A Multifaceted Surgical Site Infection Prevention Bundle for Cesarean Delivery

Abstract

Objective Surgical site infections (SSI, including wound infections, endometritis, pelvic abscess, and sepsis) may complicate cesarean section (C/S). We report outcomes before and after the introduction of an SSI prevention bundle that did not include antibiotics beyond routine prophylaxis (cefazolin, or gentamicin/clindamycin for penicillin-allergic patients).

Study Design The prevention bundle was introduced following an increase in C/S-associated SSI, which itself was associated with an institutional switch in preoperative scrub from povidone-iodine to chlorhexidine gluconate (CHG)/isopropanol. Components of the bundle included: (1) full-body preoperative wash with 4% CHG cloths; (2) retraining on surgeon hand scrub; (3) retraining for surgical prep; and (4) patient education regarding wound care. Patients delivered by C/S at ≥24 weeks of gestation were segregated into four epochs over 7 years: (1) baseline (18 months when povidone-iodine was used); (2) CHG scrub (18 months after skin prep was switched to CHG); (3) bundle implementation (24 months); and (4) maintenance (24 months following implementation).

Results A total of 3,637 patients were included (n = 667, 796, 1098, and 1076, respectively, in epochs 1–4). A rise in SSI occurred with the institutional switch from povidone-iodine to CHG (i.e., from baseline to the CHG scrub epoch, 8.4–13.3%, p < 0.01). Following the intervention (maintenance epoch), this rate decreased to below baseline values (to 4.5%, p < 0.01), attributable to a decline in wound infection (rates in the above three epochs 6.9, 12.9, and 3.5%, respectively, p < 0.01), with no change in endometritis. In multivariable analysis, only epoch and body mass index (BMI) were independently associated with SSI. The improvement associated with the prevention bundle held for stratified analysis of specific risk factors such as chorioamnionitis, prior C/S, obesity, labor induction, and diabetes.

Conclusion Implementation of a prevention bundle was associated with a reduction in post-C/S SSI. This improvement was achieved without the use of antibiotics beyond standard preoperative dosing.

Keywords

cesarean section - infection - surgical site infection - prevention of morbidity

Note

This study was presented in part at the Annual Meeting of Central Association of Obstetricians and Gynecologists, Scottsdale AZ, October 18–21, 2017.

Publication History

Received: 01 October 2019

Accepted: 26 October 2019

Article published online:
30 December 2019

• References

• 1 DeFrances CJ, Cullen KA, Kozak LJ. National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis and procedure data. Vital and health stat 13 2007; (165) 1-209
• 2 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK, Drake P. Births: final data for 2016. National Vital Statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System 2018; 67 (01) 1-55
• 3 Anderson DJ, Podgorny K, Berríos-Torres SI. et al. Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014; 35 (06) 605-627
• 4 Conroy K, Koenig AF, Yu YH, Courtney A, Lee HJ, Norwitz ER. Infectious morbidity after cesarean delivery: 10 strategies to reduce risk. Rev Obstet Gynecol 2012; 5 (02) 69-77
• 5 Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. BJOG 2012; 119 (11) 1324-1333
• 6 Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116 (06) 1302-1309
• 7 Olsen MA, Butler AM, Willers DM, Gross GA, Hamilton BH, Fraser VJ. Attributable costs of surgical site infection and endometritis after low transverse cesarean delivery. Infect Control Hosp Epidemiol 2010; 31 (03) 276-282
• 8 Currier JS, Tosteson TD, Platt R. Cefazolin compared with cefoxitin for cesarean section prophylaxis: the use of a two-stage study design. J Clin Epidemiol 1993; 46 (07) 625-630
• 9 American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2011; 117 (06) 1472-1483
• 10 Harper LM, Kilgore M, Szychowski JM, Andrews WW, Tita ATN. Economic evaluation of adjunctive azithromycin prophylaxis for cesarean delivery. Obstet Gynecol 2017; 130 (02) 328-334
• 11 Skeith AE, Niu B, Valent AM, Tuuli MG, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis: a cost-effectiveness analysis. Obstet Gynecol 2017; 130 (06) 1279-1284
• 12 Tita AT, Szychowski JM, Boggess K. et al; C/SOAP Trial Consortium. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med 2016; 375 (13) 1231-1241
• 13 Archer GL. Alteration of cutaneous staphylococcal flora as a consequence of antimicrobial prophylaxis. Rev Infect Dis 1991; 13 (Suppl. 10) S805-S809
• 14 Beigi RH, Bunge K, Song Y, Lee BY. Epidemiologic and economic effect of methicillin-resistant Staphylococcus aureus in obstetrics. Obstet Gynecol 2009; 113 (05) 983-991
• 15 Mazzola G, Murphy K, Ross RP. et al. Early gut microbiota perturbations following intrapartum antibiotic prophylaxis to prevent group B streptococcal disease. PLoS One 2016; 11 (06) e0157527
• 16 Stoll BJ, Hansen N, Fanaroff AA. et al. Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants. N Engl J Med 2002; 347 (04) 240-247
• 17 Darouiche RO, Wall Jr MJ, Itani KM. et al. chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010; 362 (01) 18-26
• 18 Tuuli MG, Liu J, Stout MJ. et al. A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med 2016; 374 (07) 647-655
• 19 Karki S, Cheng AC. Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: a systematic review. J Hosp Infect 2012; 82 (02) 71-84
• 20 Beausoleil CM, Paulson DS, Bogert A, Lewis GS. In vivo evaluation of the persistant and residual antimicrobial properties of three hand-scrub and hand-rub regimes in a simulated surgical environment. J Hosp Infect 2012; 81 (04) 283-287
• 21 Kawakita T, Iqbal SN, Landy HJ, Huang JC, Fries M. Reducing cesarean delivery surgical site infections: a resident-driven quality initiative. Obstet Gynecol 2019; 133 (02) 282-288
• 22 Ledger WJ, Blaser MJ. Are we using too many antibiotics during pregnancy?. BJOG 2013; 120 (12) 1450-1452
• 23 Neu J. The microbiome during pregnancy and early postnatal life. Semin Fetal Neonatal Med 2016; 21 (06) 373-379
• 24 Romano-Keeler J, Weitkamp JH. Maternal influences on fetal microbial colonization and immune development. Pediatr Res 2015; 77 (1-2): 189-195
• 25 Mueller NT, Whyatt R, Hoepner L. et al. Prenatal exposure to antibiotics, cesarean section and risk of childhood obesity. Int J Obes 2015; 39 (04) 665-670
• 26 Stensballe LG, Simonsen J, Jensen SM, Bonnelykke K, Bisgaard H. Use of antibiotics during pregnancy increases the risk of asthma in early childhood. J Pediatr 2013; 162 (04) 832-838
• 27 Larsen B, Galask RP. Vaginal microbial flora: practical and theoretic relevance. Obstet Gynecol 1980; 55 (5, Suppl) 100S-113S
• 28 Haas DM, Morgan S, Contreras K, Enders S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev 2018; 7: CD007892
• 29 Caissutti C, Saccone G, Zullo F. et al. Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol 2017; 130 (03) 527-538