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Am J Perinatol 2024; 41(S 01): e520-e527
DOI: 10.1055/a-1904-9583
Original Article

Perioperative Antibiotics and Other Factors Associated with Postcesarean Infections: A Case-Control Study

Cassandra R. Duffy
1   Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
,
Matthew Oberhardt
1   Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
2   NewYork-Presbyterian Value Institute, New York, New York
,
Naima Ross
3   Columbia University Vagelos College of Physicians and Surgeons, New York, New York
,
Julie Ewing
2   NewYork-Presbyterian Value Institute, New York, New York
,
Maria Messina
4   Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
5   Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
,
Kelly Fitzgerald
6   Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
,
Lisa Saiman
4   Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
5   Department of Infection Prevention and Control, New York-Presbyterian Hospital, New York, New York
,
Dena Goffman
1   Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
6   Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York
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Abstract

Objective Our objective was to determine modifiable risk factors associated with surgical site infection (SSI) and postpartum endometritis. We hypothesized that inappropriate surgical antibiotic prophylaxis would be a risk factor for both types of infections.

Study Design This was a single-center case-control study of SSI and endometritis after cesarean delivery over a 2-year period from 2016 to 2017. Cases were identified by International Classification of Diseases, 10th Revision diagnosis codes, infection control surveillance, and electronic medical records search and were subsequently confirmed by chart review. Three controls were randomly selected for each case from all cesareans ± 48 hours from case delivery. Demographic, pregnancy, and delivery characteristics were abstracted. Separate multivariable logistic regression models were used to assess factors associated with SSI and endometritis. Postpartum outcomes, including length of stay and readmission, were also compared.

Results We identified 141 cases of SSI and endometritis with an overall postpartum infection rate of 4.0% among all cesarean deliveries. In adjusted analysis, factors associated with both SSI and endometritis were intrapartum delivery, classical or other (non–low-transverse) uterine incision, and blood transfusion. Factors associated with SSI only included inadequate antibiotic prophylaxis, public insurance, hypertensive disorder of pregnancy, and nonchlorhexidine abdominal preparation; factors only associated with endometritis included β-lactam allergy, anticoagulation therapy, and chorioamnionitis. Among cases, 34% of those with SSI and 25% of those with endometritis did not receive adequate antibiotic prophylaxis, compared with 12.9 and 13.5% in control groups, respectively. Failure to receive appropriate antibiotic prophylaxis was associated with an increased risk of SSI (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 1.3–15.6) but not endometritis (aOR 0.9, 95% CI 0.4–2.0).

Conclusion Inadequate surgical antibiotic prophylaxis was associated with an increased risk of SSI but not postpartum endometritis, highlighting the different mechanisms of these infections and the importance of prioritizing adequate surgical prophylaxis. Additional potentially modifiable factors which emerged included blood transfusion and chlorhexidine skin preparation.

Key Points

  • Inadequate antibiotic prophylaxis is associated with a four-fold risk in surgical site infections.

  • The most common cause for failure to achieve adequate surgical prophylaxis was inappropriate timing of antibiotics at or after skin incision.

  • Blood transfusions are strongly associated (>10-fold risk) with both SSI and endometritis.

Keywords

cesarean - infection - endometritis - antibiotic prophylaxis

Precis

Inadequate antibiotic prophylaxis is associated with a four-fold increased risk in SSIs but not postpartum endometritis; other risk factors for postcesarean infections include nonchlorhexidine skin preparation and blood transfusion.




Publication History

Received: 31 March 2022

Accepted: 12 July 2022

Accepted Manuscript online:
20 July 2022

Article published online:
05 December 2022

© 2022. Thieme. All rights reserved.

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