|Year : 2013 | Volume
| Issue : 2 | Page : 99-102
Microbiological pattern of postcesarean wound infection at Federal Teaching Hospital, Abakaliki
Joseph Agboeze, Robinson C. Onoh, Odidika U.J. Umeora, Paul O. Ezeonu, Chukwuemeka Ukaegbe, Azubike K. Onyebuchi, Conrad Egbuji, Emmanuel Ndukwe
Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||20-Jun-2014|
Robinson C. Onoh
Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, PMB 102, Abakaliki - 480 001, Ebonyi State
Source of Support: None, Conflict of Interest: None
Background: Cesarean section is one of the most common obstetric surgeries done in women of reproductive age group. Postcesarean wound infection is a worrisome occurrence despite the observation of aseptic techniques and administration of potent antibiotics. Common offending organisms include Staphylococcus species, Enterococcus faecalis, Escherichia coli, Proteus mirabilis, and Pseudomonas species. Objective: The objective of this study is to determine the prevalence, risk factors and common bacterial pathogens for surgical site infection (SSI), following cesarean section. Materials and Methods: A prospective surveillance was conducted at Federal Teaching Hospital, Abakaliki, from July 2011 to August 2012 using a semi -structured questionnaire. The following risk factors were studied, age, parity, booking status, type of cesarean section, duration of labor and length of membrane rupture. Microbiologic culture of those that had wound infection was done. IBM ® SPSS ® statistical software 2007 version 16 was used for statistical analysis. Results: The prevalence of wound infection was 7.0%. There were 1301 deliveries out of which 399 (30.7%) had cesarean section, and 28 (7.0%) had wound infection following cesarean delivery. Booking status was the only factor that significantly influenced the occurrence of wound infection (P < 0.01). Staphylococcus aureus and Citrobacter spp. were the common organisms isolated. Conclusion: The prevalence of SSI following cesarean section was high and S. aureus and Citrobacter spp. were the common pathogens isolated.
Keywords: Abakaliki, cesarean section, microbiological pattern, surgical site infection
|How to cite this article:|
Agboeze J, Onoh RC, Umeora OU, Ezeonu PO, Ukaegbe C, Onyebuchi AK, Egbuji C, Ndukwe E. Microbiological pattern of postcesarean wound infection at Federal Teaching Hospital, Abakaliki. Afr J Med Health Sci 2013;12:99-102
|How to cite this URL:|
Agboeze J, Onoh RC, Umeora OU, Ezeonu PO, Ukaegbe C, Onyebuchi AK, Egbuji C, Ndukwe E. Microbiological pattern of postcesarean wound infection at Federal Teaching Hospital, Abakaliki. Afr J Med Health Sci [serial online] 2013 [cited 2020 Feb 17];12:99-102. Available from: http://www.ajmhs.org/text.asp?2013/12/2/99/134905
| Introduction|| |
Postcesarean wound infection is a worrisome occurrence despite the observation of aseptic techniques and administration of potent antibiotics. Cesarean wound infection is a major cause of prolonged hospital stay, high hospital bills, as well as other morbidities and mortality. ,, In Nigeria, complication of hemorrhage and infection following cesarean section are the leading causes of maternal death. ,
The incidence of wound infection has been shown to be influenced by the duration of labor prior to the cesarean section, prolonged period of rupture of membranes, postoperative anemia, skill of the surgeon, duration of operation and multiple vaginal examinations. , Emergency cesarean section, booking status, and maternal age have been implicated by other researcher as significant factors influencing the incidence of wound infection. 
The incidence ranges from 5% to 25% depending on the nature and area of practice. ,, In a hospital survey conducted by Moir -Bussy et al. the rates of postoperative wound infection varied from 0% to 20.5%, respectively.  Hospital based studies from Nigeria reported rates within this range. , In Kenya Nairobi postcesarean wound infection rate was 19%. 
The causes of cesarean wound infection are globally similar, however the relative contribution differ from region to the region and even from center to center.  The causes include prolonged labor prior to the cesarean section, prolonged period of rupture of membranes, postoperative anemia, skill of the surgeon, duration of operation and multiple vaginal examinations.
Common offending organisms include Staphylococcus species, Enterococcus faecalis, Escherichia coli, Proteus mirabilis, and Pseudomonas species. Staphylococcus aureus is the most commonly isolated bacteria in wound infections following cesarean section.  This organism causes serious infections and has been shown to be resistant to commonly available, cheap antibiotic like the penicillin.  Other workers isolated more gram negative organisms such as E. coli, P. mirabilis, Pseudomonas and Klebsiella in cesarean section wound infections. 
There have been anecdotal reports of wound infection in many hospitals and much work has not been done on microbial pattern of postcesarean section wound infection in South East Nigeria. Therefore, this study aimed at determining the microbiological pattern of postcesarean wound infection as well as the risk factors in labor at the Federal Teaching Hospital Abakaliki Nigeria. Information obtained hopefully will be used to plan a strategy to reduce post cesarean wound infection and the associated morbidity and mortality.
| Materials and Methods|| |
A prospective surveillance was conducted at Federal Teaching Hospital, Abakaliki, from July 2011 to August 2012. The Federal Teaching Hospital, Abakaliki is a tertiary health care facility. The hospital serves as a referral center for both Government and private health care facilities within and outside the state.
Ethical approval for the study was obtained before the commencement of the study from the research and ethics committee of Federal Teaching Hospital Abakaliki. Informed consent was obtained from the participants. Sample size determination was done using Taylor DW formula:
P is the maximum prevalence/incidence, Q is 1 -P (proportion of persons free from the disease), E is allowable error margin, 1.96 is a constant for standard normal deviation. Using incidence of 24.3% as reported by Makinde in Ile Ife, Nigeria would be calculated.  This gave a sample size of 275 cesarean sections and considering an attritions rate of 20% giving an approximated minimum sample size of 330 cesarean deliveries. All patients that had cesarean section were followed -up. They were interviewed on the 5 th postoperative day using a semi -structured proforma by the trained research assistant. Exclusion criteria were those that had cesarean section outside the hospital and women admitted following wound infection.
The following parameters were obtained, age, parity, booking status, type of cesarean section, duration of labor, length of membrane rupture and length of hospital stay.
Cesarean section was performed through a Pfannenstiel incision and through a transverse lower segment cesarean section. The uterine incisions were closed in two layers using monocyl suture size 2, followed by suture size 2/0 for the peritoneal layers or nonclosure of peritoneal layer. The rectus sheet was closed continuously using suture size 2 and suture size 2/0 for the apposition of the subcutaneous layer. The skin was closed subcuticularly using suture size 2/0. Cesarean wounds are cleaned with iodine solution and covered with sterile gauze and sealed with adhesive tape. All the patients received an intravenous injection of 1200 mg of amoxicillin/clavulanic acid combination and 500 mg of metronidazole statim before the surgery and thereafter 12 hourly and 8 hourly respectively for 48 h. They were continued on oral preparations of 625 mg of amoxicillin/clavulanic acid combination twice daily and 400 mg of metronidazole trice daily for 5 days.
Wound swabs for microbiologic culture of those that had wound infection (wound breakdown and or discharge) at the operation site were taken, sent to the laboratory and results analyzed. The samples were collected using swab sticks and cultured in chocolate and blood media. The samples were then gram stained using crystal violet, lugol iodine then acetone and neutral red. A biochemistry test was done using citrate test to differentiate Staphylococcus species from Streptococcus species then a coagulation test was carried out to differentiate S. aureus from other Staphylococcus species.
The information obtained was fed into the computer using the SPSS (SPSS Inc., 233 South Wacker Drive, 11 th Floor Chicago, IL, USA) software 2007 version 16 for statistical analysis. Univalent and bivalent analyses were done to obtain the values for the variables.
| Results|| |
In the period under review, there were 1301 deliveries out of which 399 (30.7%) had cesarean section, and 28 (7.0%) had wound infection following cesarean section.
The mean age was 25.1 ± 2.4 years. Most of the subjects (28.6%) were within the age bracket of 25 -30 years. Majority of the subjects were primiparous (35.7%).
Most cesarean section were emergency 24 (85.7%) and the majority of the patients were unbooked 25 (89.3%) [Table 1].
|Table 1: Sociodemographic characteristics of patients that had postcesarean wound infection|
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Of the 28 cases with surgical site infection, 25 (89.3%) had wound swab cultures done, seven (28%) yielded no growth. In five (27.8%) S. aureus and Citrobacter spp. were grown, while one (5.6%) produced E. coli, one (5.6%) Pseudomonas aeroginosa and two (11.1%) each for Enterobacter, Klebsiela and P. mirabilis [Table 2].
There were higher proportions of subjects with prolonged rupture of membrane 18 (64.3%) and prolonged duration of labor prior to cesarean section 18 (64.3%), among women that had wound infection after cesarean section [Table 3].
|Table 3: Labor events that are predisposing factors to caesarean wound infection|
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| Discussion|| |
The incidence of postcesarean wound infection in this study was 7.0%. The rate was however higher than 3.2% reported in London,  and 4.5% in Kano. It is lower than 19% reported in Kenya Nairobi  and 10% reported by Fasubaa et al.  but much lower than that 23.4% reported by Makinde from Ile Ife Nigeria.  It is also important to state that the rate of 7.0% is within 0 -20.5% reported by Moir -Bussy et al. in a hospital survey in London. , All our patients had antibiotic prophylaxis of amoxicillin/clavulanic acid (augmentin) and metronidazole (flagyl). Antibiotic prophylaxis is recommended for contaminated and infected wounds. 
Wound infection was confirmed by microbiological studies in 28 cases. Twenty -five (90.6%) had positive cultures, while three (9.4%) were sterile. S. aureus and Citobacter spp. were isolated in 27.8% of the cultures respectively. S. aureus was shown in most studies to be the predominant agent in postcesarean wound infection. ,, Most of these organisms were sensitive to cephalosporins and quinolones as observed by other workers. 
The study showed the role of prolonged rupture of membrane as a predisposing factor to developing wound infection. This was also reported by Litta et al.  and Okonofua et al.  This was not surprising in that when fetal membranes are ruptured, the protective barrier to infection is gradually lost thereby allowing bacteria to transverse the cervical canal into the amniotic cavity leading to chorioamnonitis and its complications.
In this study, postcesarean wound infection was common among women with prolonged duration of labor prior to the cesarean section, prolonged period of rupture of fetal membranes, emergency cesarean section and unbooked cases, as were implicated by other workers. ,,,
| Conclusion|| |
Postoperative wound infection complicates cesarean section in our unit. This is mostly caused by S. aureus and Citrobacter spp. Strategies for prevention of this morbidity in cesarean section patient must target prolonged labor from unbooked emergencies, reduce intraoperative blood loss and long operating time. Overall strategies that reduce cesarean section rate will lower this morbidity and its sequelae.
| References|| |
|1.||Ezechi OC, Fasubaa OB, Dare FO. Socioeconomic barriers to safe motherhood among booked patients in rural Nigerian communities. J Obstet Gynaecol 2000;20:32 -4. |
|2.||Onwudiegwu U, Makinde ON, Ezechi OC, Adeyemi A. Decision -caesarean delivery interval in a Nigerian university hospital: Implications for maternal morbidity and mortality. J Obstet Gynaecol 1999;19:30 -3. |
|3.||Ezechi OC, Nwokoro CA, Kalu BK, Njokanma FO, Okeke GC. Caesarean section: Morbidity and mortality in a private hospital in Lagos Nigeria. Trop J Obstet Gynaecol 2002;19:97 -100. |
|4.||Chama CM, El -Nafaty AU, Idrisa A. Caesarean morbidity and mortality at Maiduguri, Nigeria. J Obstet Gynaecol 2000;20:45 -8. |
|5.||Mitt P, Lang K, Peri A, Maimets M. Surgical -site infections following cesarean section in an Estonian university hospital: Postdischarge surveillance and analysis of risk factors. Infect Control Hosp Epidemiol 2005;26:449 -54. |
|6.||Litta P, Vita P, Konishi de Toffoli J, Onnis GL. Risk factors for complicating infections after cesarean section. Clin Exp Obstet Gynecol 1995;22:71 -5. |
|7.||Beattie PG, Rings TR, Hunter MF, Lake Y. Risk factors for wound infection following caesarean section. Aust N Z J Obstet Gynaecol 1994;34:398 -402. |
|8.||Fasubaa OB, Ogunniyi SO, Dare FO, Isawumi AI, Ezechi OC, Orji EO. Uncomplicated Caesarean section: Is prolonged hospital stay necessary? East Afr Med J 2000;77:448 -51. |
|9.||Makinde OO. A review of caesarean section at the University of Ife Teaching Hospitals. Trop J Obstet Gynaecol 1987;6:26 -30. |
|10.||Nice C, Feeney A, Godwin P, Mohanraj M, Edwards A, Baldwin A, et al. A prospective audit of wound infection rates after caesarean section in five West Yorkshire hospitals. J Hosp Infect 1996;33:55 -61. |
|11.||Moir -Bussy BR, Hutton RM, Thompson JR. Wound infection after caesarean section. J Hosp Infect 1984;5:359 -70. |
|12.||Osime U, Ofili OP, Duze A. A prospective randomised comparison of simple ligation and stump invagination during appendicectomy in Africans. J Pak Med Assoc 1988;38:134 -6. |
|13.||Chukwudebelu WO, Okafor EI. Burst abdomen following caesarean section. Inter J Gynecol Obstet 1978;37:77 -87. |
|14.||Ako -Nai AK, Adejuyigbe O, Adewumi TO, Lawal OO. Sources of intra -operative bacterial colonization of clean surgical wounds and subsequent post -operative wound infection in a Nigerian hospital. East Afr Med J 1992;69:500 -7. |
|15.||Egah DZ, Bello CS, Banwat EB, Allanana JA. Antimicrobial sensitivity pattern for Staphyllococcus aureus in Jos Nigeria. Niger J Med 1999;8:58 -61. |
|16.||Ogunsola FT, Oduyebo O, Iregbu KC, Coker AO, Adetunji A. A review of nosocomial infection at the Lagos university teaching hospital: Problems and strategies for improvement. J Niger Infect Control Assoc 1998;1:14 -20. |
|17.||Barbut F, Carbonne B, Truchot F, Spielvogel C, Jannet D, Goderel I, et al. Surgical site infections after cesarean section: Results of a five -year prospective surveillance. J Gynecol Obstet Biol Reprod (Paris) 2004;33:487 -96. |
|18.||NICE. Surgical Site Infection: Treatment and Prevention. London: National Institute of Health and Clinical Excellence (NICE) CG74; 2008. p. 1 -21. |
|19.||Olsen MA, Butler AM, Willers DM, Devkota P, Gross GA, Fraser VJ. Risk factors for surgical site infection after low transverse cesarean section. Infect Control Hosp Epidemiol 2008;29:477 -84. |
|20.||Ott WJ. Primary cesarean section: Factors related to postpartum infection. Obstet Gynecol 1981;57:171 -6. |
|21.||Ujah IA, Olarewaju RS, Otubu JA. Prophylactic augumentin in elective caesarean section. Niger J Med 1992;20:164 -8. |
|22.||Ng NK, Sivalingam N. The role of prophylactic antibiotics in caesarean section - A randomised trial. Med J Malaysia 1992;47:273 -9. |
|23.||Okonofua FE, Makinde ON, Ayangade SO. Yearly trends in caesarean section and cesarean mortality at Ile -Ife, Nigeria. Trop J Obstet Gynaecol 1988;1:31 -5. |
[Table 1], [Table 2], [Table 3]