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Cesarean Infection
2
Cesarean Delivery
Post-Surgical Infection Prevention
Jeanne Wigant, MD
April 25, 2018
CS Stats
Why should we care?
CS Stats
Prevalence
Prevalence
- 1.3 Million CS were performed in the US in 2015 (MC major surgery), 32% of all deliveries (1,2)
- Pregnancy associated infection 4th MCC of maternal death in the US, and CS have infection rates 5-10x higher than vaginal deliveries (2)
- 60-70% unscheduled, infection occurs in 10-15% (3)
PSIs
PSIs
Post-Surgical Infections
Morbidity
Morbidity
- MC PSIs are endometritis (6-27%), clinically significant fever (5-24%) and wound infection (2-9%)
- Postpartum endometritis occurs after 1-3% of deliveries and is up to 10x more common after CS
- Longer hospitalizations, higher readmission rates and health care costs.
- Increased risk of uterine rupture in a subsequent trial of labor after endometritis. (4)
PSIP Bundles
Perioperative Elements
* Preoperative standard antibiotics
* Chlorhexidine alcohol skin preparation
* Use of clippers instead of razor
* Vaginal cleansing by povidone-iodine
Intraoperative Elements
* Removal of placenta by traction
* Closure of SubQ tissue if thickness >2cm
* Suture skin closure instead of staples
Postoperative Elements
* Dressing removal between 24 and 48hr
* Daily use of chlorhexidine gluconate soap
Area for improvement?
Area for improvement?
Vaginal Cleansing
Not a new concept- since the 1970s it has been demonstrated that a povidone-iodine vaginal scrub before vaginal surgery or abdominal hysterectomy is associated with lower PSI morbidity. Prior studies demonstrated a decreased number of vaginal bacterial species by 98%.
Vaginal Cleansing
So why now?
So why now?
Meta-analysis of 16 trials (n=4,837) published late 2017.
- Studies came from countries including low, middle and high income.
- Publication ranged from 1997-2016, most after 2010.
- Primary outcome: incidence of endometritis
- Excluded studies in which prophylactic ABX were NOT given
Vaginal Cleansing Meta-analysis (4)
- Overall, those who received vaginal cleansing had a nearly 50% lower incidence of endometritis (4.5% compared w/ 8.8%).
- Benefit was even greater when limited to women in labor before CS (8.1% vs 13.8%) or women w/ ROM (4.3% vs 20.1%).
- The analysis of women NOT in labor or with intact membranes did not show a statistically significant benefit, nor was there any SS decrease in wound infection/complications.
- BOTTOM LINE: "Because it is generally inexpensive and a simple intervention, we recommend preoperative vaginal preparation before cesarean delivery in these women [in labor or w/ ROM prior to CS]."
How?
- Many variations, but MC 10% povidone-iodine via sponge stick for ~30 seconds AFTER the decision to perform CS is made. (4)
- Low cost intervention- $1.40 per 188mL
- One study directly compared iodine w/ chlorhexidine and found no statistically significant difference, but iodine is currently only one approved for use in the vagina. Off-label use of chlorhexidine can be considered especially if iodine allergic. (1,4)
References
References
1. Kawakita T and Landy H. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Maternal Health, Neonatology, and Perinatology. (2017) 3:12. DOI 10.1186/s40748-017-0051-3.
2. Castelli G, Flaherty A, and Jarrett J. Does azithromycin have a role in cesarean sections? The Journal of Family Practice. 2017; 66(12):762-764.
3. Boggess K, Tita A, Jauk V, Saade G, Longo S, et al. Risk factors for post cesarean maternal infection in a trial of extended-spectrum antibiotic prophylaxis. Obstetrics & Gynecology. 2017; 129(3):481-485
4. Keith A, Liu B, Valent A, Tuuli M and Caughey A. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis: a cost-effectiveness analysis. Obstetrics & Gynecology. 2017; 130(6):1279-1284.