Epidemiological, Clinical, Bacteriological, and Therapeutic Aspects of Sur-gical Site Infections in the Maternity Ward of the Batna Region, Algeria: A Prospective Study

Surgical site infections (SSIs) are nosocomial infections occurring after surgery. SSIs contribute to the increase in maternal morbidity associated with cesarean section (CS). This research aimed to study SSIs' clinical, epidemiological, bacteriological, and therapeutic aspects for cesarean and hysterectomy surgeries performed at the Maternity Hospital of Batna Region in Algeria. We carried out a prospective and descriptive study for four months (from 1 January 2018 to 30 April 2018), with real-time data collection, in the gynecology and obstetrics department of Batna’s Maternity Hospital. We included a total of 24 women who had a surgical intervention and were hospitalized with post-surgical infection. The data collection using a questionnaire allowed us to obtain information concerning the patient and the surgical procedure. Our results show that most surgeries performed were CS (95.83%) compared to hysterectomies (4.16%), among which 54.16% were planned CS. All classes of contamination were clean-contaminated. The physical status score for American Society of Anesthesiologists (ASA) 1 and ASA 2 classes was found in 83.33% and 16.66% of the patients, respectively. The SSIs in this study were concerned mainly with the surface plane (95.83%). Concerning infection, pus samples were taken from ten patients, and five germs were identified in eight patients. Escherichia coli was isolated in three patients, and Proteus mirabilis in two patients. Serratia marcescens, Acinetobacter baumanni, and Burkholderia cepacia were identified once in the three remaining patients. The most commonly prescribed antibiotherapy was Metronidazole (95.83%). We established a clinical, epidemiological, bacteriological, and therapeutic profile for SSIs at the Maternity Hospital of Batna.

INTRODUCTION

Surgical site infections (SSIs) include any infection at the operated site occurring within 30 days of surgery or a year if an implant or prosthesis has been placed¹¹. Caesarean section (CS) is a lifesaving operative technique in which a fetus, placenta, and membranes are delivered through an abdominal and uterine incision²². A survey revealed that caesarean section procedures carry a risk of infection 5–20 times that of normal delivery³³. SSIs constitute a significant public health problem and remain one of the leading causes of mortality and morbidity in surgery.

There are many risk factors for SSIs associated with cesarean section; the main risk factors involved are the pre-, per-, and postoperative environment surrounding the patient and the healthcare team, the host’s immune defences, and especially the degree of hygiene during the surgical act. In the relentless pursuit of averting surgical site infections, a two-pronged approach unfolds, centering on identifying risk factors that collectively fall into two distinctive categories: patient-related (intrinsic) and process/procedural-related (extrinsic) factors. These risk factors, whether modifiable or non-modifiable, constitute pivotal keystones in the campaign for infection prevention⁴⁴. Understanding the interplay between these factors is crucial for developing comprehensive strategies to reduce the incidence of SSIs.

The diagnosis of SSIs is essentially clinical; however, the etiological diagnosis requires the isolation of a bacterium after a culture of the purulent fluid is taken⁵⁵. Bacteria inoculated into the surgical site during surgery typically cause SSIs.E. coliandEnterococcusspecies, respectively, cause approximately 9.5%and 5.1% of all surgical site infections⁶⁶. Pathogens that cause infection vary by surgical location. Antimicrobial prophylaxis for caesarean section effectively reduces postoperative morbidity, cost, and duration of hospitalization²².

SSIs are the second most reported healthcare-associated infection (HAI) globally, accounting for 19.6% of HAIs⁷⁷. Numerous studies have reported incidence rates of post-CS SSIs, for example, 2.85% in India⁸⁸, 21% in Ethiopia³³, and in Blantyre, Malawi. The overall cumulative incidence of SSI recorded at the Queen Elizabeth Central Hospital during the study period was 9.61% (20 cases out of 208). Of these, 19 (95%) reported superficial SSI following CS²². The developing countries are the most affected. In Algeria, the incidence surveys were carried out in some hospitals, as Annaba’s hospital had 36 (1.9%) post-CS SSIs among 1,810 patients⁹⁹.

This study was conducted to determine the clinical, epidemiological, bacteriological, and therapeutic profile of surgical site infections for caesarean and hysterectomy surgeries performed at the Maternity Hospital of Batna and to identify risk factors for SSI after caesarean section for 4 months (from January 1, 2018 to April 30, 2018). A better understanding of predictors might improve infection control by reducing the clinical effects of post-cesarean infections. To our knowledge, no epidemiological study has been conducted on SSIs at the maternity hospital of Batna. This work is the first to study these different aspects of SSIs at this establishment.

METHODS

Patients and methods

This prospective and descriptive study was conducted in the Department of Obstetrics and Gynecology at the Hospital Maternity of Batna Region in Algeria. The analysis of files was spread over 4 months (from 1 January 2018 to 30 April 2018), including 24 women who underwent surgery such as caesarean delivery or hysterectomy during this period and were hospitalized at the Maternity Hospital. SSI diagnosis was established according to the Centers for Disease Control (CDC) criteria of Atlanta^10,111011, and the surgeon validated each SSI. For bacteriological analysis, a pus sample was taken for superficial and deep infections to detect the eventual presence of microorganisms (bacteria).

Data collection

The data were collected by analysis of medical records in the obstetrics-gynecology department (data were provided anonymously by the hospital services). The data collection using a questionnaire allowed us to obtain information concerning the patient, such as age, level of education, profession …etc, and information concerning the surgical procedure: the type of surgery, the emergency or programmed intervention, the number of pregnancies (G), the epidemiological and bacteriological characteristics (classe of contamination, infection site, presence of germs), the associated risk factors and length of stay. We have performed a descriptive statistical analysis of all our patients’ epidemiological and clinical characteristics.

Inclusion criteria

The recruitment was done exhaustively: systematic inclusion of all:

- Parturients who have had an emergency or planned caesarean section, for any indication.

- Primiparous or multiparous (including those who have already had a previous cesarean).

Exclusion criteria

We have excluded all of the following:

- Parturients who have given birth vaginally.

- Parturients transferred to the obstetrics-gynecology department in the postpartum period after a cesarean section performed in another establishment.

The limits of the study

Our study experienced limitations for the following reasons:

- Pus collection was not systematic for all patients.

- The operative reports were incomplete.

Statistical Analysis

This work addressed a descriptive statistical study. It evaluated the prevalence of different parameters and factors, and the results are expressed as frequency and percentage.

RESULTS

In our series, the mean age of our patients was (28.71 ± 7.049) years, with extremes of 19 and 52 years. Surgical site infections are frequent in the age group of 26-35 years (Table 1). Our results show a higher proportion, or 91.66%, of women with a good level of education.