A cesarean section (CS) is an operation in which surgery is made through a mother’s abdominal wall and underlying tissues to dislodge the baby.¹ When adequately indicated, it can prevent poor obstetric outcomes and can be a life-saving procedure for both the mother and the fetus. In last few decades, the incidence of caesarean deliveries, has risen dramatically. In the year 2018 - 2019 as per data collected by the Union Ministry of Health and Family Welfare under the Health Management Information System (HMIS), was 14 per cent of the total births took place through a C-section. 19 lakh caesarean sections took place in India alone out of total 1.3 crores deliveries in public hospitals ⁴

The incidence rate of surgical site infections (SSI) after caesarean deliveries varies from 6% to 27%, influenced by factors such as underlying patient status, co-morbidities,  wound class, maternal age, hypertensive disorders, types of caesarean procedures, number of vaginal examinations, blood loss during surgery, diabetes, maternal weight, surgical techniques, premature rupture of membranes.⁸ Studies in India consistently report higher rates ranging from 23-28%, exacerbated by low socioeconomic status and malnutrition.⁹ Compared to vaginal delivery, caesarean sections carry a 5 to 20-fold increased risk of infection.¹⁰

The SSI following CS causes physical, psychological and financial burden to the lady, her family and her community.¹¹ Difficulties to the mother and her family are exaggerated when SSI develops, especially in today’s climate of early hospital discharge, which leaves women to stay at home, sometimes with little practical and/ or emotional support.¹²

The study is planned to determine the prevalence of SSI after lower segment caesarean section. comprehensively investigate the etiology, risk factors, and antibiotic resistance patterns of aerobic bacteria causing surgical site infections (SSI) following lower segment caesarean section (LSCS).This will aid in extemporizing hospital infection control, institutional antibiotic policies, and minimizing the burden of hospital-acquired infections.

Study Population and Design

A total of 226 patients satisfying the defined inclusion and exclusion criteria, attend the outpatient (OPD)/inpatient (IPD) of Intensive care unit (ICU)/Post operative ward of gynaecology department, of Govt. Medical College Kota between Jan 2023 to June 2024. were surveyed during this period and were followed up from admission until the discharge. (Till 30 days after discharge from the hospital.)

Ethical Clearance

The study protocol was proceeded after the approval of the Institutional Ethical Clearance Committee and Research Review Board [F.3 ( )NO.62/dated 15/12/2022]

Inclusion Criteria

All clinically diagnosed cases of SSI were classified using CDC criteria⁸ .The cases satisfying the inclusion criteria were identified for surveillance .All consented pregnant female delivered by LSCS during study period irrespective of the preoperative administration of antibiotics admitted in Obstetric and gynae ward of GMC Kota and Associated groups of Hospitals. Each patient was followed from the time of admission till 30 days after discharge from the hospital.

Exclusion Criteria

1. Female with wound infection after 30 days of LSCS.
2. Patient who was already receiving antibiotic post operatively, for >one week.
3. Patients undergoing reoperation.
4. Those patients who were not willing to participate in the study.

Collection of samples

Careful cleaning of the surgical site with 70% alcohol was done before collecting the sample. The sample were collected with aseptic precautions using sterile cotton swabs. The wound margins were separated with the thumb and forefinger of one hand (wearing a sterile glove) and swabs were taken from the depth of the lesion with the other hand. Two swabs placedin a sterile container sent to the laboratory.⁶⁹

Collection of Data

The required data were collected as per the standardized SSI case report form for each case daily at the same time, which includedpatient demographic profile, clinical history, and use of any antimicrobials was collected from the patient’s record file and analyzed. • Event time frame – It is a 30-day period (considering date of event = day 1) when SSI is considered to be ongoing. Organisms identified during the event time frame are added to the case report form of the initial SSI. No new event can be reported for the patient during these 30 days.

Specimen Processing

The samples collected were processed as follows, according to the standard procedures which includes direct microscopic examination of Gram stained smear, Inoculation of the samples onto 5% sheep blood and MacConkey agar that was incubated aerobically at 37°C for 18–24 hours.Preliminary identification of growth was done and Isolates were subjected to Gram staining and further identification by the biochemical reactions along with their antimicrobial susceptibility testing by Kirby–Bauer disk diffusion method. ^69,70,71

Statistical Analysis

The descriptive statistics for quantitative and qualitative data were calculated as mean, standard deviation, and proportions, respectively. The association between qualitative variables is tested through Chi-square test.

The infection rate in our present study was 14.6%, which falls within the reported range of 2.5% to 41.9%.^75,76226 patients included in the study were in the age group 20years to more .Of the total 226 cases enrolled highest prevalence rate of SSI (25.81%) post-LSCS was found in the 35-40 year age group exhibiting a significant finding (p=0.01), which is similar to other studies done by Devjani De et al⁶⁷ and Prajapati V et al⁵⁴where mean age of highest infection was found to be35.42±3.68  and 36.5±4.1 respectively. Most of the SSIs were superficial (26; 11.5%), whereas four (7.3.10%) involved organs/spaces.

Risk Factor Analysis. Analysing the risk factors, the one showing a significant association (P < 0.05) were advancing age, anemia, emergency procedure ,prolonged preoperative hospital stay, prolonged total duration of surgery, vertical skin incision, premature or prolonged rupture of membranes (more than 24 hours), preexisting medical illness (CKD, DM,Hypertension), and intraoperative blood transfusion. The risk factor analysis is shown in Table 1

Table 2 shows the distribution of various pathogens isolates causing SSI. A total of 33 bacterial isolates were obtained. Staphylococcus aureus, Coagulase-Negative Staphylococcus (CONS) and Escherichia coli. was the most commonly exhibited isolate (21.21% each). Other Gram-organisms isolated were Pseudomonas aeruginosa, klebsiella species, and Enterococcus species .

Antimicrobial resistance pattern of these organisms is shown in Tables 3(a) and 3(b).

Table 1 Risk factor analysis of surgical site infections following LSCS

Table 2Distribution of organisms associated with SSIfollowing LSCS

TABLE 3AResistance pattern in Gram-positive organisms

TABLE 3BResistance pattern in Gram-negative organisms

In India, the prevalence of postoperative infections in various hospitals varies from 10% to 25%.⁷⁶In our investigation, we found a prevalence rate of SSI post LSCS of 14.6% which falls within the reported range of 2.5% to 41.9%.⁷⁵Higher prevalence rates of SSIs in developing countries like india, many factors influence the rate of SSI  like compromised hygienic practice unlike developed countries, difference in population sampling and study design ,  poor infection control practices, overcrowded hospitals and inappropriate use of antimicrobials[16]. In present study, notably, individuals aged 25.1-30 emerged as the largest cohort, comprising 38.05% of the study population, while SSI prevalence peaking among those aged 35.1-40 that is 25.81%. similar findings was found in other studies done by Devjani De et al⁶⁷ and Prajapati V et al⁵⁴where mean age of highest infection was found to be35.42±3.68  and 36.5±4.1 respectively. This can be explained due to compromised host immunity and associated co-morbidities in higher age group. Regarding urban-rural disparities, rural areas exhibited a higher prevalence rate of SSI that is (15.29%), although urban regions showed a slightly lower prevalence rate(14.18%). Furthermore, individuals in lower income brackets experienced a comparatively higher prevalence of SSI, contrasting with the lower rates observed among the middle-income group. Interestingly, gravidity status did not significantly affect SSI incidence rates, with both primigravida and multigravida populations showing comparable rates.

In present study,We observed that Vertical skin incision, PROM >24hrs , Intraoperative blood transfusion, emergency procedures, longer duration surgeries, and higher blood loss correlate significantly with elevated SSI incidence rates.These findings align with existing literature indicating that factors such as the type of surgical incision, prolonged exposure to amniotic fluid (in cases of PROM), and the immunomodulatory effects of blood transfusions can compromise the body's defense mechanisms against pathogens, thereby increasing the susceptibility to surgical site infections.⁹⁰In Emergency procedures, the compromised surgery planning due to inadequate preoperative preparation time were more likely to develop SSI as seen in study by Chhetry M et al. The association between prolonged surgical duration and an increased risk of developing surgical site infections, likely due to extended exposure to the environment and potential compromises in sterile conditions over time.⁹⁶

Additionally, patients with underlying medical conditions like anemia, chronic kidney disease (CKD), diabetes mellitus (DM), and hypertension (HTN) demonstrate remarkably higher SSI incidence rates, suggesting a need for tailored interventions in these populations. These findings are supported by the known immunocompromised state associated with CKD, the impaired wound healing in DM. Hyperglycemia, particularly, has detrimental effects on host immune function, notably impairing neutrophil function, and the altered immune response in HTN, which collectively contribute to the increased susceptibility to surgical site infections in these patient groups^93-95.

In our study, Staphylococcus aureus, Coagulase-Negative Staphylococcus (CONS) and Escherichia coli emerged as the most prevalent pathogens across all categories of SSI which exhibited notable prevalence of 21.21% of total SSIs. These findings are consistent with literature indicating that Escherichia coli and Coagulase-Negative Staphylococcus are common contaminants of surgical wounds, often introduced during surgery or post-operatively through inadequate sterilization or hygiene practices⁶⁷.

The study also delves into the resistance patterns observed among cultured pathogens and their association with SSI incidence rates. Among Gram positive organism, drugs which showed high resistance are Ceftriaxone Amoxicillin/clavulanic acid and Ceftazidime, drug like Imipenum showed low resistance and Vancomycin showed no resistance.

Likely, among Gram negative organism drugs which showed high resistance are Cephelosporin class of drugs like Ceftriaxone, Ceftazidime and Cefepime. Drugs like Imipenum and Levofloxacin showed low resistance.

Concluding that the prevalence of Surgical Site Infections (SSI) stood at 14.6%, the study identified several risk factors associated with their development, that can be targeted to effectively reduce SSI rates. Earliest identification of pathogen by culture and drug sensitivity can reduce the severity of SSI and thus can reduce physical and economic burden on community.

On the basis of our study some recommendations are advised for reducing SSI in future, these are-

1. Prompt Antenatal screening for any predisposing risk factor identification and if present, care of it accordingly.
2. Accurate use of prophylactic antibiotic.
3. Complete maintenance of asepsis during and post surgery.

Acknowledgement - we acknowledge the efforts of Dr Shailendra vashistha, Assistant Professor, Department of Transfusion medicine GMC Kota for his valuable suggestions in journal selection, and manuscript submission process.

Financial support and sponsorship Nil.

Conflicts of interest There are no conflicts of interest

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