sorbact and evaluate if this reduced their SSI rate, SSI readmission rate, antibiotic usage and evaluate any associated cost savings.

Methods

From January 1st 2022, Mepore® (Molnlycke) wound dressings were replaced with Leukomed Sorbact for all caesareans. Retrospective and prospective audits were undertaken to compare SSI incidence pre- and post- implementation of the dressing. No changes were made to wound cleaning products, prophylactic antibiotic use or surgical technique. Wound closure technique remained the choice of the individual surgeon.

Results

Prior to this practice change, the baseline SSI rate between January-December 2021 was 6.1% and the SSI readmission rate was 1.27%. Comparative data for January-December 2022 showed a 38% reduction in SSI rates (overall SSI rate = 3.8%), a 31% reduction in readmission rate for SSI (overall rate = 0.88%), a 38% reduction in readmission bed days and a 30% reduction in antibiotic use. There was a reduction in SSI rates in all body mass index (BMI) categories. Total savings due to the reduction in SSI rates over twelve months were £234,784. The cost savings to BHRUT solely attributable to the reduction in readmissions was £49,750 or £21 per Caesarean, which will be an ongoing saving.

Conclusion

The use of Leukomed Sorbact dressings after Caesarean resulted in improved clinical outcomes with reduced SSI and readmission rates. Investment in the new dressing was cost effective when considering bed days freed, the reduction in antibiotic usage, reduced morbidity and improved patient experience.

Single-use negative pressure wound therapy to prevent surgical site complications in high-risk patients undergoing caesarean sections: a real-world study

Surgical site complications (SSCs), including surgical site infection (SSI), are common following C-sections. Management of the post-operative incision with single-use negative pressure wound therapy (sNPWT) has been shown to reduce the risk of SSC in high-risk individuals. This study explored the outcomes of routine, real-world use of sNPWT in high-risk patients undergoing C-sections. An observational, retrospective in-service evaluation was conducted across eight obstetric centres in the Republic and Northern Ireland. Patients undergoing C-sections were stratified for their risk of developing SSC using commonly known risk factors, including BMI ≥30, smoking, diabetes, and whether the patients had undergone previous C-sections or had a previous history of wound dehiscence. Those at high-risk were treated with sNPWT post-operatively. Data relating to any SSC that developed post-operatively, for up to 30 days, were captured. Data were compared with original research previously published by Wloch et al. (2012). Of 1111 women considered high-risk, 106 (9.5%) went on to develop SSCs, predominantly superficial SSIs. SSCs were associated with extra visits with their general practitioner (GP), outpatient visits, or inpatient hospital stays in 5.7%, 2.4%, and 1.7% of the entire cohort, representing 59.4%, 25.5%, and 17.9% of the 106 patients with SSC. Patients needed on average 1.8 extra GP visits and 0.7 extra outpatient visits. Patients who needed to be readmitted to hospital had an average length of stay of 4 days. In comparison with a previously published cohort, in which sNPWT was not used, we observed a significant reduction in the incidence of SSCs across BMI groups 18.5-24.9 (P = 0.02), 25-29.9 (P = 0.003), and ≥35 kg/m2 (P = 0.04). In those patients who had undergone at least one previous C-section, the rates of complications also reduced (P = 0.006). This analysis provides further justification for using sNPWT to manage surgical incisions in patients considered at high risk of developing post-procedural SSCs, particularly those with a BMI ≥30 or a history of more than one C-section.

Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is a health-threatening complication following caesarean section (CS); however, to the authors' knowledge, there is no worldwide estimate of the burden of post-CS SSIs. Therefore, this systematic review and meta-analysis aimed to estimate the global and regional incidence of post-CS SSIs and associated factors.

METHODS

International scientific databases were searched systematically for observational studies published from January 2000 to March 2023, without language or geographical restrictions. The pooled global incidence rate was estimated using a random-effects meta-analysis (REM), and then stratified by World-Health-Organization-defined regions as well as by sociodemographic and study characteristics. Causative pathogens and associated risk factors of SSIs were also analysed using REM. Heterogeneity was assessed with I2.

RESULTS

In total, 180 eligible studies (207 datasets) involving 2,188,242 participants from 58 countries were included in this review. The pooled global incidence of post-CS SSIs was 5.63% [95% confidence interval (CI) 5.18-6.11%]. The highest and lowest incidence rates for post-CS SSIs were estimated for the African (11.91%, 95% CI 9.67-14.34%) and North American (3.87%, 95% CI 3.02-4.83%) regions, respectively. The incidence was significantly higher in countries with lower income and human development index levels. The pooled incidence estimates have increased steadily over time, with the highest incidence rate during the coronavirus disease 2019 pandemic (2019-2023). Staphylococcus aureus and Escherichia coli were the most prevalent pathogens. Several risk factors were identified.

CONCLUSION

An increasing and substantial burden from post-CS SSIs was identified, especially in low-income countries. Further research, greater awareness and the development of effective prevention and management strategies are warranted to reduce post-CS SSIs.

Cost-Utility Analysis of the Caresyntax Platform to Identify Patients at Risk of Surgical Site Infection Undergoing Colorectal Surgery

BACKGROUND

Surgical site infections (SSIs) account for up to 18% of all healthcare-associated infections (HAIs). The Caresyntax data-driven surgery platform incorporates the most common risk factors for SSI, to identify high-risk surgical patients before they leave the operating theatre and treat them prophylactically with negative pressure wound therapy (NPWT). An economic analysis was performed to assess the costs and health outcomes associated with introduction of the technology in the English healthcare setting.

METHODS

A hybrid decision tree/Markov model was developed to reflect the treatment pathways that patients undergoing colorectal surgery would typically follow, both over the short term (30-day hospital setting) and long term (lifetime). The analysis considered implementation of Caresyntax's platform-based SSI predictive algorithm in the hospital setting, compared with standard of care, from an English National Health Service (NHS) perspective. The base-case analysis presents results in terms of cost per quality-adjusted life-year (QALY) gained, as well as operational impact.

RESULTS

The base-case analysis indicates that the intervention leads to a cost saving of £55.52m across the total NHS colorectal surgery patient population in 1 year. In addition, the intervention has a 98.36% probability of being cost effective over a lifetime horizon. The intervention results in the avoidance of 19,744 SSI events, as well 191,911 excess hospital bed days saved.

CONCLUSION

Caresyntax's platform-based SSI predictive algorithm has the potential to result in cost savings and improved patient quality of life. Additionally, operational gains for the healthcare provider, including reduced infection rates and hospital bed days saved, have been shown through the economic modeling.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the "primary effects" of AMR. Previous estimates of the burden of AMR have largely ignored the potential "secondary effects," such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the “primary effects” of AMR. Previous estimates of the burden of AMR have largely ignored the potential “secondary effects,” such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study

OBJECTIVE

To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study.

DESIGN

Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire.

SETTING

Korle-Bu Teaching Hospital (KBTH), Ghana.

PARTICIPANTS

All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH.

MAIN OUTCOME MEASURES

The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel.

RESULTS

Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually.

CONCLUSION

The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.

Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database

BACKGROUND

Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database.

METHODS

IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period.

RESULTS

Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy.

CONCLUSIONS

Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.

Advanced dressings for the prevention of surgical site infection in women post-caesarean section: A systematic review and meta-analysis

OBJECTIVE(S)

Surgical site infections (SSIs) are a common complication post-caesarean section. Advanced dressings aim to provide an optimal wound environment, primarily by physically or chemically controlling moisture, in order to promote timely healing. A systematic review and meta-analysis was conducted to evaluate the effectiveness of advanced dressings in SSI prevention post-caesarean section. Secondary effectiveness outcomes included superficial SSI, endometritis, wound dehiscence, rehospitalisation and length of rehospitalisation.

STUDY DESIGN

We conducted a systematic review and meta-analysis according to PRISMA guidelines. A protocol was registered a priori. MEDLINE, EMBASE, CENTRAL and CINAHL databases were searched from inception to May 2021, without date or language restrictions. Keywords included: caesarean section; bandages; dressing and surgical wound infection. Randomised controlled trials (RCTs) were included if they investigated any advanced dressing in women post-caesarean section compared to simple dressings and assessed SSI incidence. Relative risks (RR), with 95% confidence intervals (CIs) and p-values, were calculated using Review Manager software (RevMan version 5.0, The Cochrane Collaboration). I² percentages were reported to assess heterogeneity and a funnel plot was produced to assess publication bias. Quality assessment was performed using the Cochrane Risk of Bias Assessment Tool. All data were double-extracted and discrepancies were finalised by a third reviewer.

RESULTS

From 253 citations identified, six RCTs were included in the systematic review and meta-analysis. Two studies investigated dialkylcarbamoyl chloride (DACC)-impregnated dressings; two investigated silver-impregnated dressings; one investigated copper-impregnated dressings and one investigated chlorhexidine gluconate dressings. The overall meta-analysis showed that advanced dressings did not reduce SSI risk (RR 0.81 [95% CI 0.52-1.24; p = 0.32]). However, subgroup analysis revealed that DACC-impregnated dressings reduced SSI risk (RR 0.33 [95% CI 0.14-0.77; p = 0.01]). Silver-impregnated dressings caused a nonsignificant increase in SSI risk (RR 1.20 [95% CI 0.77-1.88; p = 0.41]). All studies showed a high risk of bias.

CONCLUSION

This systematic review and meta-analysis suggests DACC dressings potentially reduce SSI. However we have shown no benefit of silver dressings. Further high-quality RCTs are required to recommend a change in clinical practice.

Microbial Air Monitoring in Turbulent Airflow Operating Theatres: Is It Possible to Calculate and Hypothesize New Benchmarks for Microbial Air Load?

Multiple studies have demonstrated the presence of microorganisms commonly associated with surgical site infections (SSIs), in the air within the operating theatre (OT). In some countries such Italy, the limit of microbial concentration in the air for OT with turbulent airflows is 35 CFU/m³ for an empty OT and 180 CFU/m³ during activity. This study aims to hypothesize new benchmarks for the airborne microbial load in turbulent airflow operating theatres in operational and at rest conditions using the percentile distribution of data through a 17-year environmental monitoring campaign in various Italian hospitals that implemented a continuous quality improvement policy. The quartile distribution analysis has shown how in operational and at rest conditions, 75% of the values were below 110 CFU/m³ and 18 CFU/m³, respectively, which can be considered a new benchmark for the monitored OTs. During the initial stages of the monitoring campaign, 28.14% of the concentration values in operational conditions and 29.29% of the values in at rest conditions did not conform to the Italian guidelines’ reference values. In contrast, during the last 5 years, all values in both conditions conformed to the reference values and 98.94% of these values were below the new benchmarks. Continuous improvement has allowed contamination to be reduced to levels well below the current reference values.

Assessing the added value of group B Streptococcus maternal immunisation in preventing maternal infection and fetal harm: population surveillance study

OBJECTIVE

To assess the incidence of maternal group B Streptococcus (GBS) infection in England.

DESIGN

Population surveillance augmented through data linkage.

SETTING

England.

POPULATION

All pregnant women accessing the National Health Service (NHS) in England.

METHODS

Invasive GBS (iGBS) infections during pregnancy or within 6 weeks of childbirth were identified by linking Public Health England (PHE) national microbiology surveillance data for 2014 to NHS hospital admission records. Capsular serotypes of GBS were determined by reference laboratory typing of clinical isolates from women aged 15-44 years. Post-caesarean section surgical site infection (SSI) caused by GBS was identified in 21 hospitals participating in PHE SSI surveillance (2009-2015).

MAIN OUTCOME MEASURES

iGBS rate per 1000 maternities; risk of GBS SSI per 1000 caesarean sections.

RESULTS

Of 1601 patients diagnosed with iGBS infections in England in 2014, 185 (12%) were identified as maternal infections, a rate of 0.29 (95% CI 0.25-0.33) per 1000 maternities and representing 83% of all iGBS cases in women aged 18-44 years. Seven (3.8%) were associated with miscarriage. Fetal outcome identified excess rates of stillbirth (3.4 versus 0.5%) and extreme prematurity (<28 weeks of gestation, 3.7 versus 0.5%) compared with national averages (P < 0.001). Caesarean section surveillance in 27 860 women (21 hospitals) identified 47 cases of GBS SSI, with an estimated 4.24 (3.51-5.07) per 1000 caesarean sections, a median time-to-onset of 10 days (IQR 7-13 days) and ten infections that required readmission. Capsular serotype analysis identified a diverse array of strains with serotype III as the most common (43%).

CONCLUSIONS

Our assessment of maternal GBS infection in England indicates the potential additional benefit of GBS vaccination in preventing adverse maternal and fetal outcomes.

Impact of changing gloves during cesarean section on postoperative infective complications: A systematic review and meta-analysis

INTRODUCTION

The cesarean section rate around the world, currently estimated at 21.1%, continues to increase. Women who undergo a cesarean section sustain a seven- to ten-fold greater risk of infective morbidity compared with those who deliver vaginally.

MATERIAL AND METHODS

We aimed to assess the impact of changing gloves intraoperatively on post-cesarean section infective morbidity (PROSPERO CRD42018110529). MEDLINE, Scopus, Web of Science, CINAHL, WHO Global Index Medicus, and Cochrane Central were searched for randomized controlled trials until June 2020. Published randomized controlled trials that evaluated the effects of glove changing during cesarean section on infective complications were considered eligible for the review. Two reviewers independently selected studies, assessed the risk of bias, and extracted data about interventions and adverse maternal outcomes. Dichotomous variables were presented and included in the meta-analyses as risk ratios (RR) with 95% confidence intervals (CI). The quality of evidence was assessed using the GRADE approach in alignment with the recommendations from the Cochrane Review Group.

RESULTS

We identified seven randomized controlled trials reporting data over 1948 women. Changing gloves during a cesarean section was associated with a statistically significantly lower incidence of wound infective complications (RR 0.41, 95% CI 0.26-0.65, p < 0.0001; GRADE moderate quality evidence). This intervention seemed to be effective only if performed after delivery of the placenta. No significant difference was seen in the incidence of endometritis (RR 0.96, 95% CI 0.78-1.20, p = 0.74; GRADE moderate quality evidence) and/or febrile morbidity (RR 0.73, 95% CI 0.30-1.81, p = 0.50; GRADE moderate quality evidence), regardless of the timing of the intervention.

CONCLUSIONS

Changing gloves after delivery of the placenta during a cesarean section is associated with a significant reduction in the incidence of post-surgical wound complications compared with keeping the same gloves throughout the whole surgery. However, an adequately powered study to assess the limitations and cost-effectiveness of the intervention is needed before this recommendation can be translated into current clinical practice.

Abdominal Cutaneous Thermography and Perfusion Mapping after Caesarean Section: A Scoping Review

Introduction: Caesarean section (CS) is the most prevalent surgical procedure in women. The incidence of surgical site infection (SSI) after CS remains high but recent observations of CS wounds using infrared thermography has shown promise for the technique in SSI prognosis. Although thermography is recognised as a 'surrogate' of skin perfusion, little is known of the relationship between skin temperature and skin perfusion in the context of wound healing. Aim: To assess the extent of literature regarding the application of infrared thermography and mapping of abdominal cutaneous perfusion after CS. Methods: Wide eligibility criteria were used to capture all relevant studies of any design, published in English, and addressing thermal imaging or skin perfusion mapping of the abdominal wall. The CINAHL and MEDLINE databases were searched, with two independent reviewers screening the title and abstracts of all identified citations, followed by full-text screening of relevant studies. Data extraction from included studies was undertaken using a pre-specified data extraction chart. Data were tabulated and synthesised in narrative format. Results: From 83 citations identified, 18 studies were considered relevant. With three additional studies identified from the reference lists, 21 studies were screened via full text. None of the studies reported thermal imaging and cutaneous perfusion patterns of the anterior abdominal wall. However, two observational studies partially met the inclusion criteria. The first explored analysis methodologies to 'interrogate' the abdominal thermal map. A specific thermal signature ('cold spots') was identified as an early 'flag' for SSI risk. A second study, by the same authors, focusing on obesity (a known risk factor for SSI after CS) showed that a 1 °C lower abdominal skin temperature led to a 3-fold odds of SSI. Conclusion: There is a significant gap in knowledge on how to forewarn of wound complications after CS. By utilising the known association between skin temperature and blood flow, thermographic assessment of the wound and adjacent thermal territories has potential as a non-invasive, independent, imaging option with which to identify tissue 'at risk'. By identifying skin 'hot' or 'cold' spots, commensurate with high or low blood flow regions, there is potential to shed light on the underlying mechanisms leading to infective and non-infective wound complications.