Surgical Site Infections in Obstetrics and Gynaecology
Keywords:
Wound infection, Postoperative complications, Sepsis, Prophylactic Antibiotics
Abstract
Surgical site infections (SSI) are a common problem among patients undergoing operative procedures, and the incidence varies between 5-10%. There are multiple risk factors for SSIs, of which obesity is gaining significance. Most infections are mono-bacterial and Staphylococcus is the single most common agent.
In obstetrics and gynaecology, lower segment caesarean section (LSCS) and abdominal and vaginal hysterectomy remain the most frequent major surgeries. This article addresses factors causing SSI, various steps in prevention and current recommendations. Timing of antibiotic prophylaxis is an important consideration.
Abdominal preparation with chlorhexidine is recommended. Closure of subcutaneous tissue more than 2 cm thickness and skin with subcuticular stitch is recommended. Dressing of SSI with conventional antimicrobial solutions and innovative methods are described. The use of evidence-based SSI reduction
bundles should be advocated, and “surgeon champions” should be encouraged to lead in the successful implementation of these.
References
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2. Madeira MZ de A, Trabasso P. Surgical site infections in women and their association with clinical conditions. Rev Soc Bras Med Trop. 2014 Jul; 47(4):457–61.
3. Sway A, Nthumba P, Solomkin J, Tarchini G, Gibbs R, Ren Y, et al. Burden of surgical site infection following cesarean section in sub-Saharan Africa: a narrative review. Int J Womens Health. 2019; 11:309–18.
4. Shree R, Park SY, Beigi RH, Dunn SL, Krans EE. Surgical site infection following cesarean delivery: patient, provider and procedure specific risk factors. Am J Perinatol. 2016 Jan; 33(2):157.
5. Vegel AJ, Benden DM, Borgert AJ, Kallies KJ, Kothari SN. Impact of Obesity on Caesarean Delivery Outcomes. WMJ. 2017 Nov; 116(4):206–9.
6. Shainker SA, Raghuraman N, Modest AM, Schnettler WT, Hacker MR, Ralston SJ. The utility of midtrimester ultrasound assessment of the subcutaneous space in predicting caesarean wound complications. J Matern Fetal Neonatal Med. 2015; 28(15):1766–9.
7. Yin X, Zhu L, Tan W, Zhu X, Liu S, Xu W. Time Intervals Between Prior Cervical Conization and Posterior Hysterectomy Influence Postoperative Infection in Patients with Cervical Intraepithelial Neoplasia or Cancer. Med Sci Monit. 2018 Dec; 24:9063–72.
8. Liu R, Lin L, Wang D. Antimicrobial prophylaxis in caesarean section delivery. Exp Ther Med. 2016 Aug ;12(2):961–4.
9. Uppal S, Harris J, Al-Niaimi A, Swenson CW, Pearlman MD, Reynolds RK, et al. Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy. Obstet Gynecol. 2016 Feb; 127(2):321–9.
10. Harper LM, Kilgore M, Szychowski JM, Andrews WW, Tita ATN. Economic Evaluation of Adjunctive Azithromycin Prophylaxis for Caesarean Delivery. Obstet Gynecol. 2017; 130(2):328–34.
11. Khlifi A, Kouira M, Bannour I, Hachani F, Kehila M, Ferhi F, et al. What is the optimal timing of prophylactic prophylaxis for elective caesarean section, before the skin incision or after clamping the umbilical cord. J Gynécologie Obs Biol la Reprod. 2016 Nov; 45(9):1133–43.
12. Tuuli MG, Liu J, Stout MJ, Martin S, Cahill AG, Odibo AO, et al. A Randomized Trial Comparing Skin Antiseptic Agents at Caesarean Delivery. N Engl J Med. 2016 Feb; 374(7):647.
13. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before caesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews: CD007892. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203198
14. Charoenkwan K, Iheozor-Ejiofor Z, Rerkasem K, Matovinovic E. Scalpel versus electrosurgery for major abdominal incisions. Cochrane database Syst Rev. 2017;
6(6):CD005987.
15. Jafarzadeh L, Hojjati H. Effect of Normal Saline on Cleaning Uterine Cavity During Caesarean Delivery. J Clin Diagn Res. 2016 Jul; 10(7): QC11-3.
16. Scrafford JD, Reddy B, Rivard C, Vogel RI. Effect of intraoperative glove changing during cesarean section on postoperative complications: a randomized controlled trial. Arch Gynecol Obstet. 2018 Jun;297(6):1449-1454.
17. Temming LA, Raghuraman N, Carter EB, Stout MJ, Rampersad RM, Macones GA, et al. Impact of evidencebased interventions on wound complications after cesarean delivery. Am J Obstet Gynecol. 2017; 217(4): 449.e1-449.e9.
18. Kwon JY, Yun HG, Park IY. n-Butyl-2-cyanoacrylate tissue adhesive (Histoacryl) vs. subcuticular sutures for skin closure of Pfannenstiel incisions following caesarean delivery. PLoS One [Internet]. 2018 [cited 2019 Jul 4];13(9): e0202074.
19. Chamariya S, Prasad MS, Chauhan A. Comparison of dermabond adhesive glue with skin suture for repair of episiotomy. Int J Reprod Contracept Obstet Gynecol 2016; 5(10): 3461-5.
20. Whitney JD, Dellinger EP, Weber J, Swenson RE, Kent CD, Swanson PE, et al. The Effects of Local Warming on Surgical Site Infection. Surg Infect (Larchmt). 2015 Oct; 16(5):595.
21. Kaplan NM, Smadi AA, Al-Taani MI, El-Qudah MA. Microbiology of wound infection after caesarean section in a Jordanian hospital. East Mediterr Health J. 2003 Sep-Nov;9(5-6):1068-74.
22. Rood KM, Buhimschi IA, Jurcisek JA, Summerfield TL, Zhao G, Ackerman WE, et al. Skin Microbiota in Obese Women at Risk for Surgical Site Infection After Caesarean Delivery. Sci Rep. 2018 Jun 8; 8(1):8756
23. Guideline Development Group. Prevention and Control Methicillin-Resistant Staphylococcus aureus (MRSA). National Clinical Guideline No. 2. Available from: https://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/infectioncontrolandhai/guidelines/File,14478,en.pdf Last accessed
on 22 Sept 2019.
24. ASHP Therapeutic Guidelines. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. https://www.
ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.ashx. Last accessed on 22 Sept 2019.
25. Wu TS, Yang CH, Brown-Elliott BA, Chao AS, Leu HS, Wu TL, et al. Postcesarean section wound infection caused by Mycobacterium massiliense. J Microbiol Immunol Infect. 2016 Dec; 49(6):955–61.
26. Amenu D, Belachew T, Araya F. Surgical site infection rate and risk factors among obstetric cases of jimma university specialized hospital, southwest ethiopia. Ethiop J Health Sci. 2011 Jul;21(2):91-100.
27. Ruhstaller K, Downes KL, Chandrasekaran S, Srinivas S, Durnwald C. Prophylactic Wound Vacuum Therapy after Caesarean Section to Prevent Wound Complications in the Obese Population: A Randomized Controlled Trial (the ProVac Study). Am J Perinatol. 2017; 34(11):1125–30.
28. Stanirowski PJ, Kociszewska A, Cendrowski K, Sawicki W. Dialkylcarbamoyl chloride-impregnated dressing for the prevention of surgical site infection in women undergoing cesarean section: a pilot study. Arch Med Sci. 2016 Oct; 12(5):1036–42.
29. Stanirowski PJ, Wnuk A, Cendrowski K, Sawicki W. Growth factors, silver dressings and negative pressure wound therapy in the management of hard-to-heal postoperative wounds in obstetrics and gynecology: a review. Arch Gynecol Obstet. 2015 Oct; 292(4):757–75.
30. Andiman SE, Xu X, Boyce JM, Ludwig EM, Rillstone HRW, Desai VB. Decreased Surgical Site Infection Rate in Hysterectomy: Effect of a Gynecology-Specific Bundle. Obstet Gynecol. 2018 Jun;131(6):991-9.
31. Carter EB, Temming LA, Fowler S, Eppes C, Gross G, Srinivas SK, et al. Evidence-Based Bundles and Caesarean Delivery Surgical Site Infections: A Systematic Review and Meta-analysis. Obstet Gynecol. 2017 Oct;130(4):735-746.
32. Temming LA, Raghuraman N, Carter EB, Stout MJ, Rampersad RM, Macones GA, et al. Impact of evidencebased interventions on wound complications after caesarean delivery. Am J Obstet Gynecol. 2017; 217(4):449.e1-449.e9.
33. Sartelli M, Kluger Y, Ansaloni L, Coccolini F, Baiocchi GL, Hardcastle TC, Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion. World J Emerg Surg [Internet]. 2018 [cited 2019 Jul 3]; 13:37. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/30140304.
2. Madeira MZ de A, Trabasso P. Surgical site infections in women and their association with clinical conditions. Rev Soc Bras Med Trop. 2014 Jul; 47(4):457–61.
3. Sway A, Nthumba P, Solomkin J, Tarchini G, Gibbs R, Ren Y, et al. Burden of surgical site infection following cesarean section in sub-Saharan Africa: a narrative review. Int J Womens Health. 2019; 11:309–18.
4. Shree R, Park SY, Beigi RH, Dunn SL, Krans EE. Surgical site infection following cesarean delivery: patient, provider and procedure specific risk factors. Am J Perinatol. 2016 Jan; 33(2):157.
5. Vegel AJ, Benden DM, Borgert AJ, Kallies KJ, Kothari SN. Impact of Obesity on Caesarean Delivery Outcomes. WMJ. 2017 Nov; 116(4):206–9.
6. Shainker SA, Raghuraman N, Modest AM, Schnettler WT, Hacker MR, Ralston SJ. The utility of midtrimester ultrasound assessment of the subcutaneous space in predicting caesarean wound complications. J Matern Fetal Neonatal Med. 2015; 28(15):1766–9.
7. Yin X, Zhu L, Tan W, Zhu X, Liu S, Xu W. Time Intervals Between Prior Cervical Conization and Posterior Hysterectomy Influence Postoperative Infection in Patients with Cervical Intraepithelial Neoplasia or Cancer. Med Sci Monit. 2018 Dec; 24:9063–72.
8. Liu R, Lin L, Wang D. Antimicrobial prophylaxis in caesarean section delivery. Exp Ther Med. 2016 Aug ;12(2):961–4.
9. Uppal S, Harris J, Al-Niaimi A, Swenson CW, Pearlman MD, Reynolds RK, et al. Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy. Obstet Gynecol. 2016 Feb; 127(2):321–9.
10. Harper LM, Kilgore M, Szychowski JM, Andrews WW, Tita ATN. Economic Evaluation of Adjunctive Azithromycin Prophylaxis for Caesarean Delivery. Obstet Gynecol. 2017; 130(2):328–34.
11. Khlifi A, Kouira M, Bannour I, Hachani F, Kehila M, Ferhi F, et al. What is the optimal timing of prophylactic prophylaxis for elective caesarean section, before the skin incision or after clamping the umbilical cord. J Gynécologie Obs Biol la Reprod. 2016 Nov; 45(9):1133–43.
12. Tuuli MG, Liu J, Stout MJ, Martin S, Cahill AG, Odibo AO, et al. A Randomized Trial Comparing Skin Antiseptic Agents at Caesarean Delivery. N Engl J Med. 2016 Feb; 374(7):647.
13. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before caesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews: CD007892. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203198
14. Charoenkwan K, Iheozor-Ejiofor Z, Rerkasem K, Matovinovic E. Scalpel versus electrosurgery for major abdominal incisions. Cochrane database Syst Rev. 2017;
6(6):CD005987.
15. Jafarzadeh L, Hojjati H. Effect of Normal Saline on Cleaning Uterine Cavity During Caesarean Delivery. J Clin Diagn Res. 2016 Jul; 10(7): QC11-3.
16. Scrafford JD, Reddy B, Rivard C, Vogel RI. Effect of intraoperative glove changing during cesarean section on postoperative complications: a randomized controlled trial. Arch Gynecol Obstet. 2018 Jun;297(6):1449-1454.
17. Temming LA, Raghuraman N, Carter EB, Stout MJ, Rampersad RM, Macones GA, et al. Impact of evidencebased interventions on wound complications after cesarean delivery. Am J Obstet Gynecol. 2017; 217(4): 449.e1-449.e9.
18. Kwon JY, Yun HG, Park IY. n-Butyl-2-cyanoacrylate tissue adhesive (Histoacryl) vs. subcuticular sutures for skin closure of Pfannenstiel incisions following caesarean delivery. PLoS One [Internet]. 2018 [cited 2019 Jul 4];13(9): e0202074.
19. Chamariya S, Prasad MS, Chauhan A. Comparison of dermabond adhesive glue with skin suture for repair of episiotomy. Int J Reprod Contracept Obstet Gynecol 2016; 5(10): 3461-5.
20. Whitney JD, Dellinger EP, Weber J, Swenson RE, Kent CD, Swanson PE, et al. The Effects of Local Warming on Surgical Site Infection. Surg Infect (Larchmt). 2015 Oct; 16(5):595.
21. Kaplan NM, Smadi AA, Al-Taani MI, El-Qudah MA. Microbiology of wound infection after caesarean section in a Jordanian hospital. East Mediterr Health J. 2003 Sep-Nov;9(5-6):1068-74.
22. Rood KM, Buhimschi IA, Jurcisek JA, Summerfield TL, Zhao G, Ackerman WE, et al. Skin Microbiota in Obese Women at Risk for Surgical Site Infection After Caesarean Delivery. Sci Rep. 2018 Jun 8; 8(1):8756
23. Guideline Development Group. Prevention and Control Methicillin-Resistant Staphylococcus aureus (MRSA). National Clinical Guideline No. 2. Available from: https://www.hpsc.ie/a-z/microbiologyantimicrobialresistance/infectioncontrolandhai/guidelines/File,14478,en.pdf Last accessed
on 22 Sept 2019.
24. ASHP Therapeutic Guidelines. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. https://www.
ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.ashx. Last accessed on 22 Sept 2019.
25. Wu TS, Yang CH, Brown-Elliott BA, Chao AS, Leu HS, Wu TL, et al. Postcesarean section wound infection caused by Mycobacterium massiliense. J Microbiol Immunol Infect. 2016 Dec; 49(6):955–61.
26. Amenu D, Belachew T, Araya F. Surgical site infection rate and risk factors among obstetric cases of jimma university specialized hospital, southwest ethiopia. Ethiop J Health Sci. 2011 Jul;21(2):91-100.
27. Ruhstaller K, Downes KL, Chandrasekaran S, Srinivas S, Durnwald C. Prophylactic Wound Vacuum Therapy after Caesarean Section to Prevent Wound Complications in the Obese Population: A Randomized Controlled Trial (the ProVac Study). Am J Perinatol. 2017; 34(11):1125–30.
28. Stanirowski PJ, Kociszewska A, Cendrowski K, Sawicki W. Dialkylcarbamoyl chloride-impregnated dressing for the prevention of surgical site infection in women undergoing cesarean section: a pilot study. Arch Med Sci. 2016 Oct; 12(5):1036–42.
29. Stanirowski PJ, Wnuk A, Cendrowski K, Sawicki W. Growth factors, silver dressings and negative pressure wound therapy in the management of hard-to-heal postoperative wounds in obstetrics and gynecology: a review. Arch Gynecol Obstet. 2015 Oct; 292(4):757–75.
30. Andiman SE, Xu X, Boyce JM, Ludwig EM, Rillstone HRW, Desai VB. Decreased Surgical Site Infection Rate in Hysterectomy: Effect of a Gynecology-Specific Bundle. Obstet Gynecol. 2018 Jun;131(6):991-9.
31. Carter EB, Temming LA, Fowler S, Eppes C, Gross G, Srinivas SK, et al. Evidence-Based Bundles and Caesarean Delivery Surgical Site Infections: A Systematic Review and Meta-analysis. Obstet Gynecol. 2017 Oct;130(4):735-746.
32. Temming LA, Raghuraman N, Carter EB, Stout MJ, Rampersad RM, Macones GA, et al. Impact of evidencebased interventions on wound complications after caesarean delivery. Am J Obstet Gynecol. 2017; 217(4):449.e1-449.e9.
33. Sartelli M, Kluger Y, Ansaloni L, Coccolini F, Baiocchi GL, Hardcastle TC, Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion. World J Emerg Surg [Internet]. 2018 [cited 2019 Jul 3]; 13:37. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/30140304.
Published
2019-11-15
How to Cite
Dr. Anahita Chouhan. (2019). Surgical Site Infections in Obstetrics and Gynaecology. The Indian Practitioner, 72(10), 21-27. Retrieved from https://articles.theindianpractitioner.com/index.php/tip/article/view/859
Section
Review article
