Prevalence and factors associated with surgical site infections among mothers after cesarean section at Mbarara Regional Referral Hospital, Uganda: an observational retrospective study

Background

The risk of infection following cesarean delivery is 5-20 times higher than that following normal delivery, contributing to 10% of pregnancy-related mortality. In 2019, Mbarara Regional Referral Hospital (MRRH) performed cesarean section for 40% of deliveries, surpassing the WHO's recommended 15%-20%. The availability and provision of effective prophylactic antibiotics are crucial in preventing surgical site infections (SSIs).

Objectives

To determine the prevalence and predictors of SSIs among mothers after cesarean section, length of hospital stay, and antibiotic use at MRRH.

Design

This was an observational retrospective study conducted in the maternity ward of the MRRH.

Methods

Data on the diagnosis of SSI, length of hospital stay, and antibiotic use were extracted and entered into EpiData software version 3.1 and analyzed using STATA version 15. We conducted logistic regression analysis to identify factors independently associated with SSIs. We also compared the length of hospital stay.

Results

The prevalence of post-cesarean SSIs was 7.9% (95% CI: 6.3%-9.9%). Mothers aged 25 years and younger were less likely to develop SSIs (adjusted odds ratio (aOR): 0.53, 95% CI: 0.30-0.93; p = 0.027). Those with more than six pregnancies were more likely to develop SSIs (aOR: 3.4; 95% CI: 1.35-8.58; p = 0.009). The median length of stay was 8 days for mothers who developed an SSI (interquartile range (IQR): 5, 16) and 3 (IQR: 3, 4) days for those who did not (p < 0.001). Prophylactic antibiotics were prescribed to 83.4% of the women (95% CI: 80.7-85.8). Ampicillin (88.2%) was the most prescribed prophylactic antibiotic, and metronidazole was the most prescribed postoperatively (97.8%) and at discharge (77.6%).

Conclusion

The current prevalence of post-cesarean SSIs is higher in Uganda than in developed countries. Older age and having had more than six pregnancies are independent predictors of SSIs, and post-cesarean SSI significantly prolonged hospital stay.

Antibiotics for preventing infection at the surgical site: Single dose vs. multiple doses

Background

Surgical site infections are common and expensive infections that can cause fatalities or poor patient outcomes. To prevent these infections, antibiotic prophylaxis is used. However, excessive antibiotic use is related to higher costs and the emergence of antimicrobial resistance.

Objectives

The present meta-analysis aimed to compare the effectiveness of a single dosage versus several doses of antibiotics in preventing the development of surgical site infections.

Methods

PubMed was used to find clinical trials evaluating the effectiveness of a single dosage versus several doses of antibiotics in avoiding the development of surgical site infections. The study included trials that were published between 1984 and 2022. Seventy-four clinical trials were included in the analysis. Odds ratios were used to compare groups with 95% confidence intervals. The data were displayed using OR to generate a forest plot. Review Manager (RevMan version 5.4) was used to do the meta-analysis.

Results

Regarding clean operations, there were 389 surgical site infections out of 5,634 patients in a single dose group (6.90%) and 349 surgical site infections out of 5,621 patients in multiple doses group (6.21%) (OR = 1.11, lower CI = 0.95, upper CI = 1.30). Regarding clean-contaminated operations, there were 137 surgical site infections out of 2,715 patients in a single dose group (5.05%) and 137 surgical site infections out of 2,355 patients in multiple doses group (5.82%) (OR = 0.87, lower CI = 0.68, upper CI = 1.11). Regarding contaminated operations, there were 302 surgical site infections out of 3,262 patients in a single dose group (9.26%) and 276 surgical site infections out of 3,212 patients in multiple doses group (8.59%) (OR = 1.11, lower CI = 0.84, upper CI = 1.47). In general, there were 828 surgical site infections out of 11,611 patients in a single dose group (7.13%) and 762 surgical site infections out of 11,188 patients in multiple doses group (6.81%) (OR = 1.05, lower CI = 0.93, upper CI = 1.20). The difference between groups was not significant.

Conclusion

The present study showed that using a single-dose antimicrobial prophylaxis was equally effective as using multiple doses of antibiotics in decreasing surgical site infections.

Single-dose versus multiple-dose antibiotics prophylaxis for preventing caesarean section postpartum infections: A randomized controlled trial

BACKGROUND

Caesarean section, a common obstetric surgical procedure, is a major predisposing factor for puerperal infections, requiring the need for antibiotic prophylaxis. Evidence suggests that single-dose antibiotic prophylaxis has comparable efficacy to multiple-dose antibiotic prophylaxis, but with a lower cost and risk of antibiotic resistance. However, single-dose antibiotic prophylaxis after caesarean section is not generally used in many centres in sub-Saharan Africa.

OBJECTIVE

This study aimed to compare the effectiveness of single- versus multiple-dose antibiotic prophylaxis to prevent post-caesarean section infections.

METHODOLOGY

This open-label, randomized controlled trial involved 162 consenting patients admitted for caesarean section (elective or emergency) at the Federal Medical Centre Keffi. They were distributed randomly into treatment arm A or B. Subjects in both arms received intravenous ceftriaxone (1 g) and metronidazole (500 mg) 30-60 min before incision; subjects in arm B received additional parenteral doses for 48 h and then cefuroxime 500 mg tablets every 12 h and metronidazole 400 mg tablets every 8 h for 5 days. The patients were monitored for 2 weeks for evidence of wound infection, febrile morbidity and clinical endometritis.

RESULT

There was no statistical difference in the incidence of wound infection (6.6% versus 7.4%; p = .882) and febrile morbidity (11.8% versus 11.1%, p = .807). However, clinical endometritis (0.0% versus 6.1%, p = .028) was statistically significant with none reported in the single-dose arm.

CONCLUSION

Single-dose ceftriaxone and metronidazole is as effective as multiple doses for antibiotic prophylaxis to prevent post-caesarean section infections. Adoption of this approach in low-risk patients would reduce the cost of prophylactic antibiotics, workload for staff and antibiotic resistance.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis

BACKGROUND

The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work.

METHODS

MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted.

RESULTS

This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis.

CONCLUSIONS

There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.