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Year : 2016 | Volume : 4 | Issue : 4 | Page : 198 - 202  


Original Articles
An Analysis of Post Caesarean Section Surgical Site Infections in a Tertiary Care Women’s and Neonate’s Hospital

RamananDuraiswami 1, Teena Rajeev 2

1 Chairman, Hospital Infection Control Committee, Malla Reddy Institute of Medical Sciences, Hyderabad

2 Infection Control Officer, Fernandez Hospital for Women and Newborn, Hyderguda, Hyderabad

Corresponding Author:

Col [Dr] Ramanan Duraiswami

E-mail: daru_r@rediffmail.com

ABSTRACT:

Background: Surgical Site Infections [SSI] are infections that develop within thirty days of surgery. They are an important cause of Hospital Acquired Infections [HAI]. The Hospital Infection Control Committee [HICC] of a hospital plays an important role in monitoring the incidence of SSI in a hospital, including the clinical audit of any outbreaks, and in suggesting measures to reduce the incidence of SSI.

Objectives: The objectives of the study were to identify factors contributing to the incidence of SSI in a tertiary care maternity hospital with a view to implementing practices that would contribute a reduction in the incidence of the same.

Methods: We monitored the incidence of SSI in a tertiary care maternity hospital geared for managing high risk pregnancies as well as normal pregnancies and carried out a clinical audit of an increase in the rates of SSI in two months. We present the details of measures which were subsequently put in place to reduce the incidence of such cases in our hospital.

Results: In cases of Surgical Site Infections [SSI] in patients delivered by LSCS at a referral tertiary care maternity and neonatology hospital, raised BMI (in 45.45% of cases), emergency versus planned LSCS (in 81.81% of cases), prolonged duration of surgery (in 72.72% of cases), and administration of prophylactic antibiotics beyond the accepted window period (in 72.72% of cases), were all found to be significant risk factors.

Conclusion: Careful monitoring of the incidence of SSI in LSCS patients along with regular audit of increase in cases and institution of appropriate preventive measures to lower the risk factors can result in the reduction of such cases.

Key words: Surgical Site Infections [SSI], clinical audit, risk factors, preventive measures

INTRODUCTION:

Surgical site infections [SSI] are the most common health care associated infections. [1] Several factors have been found to play a role in the incidence of SSI. It is necessary to monitor the incidence of SSI closely and to put in place proper protocols to ensure that the incidence of SSI is minimized in order that patient care and safety is not compromised, especially when the patients have come to undergo a perfectly normal physiological process. Fernandez Hospital is a tertiary care Women’s and Newborns’ Hospital located in Hyderabad, conducting an average of 250 - 400 Caesarean Sections per month. The Hospital Infection Control Committee (HICC), headed by the Director of Laboratory Services, meets once a month to report on the incidence of various Hospital Acquired Infections [HAI] such as SSI, Central Line Associated Blood Stream Infections [CLABSI], and Ventilator Associated Pneumonias [VAP],and Catheter Associated Urinary Tract Infection [CAUTI]. The HICC oversees adherence to standard protocols to minimize HAI and recommends corrective measures to reduce the incidence of all HAI in the Hospital.

The objectives of the study were to identify factors contributing to the incidence of SSI in a tertiary care maternity hospital with a view to implementing practices that would contribute a reduction in the incidence of the same.

MATERIAL & METHODS:

The incidence of SSI amongst patients undergoing elective or emergency Lower Segment Caesarean Section [LSCS] was monitored at Fernandez Hospital by the Infection Control team, comprising the Microbiologist [Infection Control Officer] and the two Infection Control Nurses. The criteria used for definition of SSI’s were as per CDC guidelines [2]. These included:

  1. Infection occurs within 30 days after the operation.
  2. Purulent drainage from the surgical site with or without laboratory confirmation. OR
  3. Organisms isolated from an aseptically obtained culture of fluid or tissue from the incision site. OR
  4. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat. OR
  5. Diagnosis of SSI by the treating obstetrician or physician.

All cases were identified either prior to discharge, or at first review after discharge, or those who reported with signs and symptoms of wound infection within thirty days of surgery.

The incidence of SSI for a twenty three month period from January 2014 to November 2015 is summarized in Table 1. The benchmark set for incidence of SSI in Fernandez Hospital was 2.0% or less. In view of the high incidence of SSI in the preceding month [February 2015], an audit was conducted in the month of March 2015 to identify risk factors in the cases of SSI in February using guidelines formulated by the Centre for Disease Control [CDC][2].

RESULTS:

A total of 11 cases of SSI were found amongst 257 LSCS cases [93 elective; 164 emergency LSCS] giving a percentage of 4.26%. Higher rates of SSI were found in the months of May 2014, February 2015 and June 2015 [3.08%, 4.26% and 3.98% respectively]. The causative organisms were Gram negative bacilli [Escherichia Coli, Acinetobacter and Klebsiella Pneumoniae] in nine cases and Staphylococcus Aureus in two cases.An audit was done using a checklist developed for the purpose. The risk factors identified and their incidence are summarized in Table 2. Concomitant hand hygiene audit being done on a monthly basis as part of HICC monitoring revealed about 95 – 98 % hand hygiene compliance in high risk areas. The audit revealed that prolonged surgery [>40 minutes] [72%], emergency surgery [82%], improper administration of antibiotics beyond the recommended window period for administration of prophylactic antibiotics [72%] and a Body Mass Index [BMI] more than 30 [46%] were significant contributory factors in our series of cases. Gestational hypertension and maternal age more than 30 years were associated but not significant risk factors [36% and 27 % respectively].

Based upon these findings, the HIC team made the following recommendations to try and reduce the incidence of SSI in patients:

  1. All staff should adhere strictly to the hand hygiene and other aseptic protocols in the Hospital.
  2. An attempt should be made to shorten surgical procedures to less than forty minutes wherever possible.
  3. Prophylactic antibiotics should be administered to
  4. patients not earlier than 60 minutes and not later than 15 minutes prior to incision

Table 1: Details of SSI cases in patients undergoing LSCS January 2014 to November 2015

MONTH

NO OF SSI CASES

NO OF LSCS PATIENTS

PERCENTAGE OF SSI

Jan 2014

1

344

0.32 %

Feb 2014

1

293

0.34 %

Mar 2014

5

293

1.70 %

Apr 2014

5

344

1.45 %

May 2014

9

292

3.08 %

Jun 2014

2

319

0.62 %

Jul 2014

3

288

1.04 %

Aug 2014

6

308

1.94 %

Sep 2014

3

334

0.89 %

Oct 2014

4

323

1.23 %

Nov 2014

4

331

1.20%

Dec 2014

4

343

1.16 %

Jan 2015

2

301

0.66 %

Feb 2015

11

257

4.26 %

Mar 2015

2

268

0.74 %

Apr 2015

6

319

1.88 %

May 2015

2

400

0.50 %

Jun 2015

13

326

3.98 %

Jul 2015

2

306

0.65 %

Aug 2015

6

343

1.74 %

Sep 2015

5

372

1.34 %

Oct 2015

15

388

3.86 %

Nov 2015

5

385

1.29 %

  1. Patients with high BMI should be counselled to lose weight and achieve a BMI which is acceptable.
  2. GDM and gestational hypertension should be vigorously addressed to reduce morbidity.
  3. Use of clippers rather than shaving for pre – operative preparation.

Table 2 Risk Factors Identified in 11 Cases of SSI After Audit In March 2015

Risk factor

Presence of risk factor

In numbers

In percentage

Maternal Age> 30 years

03

27.3 %

Body Mass Index > 30

05

45.45 %

Gestational Diabetes Mellitus

02

18.18 %

Gestational Hypertension

04

36.36 %

PROM

02

18.18 %

Duration of operation > 40 minutes

08

72.72 %

Type of surgery [emergency]

09

81.81 %

Antibiotics given <15 minutes or > 60 minutes prior to incision

08

72.72 %

Consequent to implementation of the above measures, there was a drop in the incidence of SSI in the subsequent three months [0.74% in March,1.88 % in April, and 0.50% in May]. However a rise in the incidence of SSI was noted in June [13 cases out of 326 LSCS performed, percentage of 3.98%]. Another audit was done in July to ascertain the reasons for the spurt in cases, the findings of which are summarized in Table 3.

Table 3: Risk Factors Identified in 13 Cases of SSI After Audit in July 2015

Risk factor

Presence of risk factor

No.

PERCENTAGE

Maternal Age> 30 years

09

69.23 %

Body Mass Index > 30

07

53.84 %

Gestational Diabetes Mellitus

04

30.76 %

Length of Hospital stay > 5 days

07

53.84 %

Pre – eclampsia

03

23.07 %

Duration of operation > 40 minutes

13

100 %

Type of surgery [emergency]

10

76.92 %

Antibiotics given <15 minutes or > 60 minutes prior to incision

09

69.23 %

The audit revealed that the same factors identified in the earlier audit continued to be significant in the present series of cases [prolonged surgery [>40 minutes] [100 %], emergency surgery [81.81 %], improper administration of antibiotics beyond the recommended window period for administration of prophylactic antibiotics [69.23 %], and a Body Mass Index [BMI] more than 30 [53.84 %] were significant contributory factors in our fresh series of cases. Additionally, length of hospital stay more than 5 days was found in 53.84% of cases and maternal age more than 30 years in 69.23 % cases. Furthermore, the intake of new nurses into the staff of Fernandez Hospital and their lack of adherence to protocols due to inadequate training were found to be contributory. It was also realized that non adherence to aseptic measures by patients after discharge was a contributory factor.

The following measures were therefore again recommended:

  1. Strict implementation of the measures suggested earlier.
  2. Intensive and pro – active training of new staff in Hospital Infection prevention protocols.
  3. A set of do’s and don’ts for patients to follow after discharge from hospital was incorporated into the discharge summary for all patients admitted for LSCS. [attached as Annexure I] This was implemented because it was found that some cases were returning to hospital with SSI after three or more days of discharge, suggesting poor personal hygiene and wound care by the patients at home.

Implementation of these measures resulted in an acceptable level of SSI in subsequent months except for a slight peak in October

DISCUSSION:

Caesarean section (CS) wound infections represent a substantial burden to the health system and the prevention of such infections should be a healthcare priority in developing countries.The single most important risk factor for postpartum maternal infection is delivery by Caesarean Section [5]. Maternal morbidity related to infections has been shown to be eight – fold higher after caesarean section than vaginal delivery [6]. Reducing the number of caesarean section deliveries and identifying risk factors for post caesarean surgical site infections [SSI’s] could contribute to a reduction in maternal morbidity[7].

The reported incidence of SSI following caesarean sections varies widely, ranging from 0.3 % in Turkey [8] to 17 % in Australia [9]. The incidence reported depends on the following: the definition of SSI being adopted, the intensity of surveillance, the prevalence of risk factors for SSI in the patient group being audited and whether the survey contains post discharge data [10]. Our data were derived from both inpatient, first review data and in patients reporting with signs and symptoms of wound infection within thirty days of surgery, and followed guidelines of the CDC. Our rates of SSI were lower than other studies. Our benchmark is better than the benchmark of 6.4% [RCOG Green top guidelines [3] or the American benchmark of 2.99% [4].

Our study showed a higher percentage of SSI in emergency LSCS versus elective LSCS, whereas the study by Mitt et al [5] did not show any significant difference. Their study did not mention the significance of the other factors such as antibiotic usage. Use of timely prophylactic antibiotics as per existing guidelines [11] reduced the incidence of SSI in our study. Cruse and Foord [12] have identified Staphylococcus Aureus and Gram negative organisms as the most common organisms isolated in SSI cases. Culture of swabs collected from our patients also showed a similar pattern. Studies have shown that the source of infection is usually endogenous [skin, mucous membranes or bowel] and rarely exogenous sources, usually unsterile instruments or staff clothing [13].

Ghuman et al in their analysis of LSCS associated SSI also found that elevated BMI, longer duration of labour, and having an emergency procedure were significant contributory factors in the incidence of post LSCS SSI [14]. The link between obesity and SSI is well established in the literature and relates to increased subcutaneous tissue thickness, impaired immune system, increased wound area, the need for larger incisions and the poor penetration of prophylactic antibiotics in adipose tissue [15, 16]. Wloch et al. observed that being overweight with a BMI >35 was a major risk factor for infection compared with cases who had a BMI 18.5–25 (OR 3.7, 95% confidence interval [CI] 2.6–5.2). The fact that emergency procedures are a statistically significant factor for wound infection is not surprising, and has been documented in previous studies [15] and may be due to rupture of membranes prior to surgery, the increased urgency of surgery, and the reduced attention to infection preventing measures. Owens and Stoessel [17] have highlighted the need for implementation of appropriate strategies to reduce infection in women at risk, which include antibiotic prophylaxisas a routine procedure, and adequate glycaemic control in diabetic patients. Other studies have highlighted the importance of uncontrolled GDM as a contributory factor in SSI [14, 18, 19].Some studies have questioned the usage of routine prophylactic antibiotics but others support the usage of appropriately timed antibiotic prophylaxis [5, 20, 21, 22].

A satisfactory surveillance system is essential in all hospitals to reduce the rate of sepsis, with reliable feedback to clinicians [23]. The HICC of Fernandez Hospital has, by pro- actively emphasising the need for strict aseptic measures for prevention of SSI, by analysing the contributing factors in SSI by means of audits, and by rigorously monitoring the adherence to all protocols in place for prevention of infections, succeeded in maintaining the incidence of SSI in post LSCS patients at an acceptably low level by international standards, thus lowering the cost of patient care. The HICC meets monthly with the clinicians and administrators to suggest measures for ensuring that infection prevention measures are formulated and implemented meticulously. Regular audits enable the HIC team to monitor the incidence of SSI and suggest appropriate measures to maintain the levels of infection at acceptable levels. A multi – disciplinary approach with infection control specialists playing a key role is mandatory to reduce the burden of suffering caused by post – caesarean section SSI.

Based upon these findings, the HIC team made the following recommendations to try and reduce the incidence of SSI in patients:

  1. All staff should adhere strictly to the hand hygiene and other aseptic protocols in the Hospital.
  2. An attempt should be made to shorten surgical procedures to less than forty minutes wherever possible.
  3. Prophylactic antibiotics should be administered to patients not earlier than 60 minutes and not later than 15 minutes prior to incision.
  4. Patients with high BMI should be counselled to lose weight and achieve a BMI which is acceptable.
  5. GDM and gestational hypertension should be vigorously addressed to reduce morbidity.
  6. Use of clippers rather than shaving for pre – operative preparation

CONCLUSION:

Strict surveillance by a multi – disciplinary team, supported by practicing established protocols for reducing Surgical Site Infections [SSI’s] is necessary to ensure a low incidence of SSI’s in a hospital setting. A regular audit of increased incidence of such cases goes a long way in pinpointing the underlying contributory factors for SSI and enables the Hospital Infection Control Committee to effectively implement preventive measures to reduce the incidence of SSI.

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