Study design
This prospective study was conducted over six months, from February 01, 2022, to July 31, 2022, at two referral hospitals in Douala, Cameroon: Laquintinie Hospital and Douala Gynaeco-Obstetric and Paediatric Hospital (DGOPH).
Study Sites
A. Laquintinie Hospital
Laquintinie Hospital, a high-volume teaching hospital, manages the most caesarean sections (CS) (approximately 950/2900 annual births) in the Douala region. It serves a diverse patient population, with patients primarily covering their own treatment costs. The obstetrical theatre unit handles CS deliveries and various gynecological surgeries. Due to the presence of trainees and high patient turnover, aseptic conditions might be suboptimal.
B. Douala Gynaeco-Obstetric and Paediatric Hospital (DGOPH)
DGOPH, a public first-category hospital specializing in maternal and child care, conducts an average of 550-600 deliveries annually, with about 25% performed by CS. Labor management adheres to established guidelines incorporating infection prevention measures. CS procedures are performed by obstetricians or senior residents under consultant supervision. The dedicated theatre unit separates obstetrical and gynecological surgeries from abscess cases. Rigorous infection prevention protocols are implemented for theatre access, surgical attire, and equipment use.
Inclusion and exclusion criteria
All women undergoing CS during the study period were approached for informed consent and inclusion. We excluded women who:
- Failed to complete the questionnaire.
- Died immediately or before 30 days after CS without an SSI diagnosis.
- Presented other surgical or infectious complications.
Sampling and sample size
Patients were recruited consecutively using a convenience sampling method.
Data collection procedure
Standardized data collection tool captured preoperative, intraoperative, and postoperative information for each woman undergoing CS.
A. Preoperative Data included sociodemographic data (age, phone number, education level, and occupation), obstetrical data (parity, gestational age, previous CS, labor duration, ruptured membranes duration), mode of admission (elective or emergency), and in-hospital or referred patient status. Body mass index (BMI), Hemoglobin level, urinary catheter insertion time, and surgical site shaving time
B. Intraoperative Data were anesthesia type, surgeon’s qualification (obstetrician or resident doctor), surgery duration, antibiotic use, quantity of blood loss quantity, and any intraoperative complications.
C. Postoperative Data comprise antibiotic use, outcome measures( occurrence of superficial surgical site infection (SSSI), deep incisional infection (DII), or organ/space infection (OI)).
Diagnosis of SSI Criteria
We used the CDC criteria for diagnosing SSIs:
- Superficial Incisional Infection (SSSI): Involves skin and subcutaneous tissues. Requires at least one of the following: purulent discharge, isolated organism, infection symptom, or surgeon’s diagnosis.
- Deep Incisional Infection (DII): Involves deep tissues (muscles and fascia). Requires at least one of the following: purulent discharge, dehiscence/reopening of the incision by the surgeon due to suspected infection, evidence of abscess formation, or other deep infection diagnosed by the surgeon.
- Organ/Space Infection (OI): Involves any organ other than the incision site but related to the surgery. Requires at least one of the following: purulent discharge from a drain placed in the organ, isolated organism from the organ, abscess, or infection involving the organ.
Participant Follow-Up
Participants were systematically reviewed at:
- Day 4: Surgical site dressing change as per hospital protocol.
- Every 2 days until day 12 at Laquintinie Hospital.
- Day 3 at DGOPH.
Following this monitoring period, patients with SSI were identified and received appropriate treatment based on hospital protocols. Patients without infection were discharged home. Before discharge, participants received education on potential SSI signs, including pain, fever, localized swelling, redness, purulent drainage, skin heat, and wound dehiscence. This enabled them to recognize infection at home and inform the research team. All participants were reviewed at day 30 for final assessment and study closure.
Data management and analysis
Data from the questionnaires were securely stored. Information was extracted and entered into Microsoft Office 365 Excel for initial analysis to create a usable database. This database was then exported into EpiInfo 7 for further analysis.
Categorical variables (occupation, education level, comorbidity) were summarized using counts and percentages, presented using a tabular form. Continuous variables (age, gestational age, BMI etc) were summarized using mean, standard deviations, medians and interquartile range where necessary. A chi square test was utilized to identify categorical risk factors that exhibit a statistically significant association with the occurrence of SSI (p < 0.05). Following the chi-square test, we calculated the Odds Ratio (OR) with a 95% confidence interval (CI) for each significant risk factor identified. Multivariate logistic regression analysis with adjusted Odds ratio (aOR) to account for potential interactions and confounding effects of factors found to be significant after bivariate analysis was finally used; the level of significance was set at p<0.05.
II-6 Ethical considerations and consent to participate
Ethical clearance was obtained from the institutional Review Board of the Faculty of Health sciences, University of Buea under the registration number 2021/1546-01/UB/SG/IRH/FHS. Administrative authorization was obtained from the directors of Laquintinie and Douala Gynaecology obstetric and Paediatric hospitals. All participants provided written informed consent after a thorough explanation of the study's purpose, procedures, potential risks and benefits, and the right to withdraw at any time without penalty.