A multifaceted prevention program to reduce infection after cesarean section: Interventions assessed using an intensive postdischarge surveillance system


      • A sequentially implemented prevention strategy reduced C-section infection rates.
      • Antibiotic prophylaxis, prenatal education, and safety checklist reduced SSI rate.
      • Most infections develop in the post-discharge period.


      We assessed the effects of the components of a multifaceted and evidence-based caesarean-section surgical site infection (SSI) prevention program on the SSI rate after cesarean section using a postdischarge surveillance (PDS) system.


      Multiple prevention interventions were serially implemented. SSI case finding was undertaken through active inpatient surveillance and intensive PDS using a standardized form at the 6-week postdischarge visit. SSI diagnosis was made using the Centers for Disease Control and Prevention standardized criteria. All cesarean deliveries between July 2007 and December 2012 were included. Changes in SSI rate were analyzed using segmented regression analysis.


      Nine thousand four hundred forty-two cesarean sections were assessed during the study period. PDS forms were completed for 7,985 women (85%). SSI was detected in 451 cases (5.6%): 91% were superficial, 9% were deep/organ-space infections. The SSI rate decreased incrementally from 8.2% at baseline to 4.1%; significant decreases were observed after optimizing antibiotic prophylaxis timing, using a surgical safety checklist, and enhancing prenatal education to discourage prehospital self-removal of hair. Nonelective surgeries or those undertaken after >12 hours of rupture of membranes had a significantly higher rate compared with those without either risk factor (6.3% vs 3.2%; P < .001).


      A multifaceted SSI prevention strategy, with periodic feedback of data, led to a significant reduction in SSI rates after cesarean section.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gravel D.
        • Taylor G.
        • Ofner M.
        • Johnston L.
        • Loeb M.
        • Roth V.R.
        • et al.
        Point prevalence survey for healthcare-associated infections within Canadian adult acute-care hospitals.
        J Hosp Infect. 2007; 66: 243-248
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) hospital infection control practices Advisory Committee.
        Am J Infect Control. 1999; 27 (quiz 133–4; discussion 96): 97-132
        • Smyth E.T.
        • McIlvenny G.
        • Enstone J.E.
        • Emmerson A.M.
        • Humphreys H.
        • Fitzpatrick F.
        • et al.
        Four country healthcare associated infection prevalence survey 2006: overview of the results.
        J Hosp Infect. 2008; 69: 230-248
        • Canadian Patient Safety Institute
        Safer healthcare now! Prevent surgical site infections: getting started kit.
        Canadian Patient Safety Institute, Edmonton, AB2010: 7-17
        • Owen J.
        • Andrews W.W.
        Wound complications after cesarean sections.
        Clin Obstet Gynecol. 1994; 37: 842-855
        • Liu S.
        • Liston R.M.
        • Joseph K.S.
        • Heaman M.
        • Sauve R.
        • Kramer M.S.
        Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term.
        CMAJ. 2007; 176: 455-460
      1. National Institutes of Health state-of-the-science conference statement: cesarean delivery on maternal request March 27-29, 2006.
        Obstet Gynecol. 2006; 107: 1386-1397
      2. How-to Guide: Prevent Surgical Site Infections. Institute for Healthcare Improvement, Cambridge, MA2012
        • Edwards J.R.
        • Peterson K.D.
        • Mu Y.
        • Banerjee S.
        • Allen-Bridson K.
        • Morrell G.
        • et al.
        National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009.
        Am J Infect Control. 2009; 37: 783-805
        • Griffiths J.
        • Demianczuk N.
        • Cordoviz M.
        • Joffe A.M.
        Surgical site infection following elective Caesarian section: a case-control study of postdischarge surveillance.
        J Obstet Gynaecol. 2005; 27: 340-344
        • Johnson A.
        • Young D.
        • Reilly J.
        Caesarean section surgical site infection surveillance.
        J Hosp Infect. 2006; 64: 30-35
        • Killian C.A.
        • Graffunder E.M.
        • Vinciguerra T.J.
        • Venezia R.A.
        Risk factors for surgical-site infections following cesarean section.
        Infect Control Hosp Epidemiol. 2001; 22: 613-617
        • Cardoso Del Monte M.C.
        • Pinto Neto A.M.
        Postdischarge surveillance following cesarean section: the incidence of surgical site infection and associated factors.
        Am J Infect Control. 2010; 38: 467-472
        • Charrier L.
        • Serafini P.
        • Ribatti A.
        • Castella A.
        • Rabacchi G.
        • Zotti C.M.
        Post-partum surgical wound infections: incidence after caesarean section in an Italian hospital.
        J Prev Med Hyg. 2009; 50: 159-163
        • Petrosillo N.
        • Drapeau C.M.
        • Nicastri E.
        • Martini L.
        • Ippolito G.
        • Moro M.L.
        • et al.
        Surgical site infections in Italian Hospitals: a prospective multicenter study.
        BMC Infect Dis. 2008; 8: 34
        • Barbut F.
        • Carbonne B.
        • Truchot F.
        • Spielvogel C.
        • Jannet D.
        • Goderel I.
        • et al.
        Surgical site infections after cesarean section: results of a five-year prospective surveillance.
        J Gynecol Obstet Biol Reprod (Paris). 2004; 33: 487-496
        • Ward V.P.
        • Charlett A.
        • Fagan J.
        • Crawshaw S.C.
        Enhanced surgical site infection surveillance following caesarean section: experience of a multicentre collaborative post-discharge system.
        J Hosp Infect. 2008; 70: 166-173
        • Opoien H.K.
        • Valbo A.
        • Grinde-Andersen A.
        • Walberg M.
        Post-cesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study.
        Acta Obstet Gynecol Scand. 2007; 86: 1097-1102
        • Reilly J.
        • Allardice G.
        • Bruce J.
        • Hill R.
        • McCoubrey J.
        Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland.
        Infect Control Hosp Epidemiol. 2006; 27: 1318-1323
        • Geubbels E.L.
        • Grobbee D.E.
        • Vandenbroucke-Grauls C.M.
        • Wille J.C.
        • de Boer A.S.
        Improved risk adjustment for comparison of surgical site infection rates.
        Infect Control Hosp Epidemiol. 2006; 27: 1330-1339
        • Noy D.
        • Creedy D.
        Postdischarge surveillance of surgical site infections: a multi-method approach to data collection.
        Am J Infect Control. 2002; 30: 417-424
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • Lipsitz S.R.
        • Breizat A.H.
        • Dellinger E.P.
        • et al.
        A surgical safety checklist to reduce morbidity and mortality in a global population.
        N Engl J Med. 2009; 360: 491-499
        • Ng W.
        • Alexander D.
        • Kerr B.
        • Ho M.F.
        • Amato M.
        • Katz K.
        A hairy tale: successful patient education strategies to reduce pre-hospital hair removal by patients undergoing elective caesarean section.
        J Hosp Infect. 2013; 83: 64-67
        • Wagner A.K.
        • Soumerai S.B.
        • Zhang F.
        • Ross-Degnan D.
        Segmented regression analysis of interrupted time series studies in medication use research.
        J Clin Pharm Ther. 2002; 27: 299-309
        • Association of Operating Room Nurses
        Recommended practices for skin preparation of patients.
        AORN J. 2002; 75: 184-187
        • Tanner J.
        • Woodings D.
        • Moncaster K.
        Preoperative hair removal to reduce surgical site infection.
        Cochrane Database Syst Rev. 2006; 2: CD004122
        • Tita A.T.
        • Rouse D.J.
        • Blackwell S.
        • Saade G.R.
        • Spong C.Y.
        • Andrews W.W.
        Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review.
        Obstet Gynecol. 2009; 113: 675-682
        • Costantine M.M.
        • Rahman M.
        • Ghulmiyah L.
        • Byers B.D.
        • Longo M.
        • Wen T.
        • et al.
        Timing of perioperative antibiotics for cesarean delivery: a metaanalysis.
        Am J Obstet Gynecol. 2008; 199: 301.e1-301.e6
        • Kaimal A.J.
        • Zlatnik M.G.
        • Cheng Y.W.
        • Thiet M.P.
        • Connatty E.
        • Creedy P.
        • et al.
        Effect of a change in policy regarding the timing of prophylactic antibiotics on the rate of postcesarean delivery surgical-site infections.
        Am J Obstet Gynecol. 2008; 199: 310.e1-310.e5
        • Thigpen B.D.
        • Hood W.A.
        • Chauhan S.
        • Bufkin L.
        • Bofill J.
        • Magann E.
        • et al.
        Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial.
        Am J Obstet Gynecol. 2005; 192 (discussion 1868–71): 1864-1868
        • Haley R.W.
        • Culver D.H.
        • White J.W.
        • Morgan W.M.
        • Emori T.G.
        • Munn V.P.
        • et al.
        The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.
        Am J Epidemiol. 1985; 121: 182-205
        • Brown R.B.
        • Bradley S.
        • Opitz E.
        • Cipriani D.
        • Pieczarka R.
        • Sands M.
        Surgical wound infections documented after hospital discharge.
        Am J Infect Control. 1987; 15: 54-58
        • Bruce J.
        • Russell E.M.
        • Mollison J.
        • Krukowski Z.H.
        The quality of measurement of surgical wound infection as the basis for monitoring: a systematic review.
        J Hosp Infect. 2001; 49: 99-108