STUDY OF SURGICAL SITE INFECTION IN OBSTETRICS AND GYNECOLOGY AT TERTIARY CARE CENTRE IN INDIA

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1 ORIGINAL ARTICLE STUDY OF SURGICAL SITE INFECTION IN OBSTETRICS AND GYNECOLOGY AT TERTIARY CARE CENTRE IN INDIA Priti Goyal 1, Meenakshi Kashyap 1, Sushila Khuteta 2, Shrigopal Goyal 3, Suchitra Narayan 4, R P Khuteta 5 1 Resident, 2 Associate Professor, 4 Assistant Professor, 5 Professor, Department of Obstetric n Gynecology, Mahila chiktsalaya, SMS Medical college, Jaipur (Rajasthan) 3 Resident, Department of Pschiatry, AIIMS, Delhi ABSTRACT BACKGROUND: Surgical site infections (SSIs) may cause considerable morbidity and have other significant consequences in terms of prolonged maternal length of hospital stay, socioeconomic implications, and increased health care costs. Postoperative wound infection is of great importance to both surgeon and patient. AIMS AND OBJECTIVES: To find out the magnitude of surgical site infection in various abdominal obstetrical and gynecological surgeries and analyze the risk factors and causative etiological agents responsible for development of surgical site infection. MATERIALS AND METHODS: This prospective study covers 900 major operations in patients of age group (20-60 years) who had undergone different abdominal obstetrical and gynecological surgeries at Mahila Chikitsalya, Sanganeri Gate, SMS Medical college, Jaipur over a 12 month period. excluded from study were those who were immunocompromised, had tuberculosis, previous history of wound sepsis or if vaginal surgeries were conducted. RESULTS: The overall wound infection rate was 16.67%. Highest wound infection rate (30.76 %) was found in laparotomy and lowest in sterilization (8.82%). The highest chance of infection was found in obstructed labour (60%), followed by PROM (40%), PID (20%) and Ectopic (36%) in various surgical procedures. The most common etiological agents isolated were Enterobactor (33%) followed by Coagulase positive staphylococcus (27%). Various risk factors like illiteracy, low socioeconomic status, high BMI, diabetes, medical illnesses in patients, prolonged duration of surgery, prolonged preoperative stay in hospital, anemia and advanced age of patients were associated with increased rate of infection. CONCLUSION: We recommended that above mentioned factor to be taken for consideration before planning for obstetrical and gynecological surgeries. If some modifiable factors controlled then chances of surgical site infection may be reduced. Keywords: Surgical site infection, obstetrical and gynecological surgeries, Risk factors, etiological agents INTRODUCTION Surgical site infections (SSIs) may cause considerable morbidity and have other significant consequences in terms of prolonged maternal length of hospital stay, socioeconomic implications, and increased health care costs. Postoperative surgical site infections are a major source of illness to a surgery patient. 1 In the united states alone, approximately infections per year, among an estimated 27 million surgical procedures. 2,3 In India incidence of postoperative infection in various hospital varies from 10-25%. 4 * Corresponding Author Dr. Meenakshi Kashyap Department of Obstetrics & Gynaecology, Mahila chiktsalaya, SMS Medical college Jaipur (Rajasthan) minaxikashy@gmail.com The development of wound infection depends on complex interplay of many factors. If the integrity and protective functions of skin breaches, large numbers of different cell types will enter the wound and initiate the inflammatory reaction. 5 Potential for infection depends on a number of patient s variables such as state of hydration, nutrition and existing medical conditions as well as extrinsic factors eg. Pre, intra and postoperative care when patient has undergone surgery. 6 Risk factors for surgical site infections(ssis) There are number of specific factors that have been indentified in relation to infection rate in surgical wound which are 7 : Time interval between skin preparation and surgery Nature of invasive procedure especially if involve bowel 73 Int J Res Med. 2013; 2(3);73-77 e ISSN: p ISSN:

2 Appropriate use of wound management materials We carried out the present study in order to find out the magnitude of surgical site infection, assess the risk factors and causative etiological agents responsible for SSI. MATERIALS AND METHODS This prospective study was conducted at Mahila Chikitsalya Sanganeri Gate, S.M.S. Medical College, Jaipur from December 2010 to December 2011.This study comprised of 900 patients in age group (20-60 years) who had undergone different abdominal obstetrical and gynecological surgeries. excluded from study were those who were immuno-compromised, had tuberculosis, previous history of wound sepsis or if vaginal surgeries were conducted (because the vaginal mucosa is different from the abdominal skin as it is prone to contamination preoperatively, intra operatively and postoperatively).these patients were reviewed for magnitude of surgical site infection, their causative etiological agents and risk factors responsible for surgical site infection. The study was conducted without any change in operating room or dressing room techniques. All patients were given at least one dose of prophylactic antibiotic before surgical procedure.this study was approved by institutional review board. METHODOLOGY Detail information was taken from all patients regarding their socio-demographic profile, menstrual history, obstetrical history, history of previous operation, medical illness and information regarding preoperative investigations (haemogram, Total leucocyte count, differential leucocyte count, liver function test, Renal function test, blood grouping), preoperative stay, type of wards, group and duration of surgery, type of operation and drain used or not were taken. Detailed general examination including BMI, systemic examination was conducted and vitals (pulse, Blood Pressure, Temp, Respiratory rate) were taken daily. Surgical site dressing was done on Day-, 5, 7 and on follow up (after 7 day of discharge). Surgical site infection was diagnosed if any one of special signs and symptoms would present like serous discharge, purulent discharge with or without signs of inflammation including edema, redness, warmth, increased local temperature,fever> 38c, tenderness and in duration. Etiological agents were detected by sending the wound swab for culture from the surgical site. Statistical analysis were divided into infected and uninfected and risk factors for surgical site infection were analyzed by using in Microsoft Excel Worksheet Surgical Site Infection In Obstetrics And Gynecology using Chi-square test and software used is SPSS 15.0 Version. RESULTS There were 900 major surgeries during the study, of which 597 were caesarean sections and 303 were gynaecological operations. Of these, 150 cases had wound infection; therefore overall rate of surgical site infection was 16.67%.There were 81 wound infections after caesarean sections (13.56%). Highest wound infection rate was found in laparotomy and lowest in sterilization. The various types of risk factors were studied and these are described below. Table1 is showing sociodemographic profile of patients and its relationship with surgical site infections. Maximum infection rate (33.33%) was found in age group (51-60) and minimum in age group (31-40) and rate of surgical site infection increases with advancing age. Mean age of infected patients was 31.36± Majority of patients were residing in urban area but the rate of surgical site infection was significantly higher in rural patients (20.14%) compared to urban patients (13.85%). Majority of patients belongs to Hindu religion but the rate of surgical site infection was significantly higher in Muslims (25%) as compared to Hindus (15.44%). There were no significant difference in rate of infection between working women and housewife. The rate of infection was significantly higher in illiterate as compared to literate. Surgical site infection was significantly higher in low socioeconomic group as compared to middle and upper groups. Table 2 is showing various risk factors responsible for surgical site infection. The rate of infection was significantly higher in patients with PROM, having comorbid medical illness and when duration of surgery was more than 30 minutes (29.85%) but rate of infection was not significantly higher in patients with history of previous surgery. Maximum infection rate (30.76 %) was found in laparotomy and minimum in sterilization (8.82%). The highest chance of infection was found in obstructed labour (60%), followed by PROM (40%), PID (20%) and Ectopic (36%) in various surgical procedures. Table 3 is showing that most common etiological agents found in infected patients were Enterobactor (33%) followed by Coagulase positive staphylococcus (27%), Acinetobactor (20%) and Citrobactor (12%) but in 8% cases the culture was sterile. Table 4 is also showing various risk factors responsible for surgical site infection. The rate of infection was significantly higher in patients where drain was used, when duration of preoperative stay in hospital was 5 days (36.36%) compared to when the duration was <5 days (15.10%) and higher when hemoglobin level was 9gm% (24.69%) compared to when hemoglobin level > 9gm% (13.69%). The 74 Int J Res Med. 2013; 2(3);73-77 e ISSN: p ISSN:

3 rate of infection was significantly higher when fasting blood sugar level (>110mg/dl) (57.14%) and was significantly higher in obese patients (80%) compared to patients who were not obese (7%) but rate of infection in patients who had emergency surgeries and patients of general wards were not higher as compared to patients who had planned surgeries. Table 1: Socio-demographic profile Total No. Profile Infected Patient Un-infected Patient Infection Rate P Value Age < Residence Rural Urban Religion Hindu Muslim Sikh Occupation Housewife Working Socio-economic Upper <0.001 status Middle Lower Total Table 2: Risk factors for surgical site infections Risk Total Infected Factors No. Uninfected Infection Rate PROM Yes <0.001 No H/O Medical Illness Yes <0.001 H/O Previous Duration Of Surgical Procedure No Yes > 0.5 No min <0.001 >30 min Lower Segment Caesarean Section P Value <0.001 STERLIZATION Hysterectomy Laprotomy TOTAL Table 3: Etiological agents for surgical site infections (N=150 ) ETIOLOGICAL AGENTS POSITIVE IN NO OF PATIENTS % OF INFECTION Enterobactor Staphylococcus Acinetobactor Citrobactor Int J Res Med. 2013; 2(3);73-77 e ISSN: p ISSN:

4 Table 4: Risk factors for surgical site infections Risk Factors Total No. Infected Surgical Site Infection In Obstetrics And Gynecology Uninfected Infection Rate P Value Drain Used <0.001 Not used Preoperative Stay <5day < day Types Of Wards General Hemoglobin (Gm/Dl) Blood Sugar Mg/Dl Private gm <0.001 > 9 gm High <0.001 (>110mg/dl) Bmi Group Of Normal High <0.001 (>25kg/m2) Normal Emergency Planned TOTAL DISCUSSION Four types of major elective and emergency obstetrical and gynecological operations were taken in my study, in which lower segment caesarean section(lscs) was 597, abdominal hysterectomy 123, laparotomy 78 and sterilization 102. Due consideration was given to secure adequate blood less surgery so that incidence of postoperative complications would remain negligible. Various indications for LSCS were obstructed labour, PROM, NPOL, for hysterectomy were chronic cervicitis (PID), dysfunctional uterine bleeding(dub), Fibroid uterus and for laparotomy were ectopic pregnancy, recanalization.in our study overall rate of surgical site infection was 16.67% was almost same as compared to other studies conducted by Kowli et al(1985) 18, Anvikar(1999) 17,Mustafa et al(2004) 4 and Joyce B.et al(2009). 10 We would expected a higher rate of infection in caesarean sections (13.56%) compared to laparotomy(30.76%) and hysterectomy(29.26%) as the majority of the former were emergency which involved higher risk of contamination from prolonged labour, foetal monitoring and repeated vaginal examination. In our study, there is a contrary. Other factors like longer operative time (Larsan JW et al,2003,lilani SP et al.2005,opoien et al,2007) 8,22,15,13 more tissue damage and use of drain in most of laparotomies(public health laboratory service,1960) 11 showed increased chances of infection. Sterlization surgery was short operations with no contamination from the vagina,so less chances of encountering infection. There were several other risk factors like illiteracy, low socioeconomic status, increased age of patients(desa et al,1984,mishriki et al,2004 and Joyce B et al,2009) 8,10,16 longer preoperative stay(desa et al,1984,kowli el al,1985,anvikar et al,1999 and Mustafa et al,2004) 4,8,18,17 high BMI( Centers of Disease Control and Prevention,1994, Lofgren M et al,2004 and Opoien et al,2007) 2,9,13,14 which showed raised chances of infection at surgical site.the most common etiological agent isolated from the culture was gram negative bacilli Enterobactor (33%) followed by gram positive Staphylococcus aureus (27%) which was same as studies conducted by Sengupta et al,1977 and Chaudhary et al, ,19 Hospital infections are preventable 18 and therefore it becomes a necessity for hospitals to recognize the growing threat of hospital infections and take immediate measures to control them. CONCLUSION We therefore recommend that above mentioned factors should be taken for consideration before planning for obstetrical and gynecological surgeries. If some modifiable factors controlled then chances of surgical site infection may be 76 Int J Res Med. 2013; 2(3);73-77 e ISSN: p ISSN:

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