Available online on 15.06.2024 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright  © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access   Full Text Article                                                                                                                                                     Research Article

Bacteriological profile in patients with cesarean infection at Ruhengeri level two teaching Hospital

HABANABAKIZE Jean Baptiste*, ISHIMWE Alain Prudence, NTEZIRIZAZA Evariste, KANOBAYITA Nadia, UWIRINGIYIMANA Athanasie 

Ines-Ruhengeri, Faculty of Applied Fundamental Sciences, Department of Biomedical Laboratory Sciences, Rwanda  

Introduction

Cesarean section (C-section) is a surgical procedure performed to deliver a baby through an incision made in the mother's abdomen and uterus. While C-sections are often necessary and generally safe, they carry the risk of postoperative complications, including infection. Cesarean infections can occur in various parts of the body, including the surgical wound, uterus, and surrounding pelvic organs, posing significant health risks to both the mother and the baby if not promptly diagnosed and treated. These infections can be caused by a variety of bacteria, including skin flora and nosocomial pathogens, which may gain entry during the surgical procedure or postoperatively. Factors such as prolonged rupture of membranes, prolonged labor, obesity, and diabetes are known to increase the risk of infection following a C-section. Thus, it is crucial to implement preventive measures and adhere to meticulous surgical techniques to minimize the risk of cesarean infections¹. In recent years, there has been a growing emphasis on optimizing preventive strategies to reduce the incidence of cesarean infections. Antibiotic prophylaxis plays a crucial role in preventing postoperative infections after C-sections. Several studies have evaluated the efficacy of antibiotic prophylaxis in reducing the risk of surgical site infections and endometritis following cesarean delivery. A Cochrane review concluded that antibiotic prophylaxis significantly reduces the risk of post-cesarean infections compared to no prophylaxis, with a lower incidence of endometritis, wound infections, and serious maternal infectious morbidity². However, the choice of antibiotics, timing of administration, and duration of prophylaxis remain areas of debate and ongoing research. Clinicians must balance the benefits of antibiotic prophylaxis in preventing infections with the risks of antimicrobial resistance and adverse effects associated with antibiotic use. Guidelines from professional organizations, such as the American College of Obstetricians and Gynecologists (ACOG), provide recommendations for the use of prophylactic antibiotics in cesarean delivery to minimize the risk of postoperative infections. ACOG recommends administering prophylactic antibiotics before skin incision to achieve adequate tissue concentrations at the time of surgery³. The choice of antibiotics should be based on local antimicrobial susceptibility patterns and individual patient factors, such as allergies and comorbidities. Additionally, ACOG advises against the routine use of postoperative antibiotics in uncomplicated cesarean deliveries, as the benefits may not outweigh the risks of promoting antimicrobial resistance¹. In addition to antibiotic prophylaxis, other measures can help reduce the risk of cesarean infections. Proper skin preparation before surgery using antiseptic agents is essential to minimize the microbial load on the skin and reduce the risk of surgical site infections. A randomized trial comparing different skin antiseptic agents at cesarean delivery found that chlorhexidine-alcohol was more effective than iodine-alcohol in reducing the risk of surgical site infections and endometritis⁴. Adequate perioperative care, including maintaining normothermia, optimizing glycemic control, and ensuring meticulous surgical technique, can further contribute to preventing cesarean infections. Despite these preventive efforts, cesarean infections may still occur, necessitating prompt diagnosis and treatment. Clinical signs of cesarean infection may include fever, abdominal or pelvic pain, uterine tenderness, foul-smelling vaginal discharge, and wound complications such as erythema, swelling, or purulent drainage. Early recognition of these signs, coupled with appropriate microbiological investigations, is essential for timely initiation of antimicrobial therapy tailored to the identified pathogens. Broad-spectrum antibiotics covering common organisms implicated in post-cesarean infections, such as Staphylococcus aureus, Streptococcus species, Escherichia coli, and anaerobic bacteria, are typically initiated empirically pending culture results¹.Cesarean infections remain a significant concern in obstetric practice, with the potential to cause substantial maternal morbidity and mortality. While preventive measures such as antibiotic prophylaxis and meticulous surgical technique have been effective in reducing the incidence of cesarean infections, ongoing research is needed to optimize strategies for infection prevention and management. Collaborative efforts between clinicians, researchers, and healthcare organizations are essential to develop evidence-based guidelines and implement best practices aimed at improving outcomes for mothers and babies undergoing cesarean delivery. By prioritizing infection prevention and timely intervention, healthcare providers can minimize the burden of cesarean infections and promote safe and successful childbirth experiences. Therefore, this study aimed at isolation and identification of bacteria in patients with cesarean infection at Ruhengeri Level two teaching Hospital

Methodology of the study

Study area 

This study was conducted at Ruhengeri Level two teaching Hospital which is a public hospital located at in Muhoza sector, Musanze district, Northern Province of Rwanda.

Study design 

A Cross-sectional study was performed on patients with cesarean infection. The qualified inpatients were approached and requested to give samples and answer to a voluntary consent form to register in the study. 

Study population and sample size

The study population include patients with cesarean infection attending Ruhengeri level two teaching Hospital. 30 pus swab Samples were collected in a sterile container; the collected samples were transported to the clinical microbiology laboratory for analysis at INES-Ruhengeri.

Statistical analysis 

Data were checked for completeness, inconsistencies, and missing values and then coded, entered using MS excel spreadsheet. Then cleaned and analyzed using SPSS version 20. Descriptive statistics were computed to determine frequencies and summary statistics (mean, standard deviation, and percentage) to describe the study population in relation to socio-demographic and other relevant variables. Data were presented using tables, graphs and figures. Chi square was also used for association.

RESULTS

Demographic characteristics of study participants

Demographic information of study participants for a cross-section study were summarized in the table1. The age, education level, economic status, employment status and marital status were investigated as variables for demographic characteristics by estimate the frequency and percentage.

Table 1: Demographic characteristics of study participants (N=30)

A total 30 patients investigated in this study, the patients who studied primary participated with high frequency was 7 with 23 %. Economic status, category 2 participated highly with 7 patients which account 23%, unemployed patients participated highly compared to others with 14/47% and on marital status, married patient participated high with 13/43%.

Isolated bacteria from cesarean infection

Table 2: Identification of bacteria that were associated with cesarean infection

The table above shows the isolated bacteria from cesarean infection where the most isolated bacterium was S.aureus with 28.1% while the least isolated  bacteria were E. coli and P.mirabilis with 6.3%.

The antibiotics susceptibility pattern of bacteria associated with cesarean infection at Ruhengeri level two teaching Hospital 

Table 3: Determination of antibiotic susceptibility pattern of bacteria associated to cesarean infection.

Antibiotics sensitivity test was performed, so this study showed the predominant antibiotic which were sensitively to different bacteria were Chloramphenicol, Gentamycin and Norfloxacin and most bacteria were resistant to Rifampicin and vancomycin.

Risk factors associated with cesarean infection patients attending Ruhengeri level two teaching Hospital

Table 4: Association between cesarean infection and associated risk factors among patients at Ruhengeri level two teaching Hospital

Chi-square test was performed to test for association between risk factors and cesarean infection. In this study, Age, marital status, economic status and education level were all statistically associated with E. coli with P value=0.041, P value=0.00, P value= 0.00 and P value= 0.008 respectively. Other factors were not statistically significant. S. aureus was statistically associated by education level with P value=0.04. age and marital status were associated with S aeruginosa with p value= 0.01 and 0.02 respectively. Age, marital status and education level were associated with K. pneumoniae with P value=0.008, P value 0.013 and 0.039 respectively. Age, marital status and education level were associated with P. mirabilis with P value= 0.006, P value=0.00 and 0.003 respectively

Discussion 

Bacterial wound infection of caesarean has been a major public health concern in healthcare which gives a burden to healthcare providers for its management. This is because of the increased trauma to the patient but also because of its burden to the financial resources, long stay in hospital and costly treatment. This study aimed to identify bacteria responsible of infected wound of caesarean, to determine their antimicrobial susceptibility pattern as well as to assess risk factors associated to cesarean infection. The demographic data of patients with infected wound of cesarean were analyzed where people with 19-23 years was predominant (Table 1). Which most similar to the study conducted by other researcher⁵. The range of incidence in Burundi, DRC and Sierra Leone was 1.7-10.4%. Respectively the rate in Kebezi referral center (Curgo hospital) the rate was 10.4%, Lubutu General Hospital the rate was 1.7% and in Gondana Referral Center the rate was 7.3%.⁶. SSI on is a multifactorial process that starts from the perioperative preparation, the patient, the type of surgery, the type of germ and other factors. As the various studies such as a study in Tanzania showing that Staphylococcus aureus as one of the most common bacteria causing SSI in post-caesarean patients, and particular superficial infections⁷. Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing post cesarean morbidity and mortality⁸. The indication for CS was obstructed labor/failure to progress in 86 (17.7%) of the patients, of these 13 (15.1%) had wound infection. Sixty-seven (13.8%) patients had severe pre-eclampsia/eclampsia, while only 3 (4.5%) had SSI. The indication in 48 (9.9%) was abnormal lie/breech presentation. all but 11 (22.9%) presented in labor and had emergency CS⁹. The wound infection rate in this group was 27.8% overall and 60% among those with retained second twin. Similarly, 5 of the 7 patients in whom CS was preceded by pre-labor rupture of membranes (PROM) had wound infection. Among 19 patients who had CS because of fetal distress, 3 (15.7%) had wound infection. Only 1 of 9 patients with prolonged pregnancy had infection and none of 7 cases with antepartum hemorrhage and 17 patients with failed instrumental delivery. Our study is in line with another study which showed that multiple species of bacteria are isolated, although they are typically considered to be relatively of low virulence¹⁰. As reported by others, the mean duration of labor prior to CS was longer in the cases 10.18(6.8) h. as against 7.13(3.9) h in the controls. Similarly, the skill of the surgeon here depicted by his level of experience just failed to achieve statistical significance, although the mean operating time significantly differed. Prolonged operating time, and poor surgical skills. Majority (83%) of obstructed labor, cord or hand prolapse were referred to our unit from outside clinics perhaps after some non-aseptic manipulations; clearly cord and hand prolapse may aid ascent of microbial pathogens from the lower genital tract to the upper genital tract. Wound infection was confirmed by microbiological studies in 32 cases. Twenty-nine (90.6%) were positive cultures while 3 (9.4%) were sterile. S. aureus was isolated in 31.8% of the cultures. This bacterium was shown to be the predominant agent in post-cesarean wound infection¹¹. Similarly in our study, S.aureus  was shown to be isolated at the same range with with a percentage of 28.1%. In research conducted in Israel, Escherichia coli is one of the organisms that are often found in caesarean SSI⁶. Which is in line with our study where E.coli was also isolated from cesarean infection patients from Ruhengeri level two teaching Hospital

Conclusion

This study was conducted to identify bacteria from cesarean wound infection and associated risk factors. Different risk factors were evaluated among participants. It revealed that almost all risk factors evaluated could be the source of bacteria isolated from their cesarean wound infection. The overall association between contaminations and associated outcomes was statistically significance. However, most of risk factors were found to be statistical significance for overall association with all isolated bacteria.

Acknowledgments

We extend our gratitude to Ruhengeri level two teaching Hospital administration for facilitating this study at their health facilities. We also extend our gratitude to Ines Ruhengeri to allow and provide to us its microbiology laboratory where all experiments were done. Our acknowledgement also goes to the patients who accepted to participate in this study.

Conflict of interest

Authors declare no conflict of interest

Authors contributions 

Habanabakize Jean Baptiste and Kanobayita Nadia conducted the laboratory experiments of this study. Ishimwe Alain Prudence designed this study and wrote the manuscript. Ntezirizaza Evariste and Uwiringiyimana Athanasie participated in this study by proof reading and correct the manuscript as well as analyzing the data to get good results. 

Availability of raw data and material

Raw data and information on material should be obtained from the corresponding author upon request.

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