A Prospective Cohort Study on the Timing of Antimicrobial Prophylaxis for Post-Cesarean Surgical Site Infections

Angie Sway; Anthony Wanyoro; Peter Nthumba; Alexander Aiken; Patrick Ching; Anna Maruta; Revathi Gunturu; Joseph Solomkin

Sepsis is the leading cause of maternal death in Sub-Saharan Africa (SSA), a region that sees some of the highest rates of maternal mortality and morbidity in the world. As one of the most commonly performed surgical procedures in SSA and a proven risk factor for surgical site infection (SSI), cesarean section (CS) is an important operation to target due to its massive impact on maternal and neonatal health. There is currently insufficient published data available on the patient and facility based context around SSI following CS to establish a true and clear understanding of this infectious category. The objective of this study was to collect accurate and valid data on the incidence of SSI following CS and the circumstances around SSI in two Kenyan hospitals. 

Our primary analysis focused on the consequences of timing of perioperative antimicrobial prophylaxis. We hypothesized that patients who were administered pre-operative antibiotics would show lower SSI rates than those administered post-operative antibiotics. 

This was an IRB-approved observational study of six hundred and nine women who had CS operations at two Kenyan hospitals from September to December 2015. Hospital A provided antimicrobial prophylaxis prior to incision for all patients and Hospital B provided only post-operative prophylaxis to all patients. It should be noted that this was due to a previous intervention at Hospital A, and was not a part of this observational study. 

Patients at the two hospitals had similar pre-operative characteristics indicating a relatively healthy population. The median age was 26±6 (18, 43) at Hospital A and 26±5 (18, 44) at Hospital B. Median parity was 1±1 (0, 7) at Hospital A and 1±1 (0, 10). Patients also went through a comparable number of antenatal care visits (median=4±1 at both hospitals). The number of patients with prolonged rupture of membranes was 103 (34.4%) at Hospital A and 99 (32.9%) at Hospital B. There were a slightly higher number of patients with meconium stained liquor at Hospital B Hospital (115) than Hospital A (74). The SSI rate was 4.0% (12/299; 11 superficial SSI, 1 deep SSI) at Hospital A and 9.3% (28/301; 18 superficial SSI, 7 deep SSI, 3 organ/space SSI) at Hospital B.

The data shows a striking difference between SSI rates in patients who were given properly timed pre-operative antibiotics and patients who were only given post-operative antibiotics.  Administration of post-operative antibiotics is currently the norm in much of SSA and there is strong evidence that many of the infectious problems encountered in this population would be reduced by the provision of antibiotic prophylaxis prior to the incision.