Surgical site infection and antimicrobial use following caesarean section at QECH in Blantyre, Malawi: a prospective cohort study

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Therefore, this study aimed to determine the incidence of SSIs, risk factors and common microorganisms associated with SSI and assess the practice of antimicrobial use in women following CS at Queen Elizabeth Central Hospital (QECH). Methods: This was a hospital-based quantitative prospective study design involving pregnant women who underwent a Caesarean Section (CS) between February, 2023 and July, 2023 at QECH with 30 day-follow-ups. Some wound specimens (pus swabs) were collected from infected CS wounds and processed at QECH main laboratory, and susceptibility testing was conducted using the Kirby-Bauer disk diffusion method with results reported only as susceptible, intermediate, or resistant and the collected data was analyzed using Stata. Results: The overall cumulative incidence of SSI recorded at QECH during the study period was 10% (20 cases out of 208). Of these, 19 (95%) of them reported superficial SSI following CS. The mean age was 26.1 years with a standard deviation of 6.2. In contrast to the previous studies, potential risk factors including skin closure, age, parity or ANC visits were not associated with SSIs. The majority of patients with SSIs (n=12, 60%) were readmitted and 5 (25%) out of 20 with SSIs had antimicrobial resistance following susceptibility testing. Staphylococcus aureus was the most common organism (3, 60%) and other bacterial isolates included were Enterobacteriaceae and Acinetobacter baumanni. All pregnant women who underwent for CS received antibiotic prophylaxis. Conclusion: The incidence of SSIs and inappropriate antimicrobial use following CS remains a challenge at QECH. Therefore, due to increased number of SSIs following CS with relative emergence of AMR ensure intensive infection prevention and control practices, establishing AMS program and routine surveillance of SSIs at QECH. Surgical site infections Healthcare-associated infections Antimicrobial resistance incidence Risk factors Figures Figure 1 Background Caesarean section (CS) is a lifesaving operative technique in which a foetus, placenta, and membranes are delivered through an abdominal and uterine incision. Surgical site infection (SSI) is defined as an infection that occurs at or near the surgical incision within 30 days of the operation or after 1 year if an implant is placed [ 1 – 3 ]. Globally, SSI is the second most reported health-care associated infection (HAI), accounting for 19.6% of HAIs [ 4 ]. Numerous studies have reported incidence rates of post-CS SSIs, for example, 2.85% in India [ 5 ], 21% in Ethiopia [ 6 ] and 7-9.6% in Nigeria [ 5 , 7 ]. HAIs and antimicrobial resistance (AMR) are major global health challenges recognized worldwide. However, the spread of HAIs and AMR is particularly alarming in low- and middle-income countries [ 8 ]. SSI accounts for 20% of all HAIs and is associated with a 2- to 11-fold increase in the risk of mortality, with 75% of SSI-associated deaths directly attributable to SSI [ 9 , 10 ]. There are limited data on surgical site infections (SSIs) in African countries such as Malawi [ 11 ]. A prospective survey conducted by Borgstein at QECH in Blantyre showed an overall infection rate of 25.8% and that for clean wounds of 14.8% [ 12 ]. In many SSIs, the responsible pathogens originate from the patient's endogenous flora [ 13 ]. The causative pathogens depend on the type of surgery; the most commonly isolated organisms are Staphylococcus aureus , coagulase-negative staphylococci , Enterococcus spp . and Escherichia coli. Other studies have shown that Staphylococcus aureus is a commonly isolated organism in SSIs, accounting for 20–30% of SSIs occurring in hospitals [ 5 , 13 , 14 ]. A survey revealed that caesarean section procedures carry a risk of infection 5 to 20 times that of normal delivery [ 6 ]. Different studies have shown that the rational use of antimicrobials in women of childbearing age is important because it affects this population as well as their offspring. The indiscriminate use of antibiotics may result in the appearance of drug-resistant organisms [ 15 ]. The use of antimicrobial prophylaxis for caesarean section has been shown to be effective in reducing postoperative morbidity, cost and duration of hospitalization. Another study reported the incidence of infection even after antimicrobial prophylaxis due to preexisting infection, debilitating disease or prolonged rupture of membranes [ 15 ]. In addition, another study reported that once antibiotics are intensively misused, they are undoubtedly the main factor associated with the high numbers of antibiotic-resistant pathogenic and commensal bacteria worldwide[ 16 , 17 ]. Similarly, a study by Classen et al. revealed that a delay in surgery reduces patient protection and can lead to the occurrence of postoperative infections [ 18 ]. Consequently, with the increasing number of surgical cases in LMICs, surgical site infections (SSIs) are becoming more prevalent due to anecdotal evidence of AMR, despite limited data on resistance patterns. Therefore, this study was important for determining the extent of surgical site infections and antimicrobial use following caesarean section at QECH in Blantyre, Malawi. The study findings could also help to reveal some areas that may require policy change and further studies so that there is a large amount of information on SSIs in clinical and other similar contexts. The criteria for defining surgical site infection (SSI) were established according to the US Centres for Disease Control (CDC) and Prevention [ 19 ]. Superficial incisional SSI : Infection occurs within 30 days after the operation, and infection involves only the skin or subcutaneous tissue of the incision and at least one of the following: purulent drainage, with or without laboratory confirmation, from the superficial incision; organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision; at least one of the following signs or symptoms of infection—pain or tenderness, localized swelling, redness, or heat and superficial incision—is deliberately opened by the surgeon unless the incision is culture negative and the diagnosis of superficial incisional surgical site infection (SSI) is made by the surgeon or attending physician. Deep incisional SSI : Infection occurs within 30 days after the operation, and infection involves deep soft tissue (e.g., fascial and muscle layers) of the incision and at least one of the following: purulent drainage from the deep incision but not from the organ/space component of the surgical site; a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (> 38°C), localized pain, or tenderness, unless the site is culture negative; abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination; or diagnosis of a deep incisional SSI by a surgeon or attending physician. Organ/space SSI : Infection occurs within 30 days after the operation, and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which is opened or manipulated during an operation and at least one of the following: purulent drainage from a drain that is placed through a stab wound into the organ/space; organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space; abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination; and diagnosis of an organ/space SSI by a surgeon or attending physician. Methods and methods Study setting, design, period and population This was a hospital–based quantitative prospective cohort study among all women who underwent a caesarean section procedure at QECH from 1st February 2023 to 31st July 2023, and they were followed up for a 30-day period to assess wound outcome (SSI). QECH has an average of 300 CS procedures performed per month and is found in Blantyre in the southern region of Malawi. QECH provides secondary and tertiary levels of care and serves as the referral hospital for the health centres in Blantyre and district hospitals in the region (primary and secondary health care). Surgical wound sites at enrolment and discharge were inspected and classified according to the CDC [ 19 ] to assess whether exposure to any microbes would cause infection secondary to caesarean section. The study excluded all women who were severely clinically ill and/or who underwent CS in other health facilities. Sample size and sampling technique The study enrolled 208 pregnant women who delivered through CS at QECH. This sample size was calculated in OpenEpi version 3, assuming that 15% of the subjects in the study population developed surgical site infections and that they received antimicrobial agents. To determine significant differences in the proportions of surgical site infections between the two groups, a power of 80%, two-sided significance of 95% confidence and a design effect of 2 were used [ 20 ]. The assumption on the percentage was based on the results from a prospective survey conducted by Borgstein at QECH in Blantyre, which showed an overall infection rate of 25.8% and that for clean wounds of 14.8% [ 12 ]. Furthermore, the assumed percentage was also based on the point prevalence survey by Bunduki, which revealed HAI of 11.4%, including surgical site infections [ 11 ]. To determine the target sample size, this study employed simple random sampling proportional to the total number of caesarean section deliveries conducted at QECH during the study period. Data collection and procedure The data were collected electronically using Open Data Kit (ODK) software. The information included sociodemographic characteristics, obstetrics-related factors, and operation- and anaesthesia-related factors. The dependent variable of this study was the incidence of SSIs following CS. The suggested independent variables included were sociodemographic variables such as maternal age, maternal educational status, occupational status, religion, and antenatal care. Relevant maternal medical history, such as HIV status, BMI, previous history of CS, and/or hypertensive disorder, was collected. Surgical intervention-related variables included type of CS (elective or emergency), type of incision (vertical, horizontal), type of skin closure, premature rupture of membranes, number of vaginal examinations, duration of the procedure, anaesthetic technique (general, spinal), indication for CS, gestational age, postoperative CS performed by a doctor (e.g., international clinical officer, clinical officer, medical officer, student or consultant) and/or antibiotic use. Pus swab samples were collected from the infected surgical wounds and processed by the Kirby-Bauer (KB) test via the disc diffusion method [ 21 ]. As part of routine clinical care, the samples collected from the patients were quickly tracked; pus swabs or pus aspirates were sent to the QECH main laboratory for microbiology culture and sensitivity. Furthermore, the data were collected by the principal investigator and research assistants, who were qualified nurse midwives and microbiologists. For consistency in the data collection process, the research assistants were oriented to the data collection instrument by the principal investigator prior to the actual data collection process. 3.6 Data management and statistical analysis After data collection to ensure completeness, consistency and correct methods of data entry, quality control was performed on a daily basis. The data were subsequently transferred to a password-protected computer and downloaded to an electronic server for storage. The server was secure, with access only granted to study data managers. Microbiological isolates/samples from surgical sites when infected were collected and matched to the microbiological evaluation of collected samples for SSI clinical diagnosis. KB testing uses disks containing antibiotics to test whether the bacteria are susceptible to particular antibiotics. Ideally, cultured bacteria are isolated from patients and then grown overnight on agar (solid growth media) plates supplemented with relevant amounts of antibiotics that diffuse into the agar. When bacteria are susceptible to specific antibiotics from a disk, the area of clear media that indicates that the bacteria are not able to grow surrounding the disk/wafer is known as the zone of inhibition. Therefore, the size of a zone of inhibition in a KB test is inversely related to the minimum inhibitory concentration (MIC), which is the amount of antibiotic required to prevent bacterial growth in an overnight culture. The MIC (in µg/ml) can be calculated from known standard-curve (linear regression) graphs based on the diameter of the observed inhibition zone (in millimeters)[ 22 ]. The statistical analyses were performed by means of Stata version 14, and statistical significance was defined by a p value ≤ 0.05 (95% confidence level). Descriptive analysis was also conducted. For the continuous variables, means (standard deviations) and interquartile ranges (IQRs) were calculated, and the summarized results are presented in a table. Descriptive data analysis was also used for frequencies and percentages. These studies were mainly focused on sociodemographic characteristics, medical-related and obstetric-related factors, and operation and anaesthesia factors. The chi-square (ꭓ 2 ) test and Fisher’s exact test for observations less than 4 were used to establish any relationships between the variables/factors and the SSIs. The analyses were performed to determine the potential risk factors or crude odds ratios. Risk factors with a p value < 0.05 in the univariate analysis were selected for inclusion in the multivariable logistic regression model. However, multivariable analysis was not performed to assess whether the relationship between C-sections and SSIs was confounded by other risk factors because ꭓ 2 showed no direct association between the variable and the outcome of interest (SSI). Results Socio-demographic and clinical characteristics The mean age was 26.1 years, with a standard deviation of 6.2 years. Approximately 111 (53.37%) of the women responded with no previous history of CS, and 20 (9.6%) of the women were HIV positive in this study (Table 1 ). A total of 208 women who underwent the CS procedure were included in this study; of these, 20 patients developed SSI following CS either clinically or through microbiological culture. A total of 208 pregnant women who underwent CS were enrolled, and 30 days of follow-up were used to assess SSI outcomes (Fig. 1 ). The minimum age of the study participants was 15 years, while the maximum age limit for the study participants was 42 years. Table 1 Socio-demographic and clinical characteristics of the study participants. Variable Frequency Proportion (%) Mean (SD)Age 26.05 (± 6.18) Age in years ≤ 30 156 75 > 30 52 25 Marital Status Married 171 82.21 Others * 37 17.79 Previous history of CS Yes 97 46.63 No 111 53.37 Education Level Primary 84 40.38 Secondary or More 124 59.62 Occupation Employed 15 7.21 Business 78 37.50 Housewife 92 44.23 Other* 23 11.06 HIV Status Positive 20 9.62 Negative 188 90.38 Married _Others * (Single, Divorced, Widowed) , Occupation_ Other * (dwellers, none) Caesarean section indications Among mothers who underwent caesarean section, previous scarring was the most common indication (63 (30.29%)), followed by cephalopelvic disproportion (61 (29.33%)) (Table 2 ). Table 2 Indications for Caesarean Section Indication Frequency % CPD*1 61 29.33 Previous scar 63 30.29 Cord prolapse 4 1.92 Eclampsia 14 6.73 Antepartum hemorrhage 7 3.37 Breech presentation 12 5.77 Fetal Distress 12 5.77 Prolonged labour 17 8.17 Other*2 18 8.65 CPD*1 Cephalopelvic disproportion Other*2 (placenta previa, twin gestation, IUGR, PROM, polyphromnious and postdates) Medical-related and obstetric-related characteristics Among the 208 women, 115 (55.5%) had a BMI greater than 25, and 22 (10.58%) had an ASA score equal to or greater than two. Furthermore, 93 (44.71%) of the patients experienced membrane rupture before CS was performed. In addition, approximately 169 (81.25%) of the participants’ gestational age was not less than 37 weeks (Table 3 ). Table 3 Medical-related and obstetric-related characteristics of women who underwent CS surgery at QECH Variable Frequency Proportion (%) Parity 0 81 38.94 1 60 28.85 2–4 64 30.77 ≥ 5 3 1.44 No. vaginal Examination 0 89 42.79 1–4 95 45.67 ≥ 5 24 11.54 Gestation Age < 37 weeks Yes 39 18.75 No 169 81.25 ANC Visits 0 2 0.96 1–4 120 57.69 ≥ 5 86 41.35 ASA Score < 2 186 89.42 ≥ 2 22 10.58 BMI < 25 93 44.71 ≥ 25 115 55.29 Membranes status pre-CS Ruptured 93 44.71 Intact 115 55.29 Anaesthesia and operation-related characteristics The average duration after the first dose of antibiotic prophylaxis to the start of the CS procedure was 12.85 minutes, with a standard deviation of 8.44 (IQR = 8, 25th percentile = 7, 75th percentile = 15). Furthermore, 134 (64.4%) CS procedures were performed by intern medical officers (IMOs), and 206 (99.04%) of the procedures involved spinal anaesthesia. Approximately 113 (54.3%) of the operation procedures were completed in more than 60 minutes, and 120 (57.7%) and 63 (30.3%) of the 208 patients underwent emergency and urgent CS, respectively. ( Table 4 ). Table 4 Anaesthesia- and operation-related characteristics of women who underwent CS surgery at QECH, Malawi Variables Frequency Percent Urgency of operation Emergency 120 57.69 Urgent 63 30.29 Semi elective 7 3.37 Elective 18 8.65 Type of incision Horizontal 206 99.04 Vertical 2 0.96 Anaesthetic technique Spinal 206 99.04 General 2 0.96 Skin closure type Interrupted 86 41.35 Continuous 122 58.65 Duration of CS (Min) < 60 min 95 45.67 ≥ 60 min 113 54.33 CS Performed by Doctor 14 6.73 Intern medical officer 134 64.42 Clinical Officer 31 14.90 Student 10 4.81 Intern Clinical Officer 6 2.88 Medical Officer 13 6.25 Incidence of surgical site infection The overall incidence of SSIs recorded at QECH during the study period was 10%. Of these, 19 (95%) reported superficial SSI, and 1 (5%) reported deep SSI following CS (Table 5 ). The majority of patients with SSIs (n = 12/60%) were readmitted, and 5 (25%) out of 20 patients with SSIs had antimicrobial resistance following susceptibility testing. Chi-square and Fisher’s exact tests were performed for observations less than or equal to 4 to determine the potential risk factors associated with the SSI at the 95% confidence level. In contrast, this study revealed that there was no factor/variable associated directly with surgical site infections. This might be due to the small sample size included in this study. The tested factors that other studies reported include skin closure technique, BMI, education level, age range in years, HIV status, parity, membrane status pre-CS, ANC visits, gestational age (weeks), duration of CS and SSI [ 23 ]. Hence, we did not perform any logistic regression model analysis because no P value < 0.05% indicated statistical significance (Table 5 ). Table 5 Univariate analysis of possible risk factors for SSIs in women who underwent CS Variable/factor SSI Chi-square P value Yes (n = 20) No (n = 188) Skin closure technique Interrupted Continuous 7 (35.00) 79 (42.02) 13 (65.00) 109 (57.98) 0.3675 0.544 BMI ≤ 25 > 25 11 (55.00) 82 (43.62) 9 (45.00) 106 (56.38) 0.9475 0.330 HIV Status* Positive Negative 4 (20.00) 16 (8.51) 16 (80.00) 168 (89.36) 0.109 Age range* ≤ 30 > 30 16 (80.00) 140 (74.47) 4 (20.00) 48 (25.53) 0.787 Education level Primary Secondary or More 8 (40.00) 76 (40.43) 12 (60.00) 112 (59.57) 0.0014 0.971 Duration of CS (min) ≤ 60 > 60 11 (55.00) 110 (58.51) 9 (45.00) 78 (41.49) 0.0916 0.762 Membrane status pre-CS Ruptured Intact 12 (60.00) 81 (43.09) 8 (40.00) 107 (56.91) 2.0922 0.148 Parity ≤ 2 > 2 10 (50.00) 71 (37.77) 10 (50.00) 117 (62.23) 1.1379 0.286 ANC Visits ≤ 4 > 4 11 (55.00) 111 (59.04) 9 (45.00) 77 (40.96) 0.1218 0.727 Gestation age (weeks)* < 37 ≥ 37 3 (15.00) 36 (19.15) 17 (85.00) 152 (80.85) 1.000 * = p value according to Fisher’s exact test, ANC = antenatal care Bacterial isolates and susceptibility pattern Pus swabs from infected CS wounds for culture and sensitivity were collected for 11 (55%) of the clinically suspected postoperative CS infections. Among the 20 cases recorded, 10 (50.0%) had microbiology culture results, and 1 sample was reportedly missing from the laboratory. Five of the 10 cultures exhibited positive/bacterial growth (Fig. 1 ). Among the etiological agents isolated, 3 (60%) were gram-positive cocci (clusters). Staphylococcus aureus was the most common organism (3, 15%). Other isolates included Enterobacteriaceae (1, 5%) and Acinetobacter baumanni (1, 5%) (Table 5 ). The Staphylococcus aureus bacteria isolated were resistant to most antibiotics, including clindamycin, erythromycin, gentamicin, and cefoxitin. However, Enterobacteriaceae were sensitive to ciprofloxacin, meropenem, amikacin and tigecycline and resistant to chloramphenicol and trimethoprim/sulfamethoxazole. Only Acinetobacter baumannii Baumanni was sensitive to gentamicin and resistant to ceftriaxone, ciprofloxacin, cefotaxime and tigecycline (Tables 6 & 7). Discussions This is the first study in Malawi to determine the extent of surgical site infections (SSIs) and antimicrobial use following cesarean section at QECH in Blantyre. The overall incidence of SSI during the study period was 10% (20 of 208 patients). Most patients were given antibiotics either prophylactically or post-CS without performing culture to ascertain AMR. Similarly, this finding is consistent with findings in Vietnam (10.9%) [ 24 ]. Of course, Borgstein's prospective survey findings at QECH in Blantyre revealed a 25.8% overall infection rate in general surgeries [ 12 ]. Similarly, other studies reported incidences of 21% in Ethiopia [ 6 ] and 7-9.6% in Nigeria [ 5 , 7 ]. The incidence of SSIs in this study was greater than that in developed nations [ 25 , 26 ]. Additionally, health care in Africa is less accessible and of poor quality than that in developed nations [ 16 ]. In the present study, among the etiological agents isolated, 3 (60%) were gram-positive cocci (clusters). Staphylococcus aureus was the most common organism. This finding is in line with previous findings that Staphylococcus aureus is the most common cause of SSIs following post-CS [ 27 , 28 ]. Similarly, other studies have shown that Staphylococcus aureus is a commonly isolated cause of SSI, accounting for 20–30% of SSIs occurring in hospitals [ 6 , 14 , 29 ]. Furthermore, other isolates identified in our study included Enterobacteriaceae and Acinetobacter baumannii . In the present study, the Staphylococcus aureus isolates were resistant to most antibiotics, such as clindamycin, erythromycin, gentamicin and cefoxitin, similar to the findings of Fantahamu et al. [ 30 ]. Furthermore, Enterobacteriaceae were sensitive to ciprofloxacin, meropenem, amikacin and tigecycline, and the same bacteria were resistant to chloramphenicol and trimethoprim-sulfamethoxazole. However, Acinebacter Baumanni was sensitive to gentamicin and resistant to ceftriaxone, ciprofloxacin, cefotaxime and Tigecycline, as also reported in other studies [ 30 , 31 ]. This study also revealed that 138 (66.35%) patients received both preop antibiotics (ceftriaxone) and post-CS antibiotics. The most common post-CS-prescribed antibiotics were metronidazole and ceftriaxone combined therapy, even for patients with noncomplicated CS. A study by Lamont et al. indicated that a single dose of antibiotics could be as effective as multiple doses given perioperatively [ 32 ]. No patient had a known infection or specific bacterial organism isolated in the current study at the time these antibiotics were prescribed and administered; hence, this may also promote antimicrobial resistance spread due to unnecessary use of antibiotics in our hospitals. In contrast to previous studies, skin closure, BMI, HIV status, education level, age, duration of CS, membrane status pre-CS, parity, ANC visits and gestational age were not significant risk factors in our study sample [ 26 , 30 , 33 , 34 ]. Additionally, Kaye et al. reported that age was a powerful predictor of SSI [ 35 ]. However, other studies have also reported contamination or dirt operation as a risk factor [ 26 ] and wound classification as clean contamination for the CS procedure [ 19 ]. The present study revealed that all the women who underwent CS were given antibiotic prophylaxis with ceftriaxone. The average duration from the first dose of antibiotic prophylaxis to the start of the CS procedure was 12.85 minutes, with a standard deviation of 8.44 (IQR = 8). The prevalence of SSI and the timing of antibiotic prophylaxis in clinical practice have not been thoroughly investigated, but some clinical trials have indicated a relationship [ 18 ]. In the same study by Classen et al. [ 18 ], few patients developed SSI among those who received antibiotic prophylaxis early before the start of surgery compared to those who received antibiotics later after surgery. Furthermore, in the present study, three patients who received post-CS antibiotic prophylaxis and two patients who did not receive antibiotics after surgery had antimicrobial resistance. Of course, these patients without any confirmed infection diagnosis received antimicrobial treatment after caesarean section; hence, this therapy cannot be applied as an indicator of SSI. The inappropriate use of antimicrobial agents needlessly exposes patients to potential toxicity and risks that promote the development and spread of antimicrobial resistance, leading to increased medical care costs in healthcare facilities [ 26 ]. However, the rational use of antimicrobials in women of child-bearing age is important because it affects this population as well as their offspring. [ 15 ]. The strengths and limitations of the study The strengths of the study include that the study revealed the emergence of AMR in the Malawian setting and that the study used primary data for SSIs following CS. However, the study was limited to SSIs following CS, and the number of HAIs occurring in other settings, such as surgical departments or wards for various hospitals for general surgery, cannot be estimated. Some patients who developed SSIs did not return to the hospital again for review, which could lead to a lack of microbiological data related to SSIs. Last, the small sample size could have affected the outcomes of interest. Conclusion This study concludes that the incidence of 10% SSI following the CS procedure was relatively greater than that in other developing countries. Most patients were given antibiotics either prophylactically or post-CS without performing culture to ascertain AMR. The inappropriate use of antibiotics may result in antimicrobial resistance. Therefore, due to the increased number of SSIs following CS and the relative emergence of antimicrobial resistance to some microorganisms, including Acinetobacter baumanni and Staphylococcus aureus , intensive infection control practices are needed and establish AMS programs and routine surveillance of SSIs at QECH. The importance of postdelivery reviews following CS for improving health education for women undergoing CS should be emphasized to reduce the need for late clinical diagnoses of SSIs. In addition, there is a need to conduct further studies on bacterial isolates and antimicrobial resistance patterns and how to best address AMR through one health approach. Abbreviations AMR: Antimicrobial Resistance, AMS: Antimicrobial Stewardship, ASA: American Society Anaesthesiologists: Abx: Antibiotics, CDC: Centres for Diseases Control and Prevention, COMREC: College of Medicine Research Ethics Committee, CS: Caesarean Section, ESBLs: Extended-spectrum β-lactamases, HAIs: Healthcare-associated infections, IQR: Interquartile Range, IPC: Infection Prevention and Control, KUHeS: Kamuzu University of Health Sciences, LMIC: Low- and middle-income countries, QECH: Queen Elizabeth Central Hospital, SSIs: Surgical Site Infections, US CDC: United States Centre for Diseases Control, WHO: World Health Organization Declarations Acknowledgments I am grateful and thank Almighty God for His gracious love and endless blessings, without Him the entire dream of completing this dissertation would not have been possible. This work is a product of collective efforts, dedication, and support from various individuals. Exceptionally, I would like to express my sincere gratitude to my supervisors, Dr. David Kulapani (primary supervisor), Dr Samuel James Meja (secondary supervisor), Associate Prof. Janelisa Musaya (third supervisor), Gabriel Maliwata (data analysis consultant from Data research centre, KUHeS) who generously and tirelessly extended their expertise, guidance, aspirations, and contribution shaping the quality of this work. Further, I would like to extend my special thanks to my family especially my beloved wife Dalitso Mayani, and my sons, Antonio and Arthur Kachipedzu who were patient during my studies. Their encouragement, advice morals, and material support were very important resources of motivation to complete my studies. Generally, my sincere gratitude is directed to B. Braun-Stiftung for financial support and anyone who in one way or another, assisted in making this research work complete. Authors’ contributions ATK originated the research idea and analyzed the data. DKK, SJM and JM contributed to supervision, data analysis and writing the manuscript. All authors reviewed the manuscript. Funding Partial funding was obtained from B. Braun Foundation, Germany for this study. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethical consideration and consent to participate The protocol for the study was reviewed and approved by the College of Medicine Research Ethics Committee (COMREC P.08/22/3697). This study was carried out following the Declaration of Helsinki, ICH – GCP guidelines, and the National Health Sciences Research Committee General Guidelines on Health Research. All participants provided written informed consent before participation in the study. Consent for publication Not applicable. Competing interests No any competing interests. References Solomkin J, Gastmeier P, Bischoff P, Latif A, Berenholtz S, Egger M, et al. 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Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281–6. Opøien HK, Valbø A, Grinde-Andersen A, Walberg M. Post-caesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study. Acta Obstet Gynecol Scand. 2007;86(9):1097–102. Sullivan KM, Dean A, Soe MM. OpenEpi version 2. Epidemiol Monit. 2007;28(1):9–10. Koneman EW, Allen SD, Janda WM, Schreckenberger PC. Color atlas and textbook of diagnostic microbiology. Lippicott Williams & Wilkins; 1997. pp. 1065–124. Bezuidenhout J. Introductory microbiology. LibreTexts. 2024. Available from: https://LibreTexts.org. Sway A, Nthumba P, Solomkin J, Tarchini G, Gibbs R, Ren Y, et al. Burden of surgical site infection following caesarean section in sub-Saharan Africa: a narrative review. Int J Womens Health. 2019;11:309. Várkonyi I, Makai I, Papdiné Nyíri G, Bacskó G, Kardos L. A császármetszés posztoperatív sebfertőzés surveillance tapasztalatai a debreceni Kenézy Kórházban [Postoperative surveillance of wound infection after caesarean section at Kenézy Hospital, Debrecen, Hungary]. Orv Hetil. 2011;152(1):14–22. Fehr J, Hatz C, Soka I, Kibatala P, Urassa H, Smith T, et al. Risk factors for surgical site infection in a Tanzanian District Hospital: a challenge for the traditional national nosocomial infections surveillance system index. Infect Control Hosp Epidemiol. 2006;27(12):1401–4. Mitt P, Lang K, Peri A, Maimets M. Surgical-site infections following caesarean section in an Estonian university hospital: post discharge surveillance and analysis of risk factors. Infect Control Hosp Epidemiol. 2005;26(5):449–54. Mawalla B, Mshana SE, Chalya PL, Imirzalioglu C, Mahalu W. Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania. BMC Surg. 2011;11. McGarry SA, Engemann JJ, Schmader K, Sexton DJ, Kaye KS. Surgical site infection due to Staphylococcus aureus among elderly patients: mortality, duration of hospitalization, and cost. Infect Control Hosp Epidemiol. 2004;25(6):461–7. Bradford PA. Extended-spectrum beta-lactamases in the 21st century: characterization, epidemiology, and detection of this important resistance threat. Clin Microbiol Rev. 2001;14(4):933–51. Mpogoro FJ, Mshana SE, Mirambo MM, Kidenya BR, Gumodoka B, Imirzalioglu C. Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania. Antimicrob Resist Infect Control. 2014;3(1). Mohammed A, Seid ME, Gebrecherkos T, Tiruneh M, Moges F. Bacterial isolates and their antimicrobial susceptibility patterns of wound infections among inpatients and outpatients attending the University of Gondar Referral Hospital, Northwest Ethiopia. Int J Microbiol. 2017;2017. Lamont RF, Sobel JD, Kusanovic JP, Vaisbuch E, Mazaki-Tovi S, Kim SK, et al. Current debate on the use of antibiotic prophylaxis for caesarean section. BJOG. 2011;118(2):193–201. Amenu D, Belachew T, Araya F. Surgical site infection rate and risk factors among obstetric cases of Jimma University Specialized Hospital, Southwest Ethiopia. Ethiop J Health Sci. 2011;21(2). Gomaa K, Abdelraheim AR, El Gelany S, Khalifa EM, Yousef AM, Hassan H. Incidence, risk factors and management of post cesarean section surgical site infection (SSI) in a tertiary hospital in Egypt: a five-year retrospective study. BMC Pregnancy Childbirth. 2021;21(1). Kaye KS, Schmit K, Pieper C, Sloane R, Caughlan KF, Sexton DJ, et al. The effect of increasing age on the risk of surgical site infection. J Infect Dis. 2005;191(7):1056–62. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4273214","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292951121,"identity":"0307b031-39be-4611-8f6e-e9bfc9e6f538","order_by":0,"name":"Amos Tumizani Kachipedzu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYJACxgYGhgQ2IEOCgcEGxG88QIqWNDCfOC0MEC2HwSJ4tfBPO3z444wauzw+6eaDN3+2nbdb234YaEuNTTQuLRK309IkNxxLLmaTOZZsIdl2O3nbmUSglmNpuQ249NzOMWN8wHYgsU0ix0zCEKjF7ABQC2PDYZxa5G/nGH988A+kJf+bRGLbuWSz8w/xazG4nWMgubENbAubxMG2A3ZmNwjYYgjyy8y+5MQ2mWPGlg3nkhPMbgBtScDjF7nbyYc/9nyzS5w/u/nhzR9ldvZm59MfPvhQY4Pb+3AgAaESwSoTCCpH0mJPlOJRMApGwSgYUQAAgwRo2O/zluEAAAAASUVORK5CYII=","orcid":"","institution":"Bwaila Hospital, P.O.Box 1274, Lilongwe","correspondingAuthor":true,"prefix":"","firstName":"Amos","middleName":"Tumizani","lastName":"Kachipedzu","suffix":""},{"id":292951122,"identity":"b97d8ee0-609f-4eae-9c4e-06e5e599b7f8","order_by":1,"name":"David King Kulapani","email":"","orcid":"","institution":"School of Life Sciences \u0026 Allied Health Professionals, Biomedical Sciences Department, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"King","lastName":"Kulapani","suffix":""},{"id":292951123,"identity":"c92eefd7-c18c-4740-9200-ce2bb96c129c","order_by":2,"name":"Samuel James Meja","email":"","orcid":"","institution":"School of Medicine \u0026 Oral Health, Obstetrics and Gynaecology Department,Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"James","lastName":"Meja","suffix":""},{"id":292951124,"identity":"cc000fed-12eb-49c1-99c2-0460f111b47f","order_by":3,"name":"Janelisa Musaya","email":"","orcid":"","institution":"School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre","correspondingAuthor":false,"prefix":"","firstName":"Janelisa","middleName":"","lastName":"Musaya","suffix":""}],"badges":[],"createdAt":"2024-04-16 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13:00:06","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1309993,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4273214/v1/5175ee856856970be64d4c51.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical site infection and antimicrobial use following caesarean section at QECH in Blantyre, Malawi: a prospective cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eCaesarean section (CS) is a lifesaving operative technique in which a foetus, placenta, and membranes are delivered through an abdominal and uterine incision. Surgical site infection (SSI) is defined as an infection that occurs at or near the surgical incision within 30 days of the operation or after 1 year if an implant is placed [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally, SSI is the second most reported health-care associated infection (HAI), accounting for 19.6% of HAIs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Numerous studies have reported incidence rates of post-CS SSIs, for example, 2.85% in India [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], 21% in Ethiopia [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and 7-9.6% in Nigeria [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. HAIs and antimicrobial resistance (AMR) are major global health challenges recognized worldwide. However, the spread of HAIs and AMR is particularly alarming in low- and middle-income countries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. SSI accounts for 20% of all HAIs and is associated with a 2- to 11-fold increase in the risk of mortality, with 75% of SSI-associated deaths directly attributable to SSI [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are limited data on surgical site infections (SSIs) in African countries such as Malawi [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A prospective survey conducted by Borgstein at QECH in Blantyre showed an overall infection rate of 25.8% and that for clean wounds of 14.8% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In many SSIs, the responsible pathogens originate from the patient's endogenous flora [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The causative pathogens depend on the type of surgery; the most commonly isolated organisms are \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, coagulase-negative \u003cem\u003estaphylococci\u003c/em\u003e, \u003cem\u003eEnterococcus spp\u003c/em\u003e. and \u003cem\u003eEscherichia coli.\u003c/em\u003e Other studies have shown that \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is a commonly isolated organism in SSIs, accounting for 20\u0026ndash;30% of SSIs occurring in hospitals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A survey revealed that caesarean section procedures carry a risk of infection 5 to 20 times that of normal delivery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDifferent studies have shown that the rational use of antimicrobials in women of childbearing age is important because it affects this population as well as their offspring. The indiscriminate use of antibiotics may result in the appearance of drug-resistant organisms [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The use of antimicrobial prophylaxis for caesarean section has been shown to be effective in reducing postoperative morbidity, cost and duration of hospitalization. Another study reported the incidence of infection even after antimicrobial prophylaxis due to preexisting infection, debilitating disease or prolonged rupture of membranes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, another study reported that once antibiotics are intensively misused, they are undoubtedly the main factor associated with the high numbers of antibiotic-resistant pathogenic and commensal bacteria worldwide[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Similarly, a study by Classen et al. revealed that a delay in surgery reduces patient protection and can lead to the occurrence of postoperative infections [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Consequently, with the increasing number of surgical cases in LMICs, surgical site infections (SSIs) are becoming more prevalent due to anecdotal evidence of AMR, despite limited data on resistance patterns. Therefore, this study was important for determining the extent of surgical site infections and antimicrobial use following caesarean section at QECH in Blantyre, Malawi. The study findings could also help to reveal some areas that may require policy change and further studies so that there is a large amount of information on SSIs in clinical and other similar contexts.\u003c/p\u003e \u003cp\u003eThe criteria for defining surgical site infection (SSI) were established according to the US Centres for Disease Control (CDC) and Prevention [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. \u003cem\u003eSuperficial incisional SSI\u003c/em\u003e: Infection occurs within 30 days after the operation, and infection involves only the skin or subcutaneous tissue of the incision and at least one of the following: purulent drainage, with or without laboratory confirmation, from the superficial incision; organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision; at least one of the following signs or symptoms of infection\u0026mdash;pain or tenderness, localized swelling, redness, or heat and superficial incision\u0026mdash;is deliberately opened by the surgeon unless the incision is culture negative and the diagnosis of superficial incisional surgical site infection (SSI) is made by the surgeon or attending physician. \u003cem\u003eDeep incisional SSI\u003c/em\u003e: Infection occurs within 30 days after the operation, and infection involves deep soft tissue (e.g., fascial and muscle layers) of the incision and at least one of the following: purulent drainage from the deep incision but not from the organ/space component of the surgical site; a deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (\u0026gt;\u0026thinsp;38\u0026deg;C), localized pain, or tenderness, unless the site is culture negative; abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination; or diagnosis of a deep incisional SSI by a surgeon or attending physician. \u003cem\u003eOrgan/space SSI\u003c/em\u003e: Infection occurs within 30 days after the operation, and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which is opened or manipulated during an operation and at least one of the following: purulent drainage from a drain that is placed through a stab wound into the organ/space; organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space; abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination; and diagnosis of an organ/space SSI by a surgeon or attending physician.\u003c/p\u003e"},{"header":"Methods and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting, design, period and population\u003c/h2\u003e \u003cp\u003e This was a hospital\u0026ndash;based quantitative prospective cohort study among all women who underwent a caesarean section procedure at QECH from 1st February 2023 to 31st July 2023, and they were followed up for a 30-day period to assess wound outcome (SSI). QECH has an average of 300 CS procedures performed per month and is found in Blantyre in the southern region of Malawi. QECH provides secondary and tertiary levels of care and serves as the referral hospital for the health centres in Blantyre and district hospitals in the region (primary and secondary health care). Surgical wound sites at enrolment and discharge were inspected and classified according to the CDC [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] to assess whether exposure to any microbes would cause infection secondary to caesarean section. The study excluded all women who were severely clinically ill and/or who underwent CS in other health facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample size and sampling technique\u003c/h2\u003e \u003cp\u003eThe study enrolled 208 pregnant women who delivered through CS at QECH. This sample size was calculated in OpenEpi version 3, assuming that 15% of the subjects in the study population developed surgical site infections and that they received antimicrobial agents. To determine significant differences in the proportions of surgical site infections between the two groups, a power of 80%, two-sided significance of 95% confidence and a design effect of 2 were used [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe assumption on the percentage was based on the results from a prospective survey conducted by Borgstein at QECH in Blantyre, which showed an overall infection rate of 25.8% and that for clean wounds of 14.8% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, the assumed percentage was also based on the point prevalence survey by Bunduki, which revealed HAI of 11.4%, including surgical site infections [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To determine the target sample size, this study employed simple random sampling proportional to the total number of caesarean section deliveries conducted at QECH during the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection and procedure\u003c/h2\u003e \u003cp\u003eThe data were collected electronically using Open Data Kit (ODK) software. The information included sociodemographic characteristics, obstetrics-related factors, and operation- and anaesthesia-related factors. The dependent variable of this study was the incidence of SSIs following CS. The suggested independent variables included were sociodemographic variables such as maternal age, maternal educational status, occupational status, religion, and antenatal care. Relevant maternal medical history, such as HIV status, BMI, previous history of CS, and/or hypertensive disorder, was collected. Surgical intervention-related variables included type of CS (elective or emergency), type of incision (vertical, horizontal), type of skin closure, premature rupture of membranes, number of vaginal examinations, duration of the procedure, anaesthetic technique (general, spinal), indication for CS, gestational age, postoperative CS performed by a doctor (e.g., international clinical officer, clinical officer, medical officer, student or consultant) and/or antibiotic use. Pus swab samples were collected from the infected surgical wounds and processed by the Kirby-Bauer (KB) test via the disc diffusion method [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs part of routine clinical care, the samples collected from the patients were quickly tracked; pus swabs or pus aspirates were sent to the QECH main laboratory for microbiology culture and sensitivity. Furthermore, the data were collected by the principal investigator and research assistants, who were qualified nurse midwives and microbiologists. For consistency in the data collection process, the research assistants were oriented to the data collection instrument by the principal investigator prior to the actual data collection process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Data management and statistical analysis\u003c/h2\u003e \u003cp\u003eAfter data collection to ensure completeness, consistency and correct methods of data entry, quality control was performed on a daily basis. The data were subsequently transferred to a password-protected computer and downloaded to an electronic server for storage. The server was secure, with access only granted to study data managers.\u003c/p\u003e \u003cp\u003eMicrobiological isolates/samples from surgical sites when infected were collected and matched to the microbiological evaluation of collected samples for SSI clinical diagnosis. KB testing uses disks containing antibiotics to test whether the bacteria are susceptible to particular antibiotics. Ideally, cultured bacteria are isolated from patients and then grown overnight on agar (solid growth media) plates supplemented with relevant amounts of antibiotics that diffuse into the agar. When bacteria are susceptible to specific antibiotics from a disk, the area of clear media that indicates that the bacteria are not able to grow surrounding the disk/wafer is known as the zone of inhibition. Therefore, the size of a zone of inhibition in a KB test is inversely related to the minimum inhibitory concentration (MIC), which is the amount of antibiotic required to prevent bacterial growth in an overnight culture. The MIC (in \u0026micro;g/ml) can be calculated from known standard-curve (linear regression) graphs based on the diameter of the observed inhibition zone (in millimeters)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The statistical analyses were performed by means of Stata version 14, and statistical significance was defined by a p value\u0026thinsp;\u0026le;\u0026thinsp;0.05 (95% confidence level). Descriptive analysis was also conducted. For the continuous variables, means (standard deviations) and interquartile ranges (IQRs) were calculated, and the summarized results are presented in a table.\u003c/p\u003e \u003cp\u003eDescriptive data analysis was also used for frequencies and percentages. These studies were mainly focused on sociodemographic characteristics, medical-related and obstetric-related factors, and operation and anaesthesia factors. The chi-square (ꭓ\u003csup\u003e2\u003c/sup\u003e) test and Fisher\u0026rsquo;s exact test for observations less than 4 were used to establish any relationships between the variables/factors and the SSIs. The analyses were performed to determine the potential risk factors or crude odds ratios. Risk factors with a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in the univariate analysis were selected for inclusion in the multivariable logistic regression model. However, multivariable analysis was not performed to assess whether the relationship between C-sections and SSIs was confounded by other risk factors because ꭓ\u003csup\u003e2\u003c/sup\u003e showed no direct association between the variable and the outcome of interest (SSI).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic and clinical characteristics\u003c/h2\u003e \u003cp\u003eThe mean age was 26.1 years, with a standard deviation of 6.2 years. Approximately 111 (53.37%) of the women responded with no previous history of CS, and 20 (9.6%) of the women were HIV positive in this study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A total of 208 women who underwent the CS procedure were included in this study; of these, 20 patients developed SSI following CS either clinically or through microbiological culture.\u003c/p\u003e \u003cp\u003eA total of 208 pregnant women who underwent CS were enrolled, and 30 days of follow-up were used to assess SSI outcomes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The minimum age of the study participants was 15 years, while the maximum age limit for the study participants was 42 years.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and clinical characteristics of the study participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProportion (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean (SD)Age\u003c/b\u003e 26.05 (\u0026plusmn;\u0026thinsp;6.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge in years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrevious history of CS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary or More\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBusiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHIV Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eMarried _Others\u003c/em\u003e \u003csup\u003e\u003cem\u003e*\u003c/em\u003e\u003c/sup\u003e \u003cem\u003e(Single, Divorced, Widowed)\u003c/em\u003e,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOccupation_ Other * (dwellers, none)\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCaesarean section indications\u003c/h2\u003e \u003cp\u003eAmong mothers who underwent caesarean section, previous scarring was the most common indication (63 (30.29%)), followed by cephalopelvic disproportion (61 (29.33%)) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIndications for Caesarean Section\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCPD*1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious scar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCord prolapse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEclampsia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntepartum hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreech presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFetal Distress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProlonged labour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther*2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCPD*1 Cephalopelvic disproportion\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eOther*2 (placenta previa, twin gestation, IUGR, PROM, polyphromnious and postdates)\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section4\"\u003e \u003ch2\u003eMedical-related and obstetric-related characteristics\u003c/h2\u003e \u003cp\u003eAmong the 208 women, 115 (55.5%) had a BMI greater than 25, and 22 (10.58%) had an ASA score equal to or greater than two. Furthermore, 93 (44.71%) of the patients experienced membrane rupture before CS was performed. In addition, approximately 169 (81.25%) of the participants\u0026rsquo; gestational age was not less than 37 weeks (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMedical-related and obstetric-related characteristics of women who underwent CS surgery at QECH\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProportion (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNo. vaginal Examination\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eGestation Age\u0026thinsp;\u0026lt;\u0026thinsp;37 weeks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eANC Visits\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eASA Score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMembranes status pre-CS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRuptured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAnaesthesia and operation-related characteristics\u003c/h2\u003e \u003cp\u003eThe average duration after the first dose of antibiotic prophylaxis to the start of the CS procedure was 12.85 minutes, with a standard deviation of 8.44 (IQR\u0026thinsp;=\u0026thinsp;8, 25th percentile\u0026thinsp;=\u0026thinsp;7, 75th percentile\u0026thinsp;=\u0026thinsp;15). Furthermore, 134 (64.4%) CS procedures were performed by intern medical officers (IMOs), and 206 (99.04%) of the procedures involved spinal anaesthesia. Approximately 113 (54.3%) of the operation procedures were completed in more than 60 minutes, and 120 (57.7%) and 63 (30.3%) of the 208 patients underwent emergency and urgent CS, respectively. \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnaesthesia- and operation-related characteristics of women who underwent CS surgery at QECH, Malawi\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eUrgency of operation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrgent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSemi elective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eType of incision\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHorizontal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAnaesthetic technique\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpinal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSkin closure type\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterrupted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDuration of CS (Min)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 60 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 60 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eCS Performed by\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntern medical officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntern Clinical Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical Officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of surgical site infection\u003c/h2\u003e \u003cp\u003eThe overall incidence of SSIs recorded at QECH during the study period was 10%. Of these, 19 (95%) reported superficial SSI, and 1 (5%) reported deep SSI following CS (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The majority of patients with SSIs (n\u0026thinsp;=\u0026thinsp;12/60%) were readmitted, and 5 (25%) out of 20 patients with SSIs had antimicrobial resistance following susceptibility testing. Chi-square and Fisher\u0026rsquo;s exact tests were performed for observations less than or equal to 4 to determine the potential risk factors associated with the SSI at the 95% confidence level.\u003c/p\u003e \u003cp\u003eIn contrast, this study revealed that there was no factor/variable associated directly with surgical site infections. This might be due to the small sample size included in this study. The tested factors that other studies reported include skin closure technique, BMI, education level, age range in years, HIV status, parity, membrane status pre-CS, ANC visits, gestational age (weeks), duration of CS and SSI [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Hence, we did not perform any logistic regression model analysis because no P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05% indicated statistical significance (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate analysis of possible risk factors for SSIs in women who underwent CS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable/factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSSI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChi-square\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eYes (n\u0026thinsp;=\u0026thinsp;20) No (n\u0026thinsp;=\u0026thinsp;188)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin closure technique\u003c/p\u003e \u003cp\u003eInterrupted\u003c/p\u003e \u003cp\u003eContinuous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (35.00) 79 (42.02)\u003c/p\u003e \u003cp\u003e13 (65.00) 109 (57.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.3675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.544\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003cp\u003e\u0026le; 25\u003c/p\u003e \u003cp\u003e\u0026gt; 25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (55.00) 82 (43.62)\u003c/p\u003e \u003cp\u003e9 (45.00) 106 (56.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV Status*\u003c/p\u003e \u003cp\u003ePositive\u003c/p\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (20.00) 16 (8.51)\u003c/p\u003e \u003cp\u003e16 (80.00) 168 (89.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge range*\u003c/p\u003e \u003cp\u003e\u0026le; 30\u003c/p\u003e \u003cp\u003e\u0026gt; 30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (80.00) 140 (74.47)\u003c/p\u003e \u003cp\u003e4 (20.00) 48 (25.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level\u003c/p\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003cp\u003eSecondary or More\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (40.00) 76 (40.43)\u003c/p\u003e \u003cp\u003e12 (60.00) 112 (59.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.971\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of CS (min)\u003c/p\u003e \u003cp\u003e\u0026le; 60\u003c/p\u003e \u003cp\u003e\u0026gt; 60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (55.00) 110 (58.51)\u003c/p\u003e \u003cp\u003e9 (45.00) 78 (41.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMembrane status pre-CS\u003c/p\u003e \u003cp\u003eRuptured\u003c/p\u003e \u003cp\u003eIntact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (60.00) 81 (43.09)\u003c/p\u003e \u003cp\u003e8 (40.00) 107 (56.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003cp\u003e\u0026le; 2\u003c/p\u003e \u003cp\u003e\u0026gt; 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (50.00) 71 (37.77)\u003c/p\u003e \u003cp\u003e10 (50.00) 117 (62.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANC Visits\u003c/p\u003e \u003cp\u003e\u0026le; 4\u003c/p\u003e \u003cp\u003e\u0026gt; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (55.00) 111 (59.04)\u003c/p\u003e \u003cp\u003e9 (45.00) 77 (40.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.727\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestation age (weeks)*\u003c/p\u003e \u003cp\u003e\u0026lt; 37\u003c/p\u003e \u003cp\u003e\u0026ge; 37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.00) 36 (19.15)\u003c/p\u003e \u003cp\u003e17 (85.00) 152 (80.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e* = p value according to Fisher\u0026rsquo;s exact test, ANC\u0026thinsp;=\u0026thinsp;antenatal care\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eBacterial isolates and susceptibility pattern\u003c/h2\u003e \u003cp\u003ePus swabs from infected CS wounds for culture and sensitivity were collected for 11 (55%) of the clinically suspected postoperative CS infections. Among the 20 cases recorded, 10 (50.0%) had microbiology culture results, and 1 sample was reportedly missing from the laboratory. Five of the 10 cultures exhibited positive/bacterial growth (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among the etiological agents isolated, 3 (60%) were gram-positive cocci (clusters). \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was the most common organism (3, 15%). Other isolates included \u003cem\u003eEnterobacteriaceae\u003c/em\u003e (1, 5%) and \u003cem\u003eAcinetobacter baumanni\u003c/em\u003e (1, 5%) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The \u003cem\u003eStaphylococcus aureus\u003c/em\u003e bacteria isolated were resistant to most antibiotics, including clindamycin, erythromycin, gentamicin, and cefoxitin. However, \u003cem\u003eEnterobacteriaceae\u003c/em\u003e were sensitive to ciprofloxacin, meropenem, amikacin and tigecycline and resistant to chloramphenicol and trimethoprim/sulfamethoxazole. Only \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e Baumanni was sensitive to gentamicin and resistant to ceftriaxone, ciprofloxacin, cefotaxime and tigecycline (Tables\u0026nbsp;6 \u0026amp; 7).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussions","content":"\u003cp\u003eThis is the first study in Malawi to determine the extent of surgical site infections (SSIs) and antimicrobial use following cesarean section at QECH in Blantyre. The overall incidence of SSI during the study period was 10% (20 of 208 patients). Most patients were given antibiotics either prophylactically or post-CS without performing culture to ascertain AMR. Similarly, this finding is consistent with findings in Vietnam (10.9%) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Of course, Borgstein's prospective survey findings at QECH in Blantyre revealed a 25.8% overall infection rate in general surgeries [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, other studies reported incidences of 21% in Ethiopia [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and 7-9.6% in Nigeria [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The incidence of SSIs in this study was greater than that in developed nations [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Additionally, health care in Africa is less accessible and of poor quality than that in developed nations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, among the etiological agents isolated, 3 (60%) were gram-positive cocci (clusters). \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was the most common organism. This finding is in line with previous findings that \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is the most common cause of SSIs following post-CS [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similarly, other studies have shown that \u003cem\u003eStaphylococcus aureus\u003c/em\u003e is a commonly isolated cause of SSI, accounting for 20\u0026ndash;30% of SSIs occurring in hospitals [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Furthermore, other isolates identified in our study included \u003cem\u003eEnterobacteriaceae\u003c/em\u003e and \u003cem\u003eAcinetobacter baumannii\u003c/em\u003e. In the present study, the \u003cem\u003eStaphylococcus aureus\u003c/em\u003e isolates were resistant to most antibiotics, such as clindamycin, erythromycin, gentamicin and cefoxitin, similar to the findings of Fantahamu et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Furthermore, \u003cem\u003eEnterobacteriaceae\u003c/em\u003e were sensitive to ciprofloxacin, meropenem, amikacin and tigecycline, and the same bacteria were resistant to chloramphenicol and trimethoprim-sulfamethoxazole. However, \u003cem\u003eAcinebacter Baumanni\u003c/em\u003e was sensitive to gentamicin and resistant to ceftriaxone, ciprofloxacin, cefotaxime and Tigecycline, as also reported in other studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study also revealed that 138 (66.35%) patients received both preop antibiotics (ceftriaxone) and post-CS antibiotics. The most common post-CS-prescribed antibiotics were metronidazole and ceftriaxone combined therapy, even for patients with noncomplicated CS. A study by Lamont et al. indicated that a single dose of antibiotics could be as effective as multiple doses given perioperatively [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. No patient had a known infection or specific bacterial organism isolated in the current study at the time these antibiotics were prescribed and administered; hence, this may also promote antimicrobial resistance spread due to unnecessary use of antibiotics in our hospitals.\u003c/p\u003e \u003cp\u003eIn contrast to previous studies, skin closure, BMI, HIV status, education level, age, duration of CS, membrane status pre-CS, parity, ANC visits and gestational age were not significant risk factors in our study sample [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Additionally, Kaye et al. reported that age was a powerful predictor of SSI [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. However, other studies have also reported contamination or dirt operation as a risk factor [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and wound classification as clean contamination for the CS procedure [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study revealed that all the women who underwent CS were given antibiotic prophylaxis with ceftriaxone. The average duration from the first dose of antibiotic prophylaxis to the start of the CS procedure was 12.85 minutes, with a standard deviation of 8.44 (IQR\u0026thinsp;=\u0026thinsp;8). The prevalence of SSI and the timing of antibiotic prophylaxis in clinical practice have not been thoroughly investigated, but some clinical trials have indicated a relationship [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In the same study by Classen et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], few patients developed SSI among those who received antibiotic prophylaxis early before the start of surgery compared to those who received antibiotics later after surgery. Furthermore, in the present study, three patients who received post-CS antibiotic prophylaxis and two patients who did not receive antibiotics after surgery had antimicrobial resistance. Of course, these patients without any confirmed infection diagnosis received antimicrobial treatment after caesarean section; hence, this therapy cannot be applied as an indicator of SSI. The inappropriate use of antimicrobial agents needlessly exposes patients to potential toxicity and risks that promote the development and spread of antimicrobial resistance, leading to increased medical care costs in healthcare facilities [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, the rational use of antimicrobials in women of child-bearing age is important because it affects this population as well as their offspring. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThe strengths and limitations of the study\u003c/h2\u003e \u003cp\u003eThe strengths of the study include that the study revealed the emergence of AMR in the Malawian setting and that the study used primary data for SSIs following CS. However, the study was limited to SSIs following CS, and the number of HAIs occurring in other settings, such as surgical departments or wards for various hospitals for general surgery, cannot be estimated. Some patients who developed SSIs did not return to the hospital again for review, which could lead to a lack of microbiological data related to SSIs. Last, the small sample size could have affected the outcomes of interest.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study concludes that the incidence of 10% SSI following the CS procedure was relatively greater than that in other developing countries. Most patients were given antibiotics either prophylactically or post-CS without performing culture to ascertain AMR. The inappropriate use of antibiotics may result in antimicrobial resistance. Therefore, due to the increased number of SSIs following CS and the relative emergence of antimicrobial resistance to some microorganisms, including \u003cem\u003eAcinetobacter baumanni\u003c/em\u003e and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, intensive infection control practices are needed and establish AMS programs and routine surveillance of SSIs at QECH. The importance of postdelivery reviews following CS for improving health education for women undergoing CS should be emphasized to reduce the need for late clinical diagnoses of SSIs. In addition, there is a need to conduct further studies on bacterial isolates and antimicrobial resistance patterns and how to best address AMR through one health approach.\u003c/p\u003e"},{"header":"Abbreviations","content":"AMR: Antimicrobial Resistance, AMS: Antimicrobial Stewardship, ASA: American Society Anaesthesiologists: Abx: Antibiotics, CDC: Centres for Diseases Control and Prevention, COMREC: College of Medicine Research Ethics Committee, CS: Caesarean Section, ESBLs: Extended-spectrum β-lactamases, HAIs: Healthcare-associated infections, IQR: Interquartile Range, IPC: Infection Prevention and Control, KUHeS: Kamuzu University of Health Sciences, LMIC: Low- and middle-income countries, QECH: Queen Elizabeth Central Hospital, SSIs: Surgical Site Infections, US CDC: United States Centre for Diseases Control, WHO: World Health Organization"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI am grateful and thank Almighty God for His gracious love and endless blessings, without Him the entire dream of completing this dissertation would not have been possible. This work is a product of collective efforts, dedication, and support from various individuals. Exceptionally, I would like to express my sincere gratitude to my supervisors, Dr. David Kulapani (primary supervisor), Dr Samuel James Meja (secondary supervisor), Associate Prof. Janelisa Musaya (third supervisor), Gabriel Maliwata (data analysis consultant from Data research centre, KUHeS) who generously and tirelessly extended their expertise, guidance, aspirations, and contribution shaping the quality of this work.\u003c/p\u003e\n\u003cp\u003eFurther, I would like to extend my special thanks to my family especially my beloved wife Dalitso Mayani, and my sons, Antonio and Arthur Kachipedzu who were patient during my studies. Their encouragement, advice morals, and material support were very important resources of motivation to complete my studies. Generally, my sincere gratitude is directed to B. Braun-Stiftung for financial support and anyone who in one way or another, assisted in making this research work complete.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eATK originated the research idea and analyzed the data. DKK, SJM and JM contributed to supervision, data analysis and writing the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePartial funding was obtained from B. Braun Foundation, Germany for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical consideration and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol for the study was reviewed and approved by the College of Medicine Research Ethics Committee (COMREC P.08/22/3697). This study was carried out following the Declaration of Helsinki, ICH \u0026ndash; GCP guidelines, and the National Health Sciences Research Committee General Guidelines on Health Research. All participants provided written informed consent before participation in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo any competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSolomkin J, Gastmeier P, Bischoff P, Latif A, Berenholtz S, Egger M, et al. WHO guidelines to prevent surgical site infections. Lancet Infect Dis. 2017;17(3):262\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGibbons L, Beliz\u0026aacute;n JM, Lauer JA, Betr\u0026aacute;n AP, Merialdi M, Althabe F. The global numbers and costs of additionally, needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. Working Paper-World Health Report 2010. 2010. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf\u003c/span\u003e\u003cspan address=\"http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuropean Centre for Disease Prevention and Control. Surveillance of surgical site infections in Europe 2010\u0026ndash;2011. Stockholm: ECDC; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllegranzi B, Pittet D. Preventing infections acquired during healthcare delivery. Lancet. 2008;372(9651):1719\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNjoku CO, Njoku AN. 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Postoperative wound infection in developing country - a prospective survey at the Q.E.C.H., Blantyre, Malawi. Malawi Med J. 1986;3(2):33\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOwens CD, Stoessel K. Surgical site infections: epidemiology, microbiology and prevention. J Hosp Infect. 2008;70(Suppl 2):3\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson DJ, Kaye KS. Staphylococcal surgical site infections. Infect Dis Clin North Am. 2009;23(1):53\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu R, Lin L, Wang D. Antimicrobial prophylaxis in caesarean section delivery. Exp Ther Med. 2016;12(2):961.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarbosa TM, Levy SB. The impact of antibiotic use on resistance development and persistence. Drug Resist Updat. 2000;3(5):303\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBj\u0026ouml;rkman J, Andersson DI. The cost of antibiotic resistance from a bacterial perspective. Drug Resist Updat. 2000;3(4):237\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClassen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOp\u0026oslash;ien HK, Valb\u0026oslash; A, Grinde-Andersen A, Walberg M. Post-caesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study. Acta Obstet Gynecol Scand. 2007;86(9):1097\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSullivan KM, Dean A, Soe MM. OpenEpi version 2. Epidemiol Monit. 2007;28(1):9\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoneman EW, Allen SD, Janda WM, Schreckenberger PC. Color atlas and textbook of diagnostic microbiology. Lippicott Williams \u0026amp; Wilkins; 1997. pp. 1065\u0026ndash;124.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBezuidenhout J. Introductory microbiology. LibreTexts. 2024. Available from: https://LibreTexts.org.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSway A, Nthumba P, Solomkin J, Tarchini G, Gibbs R, Ren Y, et al. Burden of surgical site infection following caesarean section in sub-Saharan Africa: a narrative review. Int J Womens Health. 2019;11:309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eV\u0026aacute;rkonyi I, Makai I, Papdin\u0026eacute; Ny\u0026iacute;ri G, Bacsk\u0026oacute; G, Kardos L. A cs\u0026aacute;sz\u0026aacute;rmetsz\u0026eacute;s posztoperat\u0026iacute;v sebfertőz\u0026eacute;s surveillance tapasztalatai a debreceni Ken\u0026eacute;zy K\u0026oacute;rh\u0026aacute;zban [Postoperative surveillance of wound infection after caesarean section at Ken\u0026eacute;zy Hospital, Debrecen, Hungary]. Orv Hetil. 2011;152(1):14\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFehr J, Hatz C, Soka I, Kibatala P, Urassa H, Smith T, et al. Risk factors for surgical site infection in a Tanzanian District Hospital: a challenge for the traditional national nosocomial infections surveillance system index. Infect Control Hosp Epidemiol. 2006;27(12):1401\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitt P, Lang K, Peri A, Maimets M. Surgical-site infections following caesarean section in an Estonian university hospital: post discharge surveillance and analysis of risk factors. Infect Control Hosp Epidemiol. 2005;26(5):449\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMawalla B, Mshana SE, Chalya PL, Imirzalioglu C, Mahalu W. Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania. BMC Surg. 2011;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGarry SA, Engemann JJ, Schmader K, Sexton DJ, Kaye KS. Surgical site infection due to \u003cem\u003eStaphylococcus aureus\u003c/em\u003e among elderly patients: mortality, duration of hospitalization, and cost. Infect Control Hosp Epidemiol. 2004;25(6):461\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradford PA. Extended-spectrum beta-lactamases in the 21st century: characterization, epidemiology, and detection of this important resistance threat. Clin Microbiol Rev. 2001;14(4):933\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMpogoro FJ, Mshana SE, Mirambo MM, Kidenya BR, Gumodoka B, Imirzalioglu C. Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania. Antimicrob Resist Infect Control. 2014;3(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammed A, Seid ME, Gebrecherkos T, Tiruneh M, Moges F. Bacterial isolates and their antimicrobial susceptibility patterns of wound infections among inpatients and outpatients attending the University of Gondar Referral Hospital, Northwest Ethiopia. Int J Microbiol. 2017;2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLamont RF, Sobel JD, Kusanovic JP, Vaisbuch E, Mazaki-Tovi S, Kim SK, et al. Current debate on the use of antibiotic prophylaxis for caesarean section. BJOG. 2011;118(2):193\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmenu D, Belachew T, Araya F. Surgical site infection rate and risk factors among obstetric cases of Jimma University Specialized Hospital, Southwest Ethiopia. Ethiop J Health Sci. 2011;21(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGomaa K, Abdelraheim AR, El Gelany S, Khalifa EM, Yousef AM, Hassan H. Incidence, risk factors and management of post cesarean section surgical site infection (SSI) in a tertiary hospital in Egypt: a five-year retrospective study. BMC Pregnancy Childbirth. 2021;21(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaye KS, Schmit K, Pieper C, Sloane R, Caughlan KF, Sexton DJ, et al. The effect of increasing age on the risk of surgical site infection. J Infect Dis. 2005;191(7):1056\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Surgical site infections, Healthcare-associated infections, Antimicrobial resistance, incidence, Risk factors","lastPublishedDoi":"10.21203/rs.3.rs-4273214/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4273214/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Surgical site infections (SSIs) are the third most common healthcare-associated infections (HAIs) and preventable complication of surgical procedure; continue to threaten public health with significant effects on the patients and health care human and financial resources. Therefore, this study aimed to determine the incidence of SSIs, risk factors and common microorganisms associated with SSI and assess the practice of antimicrobial use in women following CS at Queen Elizabeth Central Hospital (QECH).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This was a hospital-based quantitative prospective study design involving pregnant women who underwent a Caesarean Section (CS) between February, 2023 and July, 2023 at QECH with 30 day-follow-ups. Some wound specimens (pus swabs) were collected from infected CS wounds and processed at QECH main laboratory, and susceptibility testing was conducted using the Kirby-Bauer disk diffusion method with results reported only as susceptible, intermediate, or resistant and the collected data was analyzed using Stata.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The overall cumulative incidence of SSI recorded at QECH during the study period was 10% (20 cases out of 208). Of these, 19 (95%) of them reported superficial SSI following CS. The mean age was 26.1 years with a standard deviation of 6.2. In contrast to the previous studies, potential risk factors including skin closure, age, parity or ANC visits were not associated with SSIs. The majority of patients with SSIs (n=12, 60%) were readmitted and 5 (25%) out of 20 with SSIs had antimicrobial resistance following susceptibility testing. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e was the most common organism (3, 60%) and other bacterial isolates included were \u003cem\u003eEnterobacteriaceae\u003c/em\u003e and \u003cem\u003eAcinetobacter baumanni. \u003c/em\u003eAll pregnant women who underwent for CS received antibiotic prophylaxis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The incidence of SSIs and inappropriate antimicrobial use following CS remains a challenge at QECH. Therefore, due to increased number of SSIs following CS with relative emergence of AMR ensure intensive infection prevention and control practices, establishing AMS program and routine surveillance of SSIs at QECH.\u003c/p\u003e","manuscriptTitle":"Surgical site infection and antimicrobial use following caesarean section at QECH in Blantyre, Malawi: a prospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-29 13:00:01","doi":"10.21203/rs.3.rs-4273214/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-20T07:00:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-18T22:38:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-18T22:38:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Antimicrobial Resistance \u0026 Infection Control","date":"2024-04-16T04:52:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6813ad19-ebf6-4d44-9314-f0b30da1a462","owner":[],"postedDate":"April 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-04T16:22:45+00:00","versionOfRecord":{"articleIdentity":"rs-4273214","link":"https://doi.org/10.1186/s13756-024-01483-5","journal":{"identity":"antimicrobial-resistance-and-infection-control","isVorOnly":false,"title":"Antimicrobial Resistance \u0026 Infection Control"},"publishedOn":"2024-10-29 15:57:07","publishedOnDateReadable":"October 29th, 2024"},"versionCreatedAt":"2024-04-29 13:00:01","video":"","vorDoi":"10.1186/s13756-024-01483-5","vorDoiUrl":"https://doi.org/10.1186/s13756-024-01483-5","workflowStages":[]},"version":"v1","identity":"rs-4273214","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4273214","identity":"rs-4273214","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}