Article Type : Research Article
Authors : Zaman F, Akhtar S, Fatema B and Begum M
Keywords : Post caesarean; Wound infection; Surgical incision; Bacterial infection
Background: Post caesarean wound infection is a bacterial infection in the surgical incision following caesarean delivery. Wound infection following caesarean section is not only a leading cause of prolonged hospital stay but a major cause of the widespread aversion to caesarean delivery in developing countries. The incidence ranges from 5% to 25% depending on the nature and area of practice.
Objective: The aim of this study was to evaluate the possible etiopathology of wound infection and to take possible measures to reduce the incidence of wound infection at hospitals.
Methods: This descriptive type of cross-sectional study was carried out in the Department of Obstetrics and Gynaecology in Institute of Child and Mother Health (ICMH), Dhaka from November 2009 – April 2010. Here in ICMH, fifty patients who developed post caesarean wound infection were randomly selected for the study. Data was collected from the patients regarding history, pre-operative, per-operative, post-operative findings and bacteriological studies. The data was analyzed by using computer software program SPSS (version- 10).
Results: This study showed that there was close relationship between inadequate antenatal checkup (56%), anaemia (76%), and malnutrition and wound infection. It is evident that prolonged labour (48 hrs. 40%), premature ruptures of membrane (48hrs, 28%), emergency operation (92%), intervention for delivery before admission, prolonged operation time (>1hrs) were important predisposing factors for wound infection. Serosanguinous discharge was present in 68% of the patients and culture of wound discharge showed in 64% positive and Pseudomonas (28%) was the most frequent organism and Escherichia coli (24%) was the second most common organism.
Conclusion: This study shows that post caesarean wound infection is more following emergency operation. Effort should be geared towards the prevention of wound infection by a well-equipped obstetric ward with clean environment and adequate facilities, modern planned operation theatre, the reduction of prolonged operation time, the use of potent antibiotics, early intervention and use of good surgical technique.
Caesarean
section is a common operation in obstetric practice. The incidence is raising
worldwide and the reported incidence ranges from 5% to 25% depending on the
nature and area of practice [1]. Surgical site infection following caesarean
section is a common cause of morbidity with socio-economic consequences for the
woman and her family [2]. Recovery from caesarean section is more difficult for
women who developed post-operative wound infection. The most recent data from
the National Nosocromial Infection Surveillance (NNIS) of Centre for Disease
Control and Prevention indicates that surgical site infections are the third
most frequently reported hospital associated infection, accounting for 14%
to16% of all infections in hospitalized patients [3]. Surgical site infection
is confined to either incisional wound or involving structures adjacent to the
wound that were entered or exposed during an operation [4]. Post caesarean
wound infection is a bacterial infection in the surgical incision following
caesarean delivery [5]. This complication accounts approximately 4% to 12% of
women who have a caesarean delivery [6]. A study done in Lagos, Nigeria over a
period of 56 months (Jan’2004 to August 2008) had shown that post caesarean
wound infection varied from zero to 20.5% in a hospital survey. The risk of
developing infection is proportionate to the amount and type of microbial
contamination in the wound. It also depends on the condition of the wound at
the end of the operation, surgical technique and lastly on host susceptibility
that is the patient intrinsic ability to deal with microbial contamination.
Poor surgical technique, prolonged operation time, presence of dead space or
haematoma can result wound infection [5]. A common cause is poor hand washing.
Inadequately filtered air in the operating theatre or contamination at surgery
can also result infection. The following risk factors predispose to subsequent
wound infection in women undergoing caesarean section – obesity, diabetes,
prolonged hospitalization before caesarean section, prolonged rupture of the
membrane, chorioamnionitis, endomyometritis, prolonged labor, emergency rather
than elective indications for caesarean section and anemia [6,7]. Usually
post-operative wound infection appears in early post-operative period between
3rd to 5th post-operative day.8 Fever with no apparent cause which persists to
the 4th or 5th post-operative day strongly suggest a wound infection.The
organisms responsible for most wound infections originate on the patient’s skin
[8]. Facultative and anaerobic gram-negative rods, beta-hemolytic streptococci
and staphylococci are the pathogens most commonly cultured from infected wound
[9]. Avoidance of the factors as well as early diagnosis by clinical features
and laboratory finding and thereby using most appropriate antibiotic according
to wound culture sensitivity test, the morbidity and mortality of post
caesarean wound infection can be reduced.
Methodology
This is a descriptive type of cross- sectional study. This study was carried out on 50 post-operative patients the find out about the population in the department of Obstetrics and Gynaecology, in Institute of Child and Mother Health, Matuail, Dhaka Bangladesh. The duration of the period from Six months (November 2009 to April 2010). After collection, the data were checked and cleaned, followed by editing, compiling, coding and categorizing according to the objectives and variable to detect errors and to maintain consistency, relevancy and quality control. The choice of treatment was made by the patient after a full discussion with the multidisciplinary team consisting of Transfusionists. The data for this study about had been accumulated from patients’ medical information. Statistical evaluation of the results used to be got via the use of a window-based computer software program devised with Statistical Packages for Social Sciences (SPSS-24).
Result
Figure 1: Age distribution (n=50).
Figure 2: Host condition and wound infection (n=50).
Figure 3: Occurrence of Wound infection in post-operative days.
(Figure 1) shows that rate of wound infection height in the age group between 21-30 years (56%), followed by 15-20 years (32%) and 31-40 years (12%). (Table 1) shows that wound infection is most common 56% of women who had no antenatal check-up. (Table 2) shows that post-operative wound infection is more common (56%) in patients who belong to poor social circumstances. (Table 3) shows that post-operative wound infection is more common (40%) in patients having 25-48 hours labour pain. (Table 4) shows that maximum wound infection is among patients having rupture membrane 25-48 hours (28%). Intact membrane was present in 12% patients (Table 5).
Table 1: Status of Ante natal Check-up (n=50).
Status |
Number of patients (n=50) |
Percentage |
Regular |
06 |
12% |
Irregular |
16 |
32% |
None |
28 |
56% |
Table 2: Status of Socio-economic
circumstances (n=50).
Status |
Number of patients (n=50) |
Percentage |
Poor |
28 |
56% |
Low-middle |
06 |
12% |
Middle |
06 |
12% |
Table 3: Duration of Labour Pain in patients
having wound infection.
Duration (hour) |
Number of patients (n=50) |
Percentage |
0 - 12 |
06 |
12% |
13 - 24 |
12 |
24% |
25 - 48 |
20 |
40% |
>48 |
06 |
12% |
No Labour Pain |
06 |
12% |
Table 4: Duration of Rupture of Membrane
(n=50).
Time (hour) |
Number of patients (n=50) |
Percentage |
<12 |
08 |
16% |
13 - 24 |
12 |
24% |
25 - 48 |
14 |
28% |
>48 |
10 |
20% |
Intact membrane |
06 |
12% |
The
rate of wound infection is highest among patients who underwent emergency
operation (92%) and majority is due to obstructed labour (32%). (Figure
2) shows that height rate wound infection is due to moderate to severely
anaemia (75%). (Figure 3) shows that wound infection
developed in 50% cases on 5th postoperative day, followed by 20% on the 6th
postoperative day, 15% on 7th postoperative day, 10% on 3rd postoperative day
and 5% on 4th postoperative day. (Table 6) shows color and
smell of wound discharge. Color is Serosanguineous in 60% cases and purulent in
40% cases, and foul-smelling discharge is present in 32% cases.
Table 5: Indication for Operation (n=50).
Indication |
Number of patients (n=50) |
Percentage |
Elective (n=4) |
||
Previous H/O Caesarean section |
03 |
06% |
Twin pregnancy (1st baby breech) |
01 |
02% |
Emergency (n=46) |
||
Obstructed labour |
16 |
32% |
PROM and Fetal distress |
14 |
28% |
Antepartum Eclampsia |
06 |
12% |
Prolonged labour & Cervical dystosia |
10 |
20% |
Total |
50 |
100% |
Table 6: Character of Wound Discharge (n=50).
Characteristics of wound discharge |
Number of patients (n=50)
|
Percentage |
Color
Serosanguineous |
30 |
60% |
Purulent |
20 |
40% |
Smell
Foul smelling |
16 |
32% |
No smell |
24 |
48% |
Table 7: Bacteriological study of Wound
Discharge (n=50).
Organism
isolated |
Number of
patients (n=50) |
Percentage |
Escherichia
coli |
12 |
24% |
Staphylococcus |
06 |
12% |
Pseudomonas |
14 |
28% |
No growth |
18 |
36% |
Table 8: Post-operative Hospital Stay (n=50).
Hospital stays (days) |
Number of
patients (n=50)
|
Percentage |
7-10 |
12 |
24% |
11-15 |
24 |
48% |
>16 |
14 |
28% |
(Table
7) shows that 64% wound discharge have organisms and the rest36% shows no
growth. Pseudomonas is isolated from highest number of patients (28%). (Table
8) shows that hospital stay of the patients varies from seven to more than
sixteen days. Among the patients 48% of the patients stay for 11to15 days and
for 28% of the patients, the hospital stay is seven to ten days.
This
descriptive type of cross-sectional study was investigated to find out the
possible profile of wound infection that developed in patients following
caesarean section at ICMH and to take maximum possible measures to reduce the
rate of wound infection. Decherney and Nathan in 2004 showed that, this
complication accounts approximately 4% to 12% of women who have a caesarean
delivery [10]. Riou et at, in 1992 showed an incidence of wound infection of
0.2 to 6 percent, and Al-Fallouje and Mc Brien in 1998 showed the pick
incidence between sixth and eighth post-operative day [11]. My study found
that, the appearance of abdominal wound infection was highest on fifth
postoperative day (50%), followed by sixth post-operative day (20%), seventh
post-operative day (15%). So, it indicates the prime source of infection is
Operation Theatre. Usually wound infection manifested on the fifth
post-operative day. In case of superficial wound infection half of the
abdominal wound infection started to appear on the fifth post-operative day and
majority of the deep wound infection occurred on the seventh post-operative
day. Wound infection occurred on an average of 8 +/-2 post-operative day [12].
Haddad, Alexander and Prudden showed that largest number of wound dehiscence
became clinically evident on the seventh post-operative day and on an average
of 6.8 post-operative days, respectively [13]. They suggested that early
development of wound infection indicate the source of contamination was likely
to be operation theatre. However, in their series, late development of wound
infection was associated with formation of haematoma, anaemia, wound infection,
hypoproteinaemia etc. Various factors affect wound healing and then give rise
to wound dehiscence. The factors that cause wound infection have been studied
extensively throughout the world. In this study, post-operative wound infection
occurred with peak incidence at third decade (21-30yrs) of life (56%) and among
the people of low-middle social circumstances (56%). Actually, there was no
direct relationship between age and social circumstances with wound infection.
Probably as number of operated cases were more in this age group and regarding
social circumstances that group of people are more in that particular area, so
infection rate was also high among them. Aziz in 1997 in Bangladesh also made
similar observation in that age group [14]. Royal Women’s Hospital, Australia
have shown that repeated antenatal visit reduces the incidence of wound
infection following caesarean section [15]. Regarding Antenatal check-up this
study showed, 56 percent patients had no ANC whereas only 12 percent had
regular ANC. The rate of infection is more in the patients no ANC is due to
absence of detection of complication during pregnancy like anaemia,
malnutrition, PET, CPD etc. This study showed that there was direct
relationship between higher duration of labour pain had highest rate of wound
infection. It was 40% who had labour pain 25-48 hours, followed by 13-24 hours
(24%) and <12 hours (12%). Prolonged rupture membrane was also related with
wound infection, rupture membrane for 25-48 hours was highest (28%) and 12
percent had intact membrane. Oliver C
Ezechi in 2009 shown that the risk of developing wound infection was increased
by more than four times in patients having prolonged rupture of membrane when
adjustment was made for the potential confounders. Bacteria are now able to
traverse the cervical canal into the amniotic cavity leading to chorioamnitis
and its sequel. The prevalence of wound dehiscence was highest among the patients
who underwent emergency operation (92%) rather than elective (4%). Majority of
emergency operations were due to obstructed labour (32%) followed by PROM and
Fetal distress (28%), prolonged labour and cervical dystocia (20%) and ante
partum eclampsia (12%) Among the four elective caesarean section, three
patients had history of previous caesarean section and another patient had twin
pregnancy with first baby breech presentation. Haddat et al in 1980 observed a
higher incidence of wound infection in cases of vertical incision [16]. Riou et
al in 1992 found that 93 percent of wound infection had midline incision
compared with 63percent in non-dehiscence group [17]. In my study all the cases
were given pfannenstiel incision. There is direct relationship between
haemoglobin status and wound healing. Decreased haemoglobin level contributes
to wound infection by hypoxic effect in tissue of healing area. Riou et al in
1992 defined anaemia as haemoglobin less than 10 gm/dl at the time of wound
disruption in the infection group or early post-operative period in the
non-infection group. In this series patients had moderate anaemia was among 48
percent patients, severe anaemia 28 percent patients and mild anaemia accounted
24 percent cases. Makle et al in 1995 recorded anaemia in 38 percent patients
in the infection group and only 10 percent in the control group. Patients
considered to be malnurished prior to surgery were more common in the infection
group (41%) than that of control group (21%) [18]. Cruse PJE, Frood R in their
study of prospective study of surgical wound have shown that wound infection
rate rises with anaemia, DM and malnutrition [19]. Riou et al found anaemia in
90 percent patients in the dehiscence group and only 16 percent in the control
group. This study revealed all most all of the patients (75%) were moderate to
severely anaemic, 20 percent were malnourished which contribute to infection by
defective collagen synthesis. Urinary tract infection is the associated
infection (16%). William J et al have found wound infection in only 1.54
percent cases and UTI in 4.64 percent cases after caesarean section at Sioux
Valley Hospital, South Dakota, which is much less than in our situation [20].
Operation time also had contribution in wound infection. My study showed that
infection rate was higher (70%) when operation time is more than one hour.
Osime U et al in 1988 and Ezechi O C in 2009 found that the risk of developing
postoperative wound infection is considerably reduced when the operation time
is short. In the course of prolonged operation, there is significant tissue
devitalisation resulting from tissue handling and reduced tissue perfusion and
the bacterial contamination increases with time [21]. A. Johnson, D. Young, J.
Reilly have showed in their study done in the Queen Mother’s Hospital at
Glasgow in UK in 2006 that, suture materials and wound infection also has some
relation Catgut, dexon, vicryl, silk were used in different cases. The
conventional absorbable suture material provokes strong inflammatory reaction
and prolonged the lag phase of wound healing. It is also synergistic with
organisms in the promotion of wound infection [22]. Regarding bacteriological
study of wound discharge, negative culture was in 36 percent cases probably due
to use of antibiotics. Positive culture was 64 percent and microorganisms
isolated were Pseudomonas (28%), Escherichia coli (24%) and Staphylococcus
(12%). Nature of wound discharge revealed that serosanguinous (60%) and 32
percent were foul smelling discharge. Riou et al, in 1992 stated that
Staphylococcus aureus was the most common organism responsible for wound
infection and polymicrobial infection were noted in a smaller number of
patients [23]. Pollock and Greenal in 1979 found Escherichia coli as the
commonest infecting organism. They also found Salmonella typhi in one of his
cases [24]. Matin in 1981 in the Institute of Post Graduate Medicine and
Research (now BSMMU) noted the commonest infective organism in his series as
Coliform (60%) followed by Staphylococcus (40%).
Limitations of the Study
1.
This small study of only fifty patients cannot be the representative of the
entire spectrum of post caesarean wound infection.
2.
Anaerobic culture of the wound discharge could not be done due to limitation of time and hospital facilities
3. Due to low socioeconomic status and shortage
of hospital bed number some patients had to be released earlier from hospital.
Conclusion
In
this study it is evident that there was close relationship between inadequate
antenatal check-up, anaemia, and malnutrition and wound infection. So, great
importance should be given for regular antenatal check-up, adequate assessment
and preoperative preparation of the patients. The quality of surgical care is
often correlated with post-operative wound infection rate in a hospital. So, it
is important to prevent the development of wound infection by targeting –
educating and intervention strategies to the identified risk factors to
community health workers and nurses as it increases the cost of care and ties
up professional care and resources that might otherwise be available to clients
residing in the community.
Recommendation
As
the series was conducted with only 50 cases, similar studies with large sample
size and longer duration are required for further evaluation.
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