Effect of interventions in reducing the

rate of infection after cesarean delivery

Raed Salim, MD,a,b Meirav Braverman, MD,a Ilanit Berkovic, RM,a Abeer Suliman, MD,a Nava Teitler, RNMA,c
and Eliezer Shalev, MDa,b
Afula and Haifa, Israel

Background: Post–cesarean delivery (CD) surgical site infections can cause considerable maternal morbidity. We aimed to estimate
the efficacy of a medical personnel education program in aseptic and scrub techniques on the rate of infectious morbidity after CD.
Methods: A prospective, 2-period cohort intervention study was performed at a single institution. The first era, which included all
CDs performed between September 2006 and August 2007, was used to obtain baseline infection rates. During this period, prophy-
lactic antibiotics were given only to women undergoing elective CD. In era 2, July 2009 through June 2010, prophylactic antibiotics
were given to all women. In addition, medical personnel underwent an education program, refresher course, and retraining in
aseptic and scrub techniques. The study’s primary outcome included any infectious morbidity related to the CD within 30 days
from the operation.
Results: The 1,616 CDs analyzed included 751 performed in era 1 and 865 performed in era 2. The incidence of any infectious
morbidity dropped from 6.4% in era 1 to 2.5% in era 2 (P 5 .001). The incidence of any infectious morbidity in women undergoing
elective CD fell from 5.3% to 0.9% (P 5 .001). Among women undergoing nonelective CD, the difference between the first and
second eras was not statistically significant (7.5% vs 4.5%; P 5 .09). However, the rate of incisional surgical site infection fell sig-
nificantly, from 4% in era 1 to 1.5% in era 2 (P 5 .05).
Conclusions: The interventions implemented at our institution led to a considerable decline in post-CD infectious morbidity.
Key Words: Personnel education program; post-cesarean surgical site infection.
Copyright ª 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights
reserved. (Am J Infect Control 2011;39:e73-8.)

Post–cesarean delivery (CD) surgical site infections
(SSIs) may cause considerable morbidity and have
other significant consequences in terms of prolonged
maternal length of hospital stay, socioeconomic impli-
cations, and increased health care costs. Estimates of
post-CD SSI rates range from 7% to 20%, depending
on demographic and obstetric variables and on the cri-
teria used to diagnose infection.1,2 The incidence might
be underestimated when SSIs are not defined in accor-
dance with the US Centers for Disease Control and
Prevention criterion of an infection occurring up to
30 days after the surgical procedure.3
Several strategies to reduce the incidence of SSI have
been proposed. The efficacy of perioperative antibiotics
in reducing SSIs after CD in women in labor has
been documented in a number of studies, and this
From the Department of Obstetrics and Gynecology, Emek Medical
Center, Afula, Israela; Rappaport Faculty of Medicine, Technion, Haifa,
Israelb; and Infectious Diseases Unit, Emek Medical Center, Afula, Israel.c
Address correspondence to Raed Salim, MD, Department of Obstetrics
and Gynecology, Emek Medical Center, Afula 18101, Israel. E-mail:
salim_ra@clalit.org.il.
Conflict of interest: None to report.
0196-6553/$36.00
Copyright ª 2011 by the Association for Professionals in Infection
Control and Epidemiology, Inc. Published by Elsevier Inc. All rights
reserved.
doi:10.1016/j.ajic.2011.05.001
strategy is recommended by the American College of
Obstetricians and Gynecologists4 and other consensus
panels.3,5 Contradictory findings regarding the efficacy
of perioperative antibiotics in women undergoing CD
while not in labor have been reported.6-9 A meta-
analysis of prophylactic antibiotic therapy in nonlabor-
ing CD reported a reduced risk for endometritis and
postoperative fever but only a trend toward a reduced
risk for incisional SSI.10 The use of staff education and
retraining in scrub technique and appropriate skin
preparation is another intervention aimed at reducing
the incidence of SSI. The superior protection afforded
by appropriate skin preparation is attributed primarily
to a reduced rate of incisional SSI rather than to a re-
duced rate of organ infection. Regardless, contradictory
results regarding the efficacy of this intervention in
women undergoing CD have been reported.11,12
The present study was undertaken to first document
the true incidence of post-CD SSI according to the Cen-
ters for Disease Control and Prevention’s criterion at
our institution, and then to estimate the efficacy of
medical personnel education and retraining in aseptic
and scrub techniques in addition to antibiotic prophy-
laxis in reducing that incidence.
METHODS
This was a prospective, 2-period cohort interven-
tion study of women who underwent CD at a single

e73
e74 Salim et al.
academic institution. The study’s first era included all
CDs performed between September 2006 and August
2007. Up to the end of this period, prophylactic anti-
biotic therapy (cefalotin 1 g as a single intravenous
[IV] dose) after umbilical cord clamping was given
only to women undergoing nonelective CD. Women
presumed to be allergic to cefalotin were instead given
clindamycin 600 mg as a single IV dose after umbilical
cord clamping. Data from era 1 were analyzed to ob-
tain baseline infection rates.
Before the beginning of era 2, which included all
CDs performed between July 2009 and June 2010,
medical personnel underwent a refresher course in
aseptic and scrub techniques by the infection con-
trol nurse. This education and retraining included
review of aseptic practices in the operating room to-
gether with scrubbing, room setup, proper attire,
and surgical preparation technique.11,13 The specific
steps for skin preparation with chlorhexidine gluco-
nate (CHG) 4% scrub for 2 minutes, followed by
2 minutes of disinfection with CHG 0.5% in alcohol
70%, and letting the skin air-dry for 1 minute was
also emphasized. The theatre nursing team under-
went a refresher team session with the infection
control nurse, discussing hand hygiene, urinary
catheter insertion, patient preparation, and aseptic
principles. Observation and feedback took place dur-
ing the intervention period. In addition, prophylactic
antibiotics after cord clamping were given to all
women undergoing CD. The same protocol as in
era 1 was applied in era 2 for both elective and non-
elective CDs.
A CD was defined as elective if the woman had intact
membranes, did not have regular uterine contractions
regardless of membrane status, and was in a fasting
state for a period of 6-8 hours before the procedure,
and as nonelective otherwise. Women who had an ac-
tive infection within 1 week of admission or during la-
bor were excluded, as were women who had placenta
accreta or a cesarean hysterectomy.
Although deep incisional infections involving the
fascial and muscle layers rarely occur after CD,14 for
the purpose of this study SSIs were classified as either
incisional or organ (endometritis). Postpartum endo-
metritis was defined as a postpartum temperature of
388C or higher measured on 2 separate occasions ac-
companied by abnormal uterine tenderness or puru-
lent drainage from the uterus requiring postpartum
antibiotic therapy. Criteria for defining incisional SSI
included pain or tenderness, localized swelling, red-
ness, or heat with or without purulent drainage. Other
infectious complications recorded included urinary
tract infection (diagnosed clinically and confirmed
by positive urinary culture) and pneumonia (diag-
nosed clinically and confirmed by positive chest
American Journal of Infection Control
December 2011
X-ray). Other infections included necrotizing fasciitis,
pelvic abscess, and septic pelvic thrombophlebitis. A
composite postpartum infectious morbidity was de-
fined as the presence of any postpartum infection
outcome.
All procedures in both eras were performed jointly
by a senior physician and a resident. Technically, the
procedure was performed similarly in both eras. A
skin stapler (Royal AutoSuture; Covidien, Mansfield,
MA) was used to approximate the skin edges.
Data on demographic characteristics, medical and
obstetric history, course of labor and delivery, and post-
operative maternal complications were collected. Data
on infectious complications in each era were collected
during the in-hospital stay and in the community set-
ting on postoperative day 30-35. In-hospital, infectious
complications were diagnosed by a surgeon or infec-
tious disease specialist and recorded on a standard
data collection form. Postdischarge surveillance was
based on telephone contacts with the women and per-
formed using a standard questionnaire format. All
women were contacted by telephone at 30-35 days af-
ter surgery and were asked to answer a brief question-
naire regarding their general health, fever and other
potential symptoms of infection, antibiotic use, and
emergency department visits. In cases of readmission,
surveillance was expanded using hospital databases
that included data on administrative claims and
treatments.
The study’s primary outcome was a comparison of
the incidence of composite postpartum infectious mor-
bidity in era 2 (study group) and in era 1 (control
group). Secondary outcomes included comparisons of
the rate of any infectious morbidity between the 2
eras, as well as between women with elective CD and
those with nonelective CD. The study was approved
by the local Institutional Review Board before each era.
Statistical analysis
As appropriate, x2 or Fisher’s exact test was used to
compare categorical data across the 2 eras. An inde-
pendent sample t test, or the Mann-Whitney U test in
the case of nonnormally distributed data, was used to
compare continuous data across the 2 eras. Logistic
regression was used to adjust the infection rate for var-
iables that were significant in a univariate analysis of
the 2 eras. Poisson regression was used to adjust the
infection rate in women undergoing elective CD with
urinary tract infection, because of the small number
of cases. Statistical significance was set at P , .05. An
analysis of the data from era 1 showed that a total of
749 women in each era would be required to provide
80% power to detect a 50% reduction in the incidence
of composite postpartum infectious morbidity in the
www.ajicjournal.org Salim et al. e75
Vol. 39 No. 4

Table 1. Demographic and obstetric characteristics of all women who underwent CD during eras 1 and 2
Era 1 (n 5 751) Era 2 (n 5 865) P

Ethnicity, n (%) .63

Jewish 399 (53.1) 454 (52.5)
Arab 352 (46.9) 411 (47.5)
Maternal age, years, mean 6 SD 31.9 6 5.4 31.7 6 5.6 .42
Gestational age, weeks, mean 6 SD 38.1 6 2.5 37.9 6 2.5 .14
Parity, mean 6 SD 2.75 6 1.7 2.68 6 1.5 .38
Body mass index, kg/m2, mean 6 SD 30.9 6 5.3 31.3 6 5.8 .19
Body mass index .35 kg/m2, n (%) 158 (21.0) 208 (24.0) .14
Diabetes, n (%) 98 (13.1) 97 (11.2) .25
Previous cesareans, mean 6 SD 1.76 6 0.9 1.76 6 0.9 .98
Nonelective cesareans, n (%) 373 (49.7) 400 (46.2) .17
Internal monitoring, n (%) 38 (5.1) 46 (5.3) .81
Vaginal examinations, mean 6 SD 1.9 6 3.3 2.1 6 3.5 .38
Time in delivery ward, hours, mean 6 SD (range) 2.2 6 6.0 (0-70) 2.2 6 5.4 (0-36) ,.99
Rupture of membranes, n (%) 179 (23.8) 163 (18.8) .01
Duration of membrane rupture, hours, mean 6 SD (median; range) 16.3 6 29.7 (8; 0.4-288) 26.7 6 95.2 (8; 0.5-840) .58
Hospital days before cesarean, mean 6 SD (median; range) 0.9 6 1.7 (1; 0-25) 1.0 6 2.4 (1; 0-36) .14
Anesthesia, n (%) .65
General 121 (16.1) 125 (14.5)
Spinal 573 (76.3) 674 (77.9)
Epidural 57 (7.6) 66 (7.6)
Skin cleansing, n (%) .67
Yes 748 (99.6) 863 (99.8)
No 3 (0.4) 2 (0.2)
GBS prophylaxis, n (%) 7 (0.9) 8 (0.9) .99
Duration of operation, minutes mean 6 SD 31 6 15 34 6 15 .001
,30 minutes, n (%) 386 (51.4) 364 (42.1)
30-60 minutes, n (%) 341 (45.4) 462 (53.4)
.60 minutes, n (%) 24 (3.2) 39 (4.5)
Blood loss .1,000 mL, n (%) 16 (2.1) 29 (3.4) .14
Days of hospitalization after cesarean, mean 6 SD (median; range) 4.5 6 1.4 (4; 2-21) 4.4 6 1.2 (4; 1-14) .39
CI, confidence interval; GBS, Group B Streptococcus.

study group compared with the control group (ie, first
era) with 95% confidence.
RESULTS
Among the 4,105 women who gave birth during era
1, 761 (18.5%) underwent CD. Ten women were ex-
cluded from the analysis because of intrapartum fever
(n 5 6) or placenta accreta (n 5 4). Of the remaining
751 CDs, 378 (50.3%) were elective and 373 (49.7%)
were nonelective. Among the 4,129 women who gave
birth during era 2, 875 (21.2%) underwent CD. Again,
10 women were excluded because of intrapartum fever
(n 5 8) or placenta accreta (n 5 2). Of the remaining
865 CDs, 465 (53.8%) were elective and 400 were non-
elective (46.2%). In total, 1,616 women were included
and analyzed in the 2 eras. Demographic and obstetric
characteristics were similar in the 2 eras (Table 1), ex-
cept that the rate of rupture of membranes was signif-
icantly higher in era 1 than in era 2 (23.8% vs 18.8%;
P 5 .01). In addition, the mean operation time was lon-
ger in era 2 (34 minutes vs 31 minutes; P 5 .001),
although the proportion of patients with an operation
time .1 hour was similar in the 2 eras (P 5 .20).
The interventions significantly decreased the inci-
dence of composite postpartum infectious morbidity
in era 2 compared with era 1, with the most significant
decrease seen in incisional SSI (Table 2).
There was a statistically significant reduction in
overall infectious morbidity among elective CDs
(Table 2), notably in incisional SSI and urinary tract in-
fection. Although the incidence of organ SSI was re-
duced by 70%, this reduction was not statistically
significant.
Among the nonelective CDs, the reduction in overall
infectious morbidity was not statistically significant;
however, the incidence of incisional SSI was signifi-
cantly reduced. Adjustment of incisional SSI for rup-
ture of membranes or duration of operation did not
change the results (Table 2).
We were able to contact 99.1% of the women in era
1 and 99.2% of those in era 2 at 30-35 days after sur-
gery. Out of all women with any infectious morbidity
during era 1, 17 (34%) were diagnosed after discharge;
e76 Salim et al. American Journal of Infection Control
December 2011

Table 2. Incidence of infectious morbidity in eras 1 and 2

All CDs Elective CDs Nonelective CDs
Era 1 Era 2 P* OR Era 1 Era 2 P* OR Era 1 Era 2 P* OR
Variables (n 5 751) (n 5 865) (95% CI) (n 5 378) (n 5 465) (95% CI) (n 5 373) (n 5 400) (95% CI)

Composite infectious 48 (6.4) 22 (2.5) 0.001 20 (5.3) 4 (0.9) .001 28 (7.5) 18 (4.5) .09
morbidity, n (%) .38 (0.23-0.64) 0.14 (0.05-0.42) 0.59 (0.32-1.09)
SSI, n (%) 37 (4.9) 18 (2.1) 0.002 16 (4.2) 4 (0.8) .002 21 (5.6) 14 (3.5) .17
.40 (0.23-0.72) 0.18 (0.06-0.53) 0.61 (0.30-1.23)
Incisional SSI 26 (3.5)y 8 (0.9) 0.001 11 (2.9) 2 (0.4) .009 15 (4.0)y 6 (1.5) .05
.27 (0.12-0.59) 0.13 (0.03-0.61) 0.38 (0.14-0.99)
Organ SSI 12 (1.6)y 10 (1.2) 0.52 5 (1.3) 2 (0.4) .12 7 (1.9)y 8 (2.0) .99
.67 (0.28-1.56) 0.27 (0.05-1.44) 1.01 (0.36-2.84)
Pneumonia, n (%) 2 (0.3) 1 (0.1) 0.36 0 (0.0) 0 (0.0) - 2 (0.5) 1 (0.3) .37
.31 (0.02-3.96) 0.31 (0.02-4.00)
Urinary tract infection, n (%) 9 (1.2) 3 (0.3) 0.08 4 (1.1) 0 (0.0) .003z 5 (1.3) 3 (0.8) .49
.31 (0.08-1.17) 0.80 (0.71-0.93) 0.60 (0.14-2.55)
CI, confidence interval; OR, odds ratio.
*Adjusted for rupture of membranes and duration of operation.
y
One woman had both organ SSI and incisional SSI.
z
Poisson regression.

all were related to incisional SSI. In era 2, 8 women
(32%) were diagnosed after discharge, 6 with inci-
sional SSI and 2 with organ SSI. There were no cases
of necrotizing fasciitis, pelvic abscess, or septic pelvic
thrombophlebitis.
DISCUSSION
This study demonstrates that a staff education pro-
gram and a refresher course in effective and proper
skin antisepsis in addition to antimicrobial prophylaxis
after cord clamping significantly reduced the incidence
of post-CD infectious morbidity. Although the main re-
duction in this study was attributed to a reduced inci-
dence of incisional SSI and urinary tract infection, a
trend toward a reduction in organ SSI was also observed
among the elective procedures. Although the reduction
from 1.3% in era 1 to 0.4% in era 2 was not significant
among the elective CDs, it was calculated that ;4,000
women in each era would be required to provide 80%
power with an a of 0.05 to detect a 50% reduction
from a relatively low baseline rate of 1.3%.
The fundamental cornerstones in any program
aimed at reducing the incidence of SSI include exqui-
site surgical technique, timely and appropriate anti-
microbial prophylaxis, and effective and persistent
skin antisepsis.15 Contradictory findings have been
published regarding the efficacy of perioperative anti-
biotics in nonlaboring CD.6-9 A meta-analysis of pro-
phylactic antibiotic regimens for nonlaboring CDs
found reduced risks for endometritis and postopera-
tive fever, but only a trend toward a reduced risk of in-
cisional SSI.10 Based on those results, the authors
recommended prophylaxis in populations with a
.5% incidence of infectious morbidity among nonla-
boring women undergoing CD. Hunt et al16 also rec-
ommended the use of antibiotic prophylaxis when
the rate of SSI exceeds 5%. According to these recom-
mendations, we implemented perioperative antibi-
otics after documenting an infectious morbidity rate
of 5.3% in women undergoing elective CD in era 1.
Nonetheless, it has been reported that up to two-
thirds of SSIs are confined to the incision,3,17,18 and
optimizing skin antisepsis before surgery could have
a significant clinical benefit.
Antiseptics act mainly against organisms that re-
side on the patient’s integument, and the overall su-
perior protection afforded by CHG likely can be
attributed primarily to a reduced rate of incisional
SSI rather than to a reduction in organ SSI. In addi-
tion, implementation of an intensive surveillance
program with engaged clinicians and infection con-
trol personnel is known to contribute to a reduced
incidence of health care–associated infections.19
Identified barriers to adhering to clinical guidelines
include lack of awareness of guidelines, lack of famil-
iarity with the guidelines, lack of agreement, lack of
self-efficacy, lack of outcome expectancy, and inertia
of previous practice.20 Compliance to clinical guide-
lines could be improved by educating staff on the im-
portance of their contributions in reducing infection
rates.21 Accordingly, we implemented a program of
medical personnel education before the start of era
2 that included a refresher course in aseptic and scrub
techniques. Compared with Kaimal et al,12 who re-
ported no effect of policy changes to improve aseptic
technique, we found a significant reduction in the in-
cidence of incisional SSI. This effect was obvious in
www.ajicjournal.org
Vol. 39 No. 4
the women who underwent nonelective CD, in whom
only staff education differed between the 2 eras. In
the group with elective CD, in whom staff education
was implemented in addition to perioperative antibi-
otics in era 2, reductions in both composite infectious
morbidity and incidence of incisional SSI were ob-
served. Whereas Chelmow et al10 reported only a
trend toward a reduced rate of incisional SSI with
the use of perioperative antibiotics in elective CD,
our results point to an additive effect of staff educa-
tion in reducing the incidence of incisional SSI in
elective CD.
The wide variation in the reported incidence of post-
CD SSI of 7%-20%1,2 likely can be attributed to several
factors, including whether or not postdischarge data
are considered.22 Postdischarge surveillance is an im-
portant element of intensive surveillance to determine
accurate infection rates. Underestimates of the inci-
dence of infection ranging from 20% to 70% have
been reported in patients undergoing general surgery
in the absence of postdischarge monitoring.23 These
data are important to provide feedback to improve
performance. In the present study, approximately
one-third of SSIs were detected during postdischarge
surveillance in both eras. But although postdischarge
surveillance has become increasingly important to ob-
tain accurate SSI rates,24 consensus as to the ideal sur-
veillance method remains elusive.25 In this study we
used a telephone questionnaire and achieved a
99.2% compliance rate. In addition, in cases of read-
mission, we expanded surveillance using hospital data-
bases that included data on administrative claims and
treatment. The telephone questionnaire is an accept-
able method. Taylor et al26 were able to contact their
patients only by telephone. They had a compliance
rate was 93.3%, and concluded that this method of
contact is feasible and effective. Withby et al27 reported
that patients’ assessment of their incisions has a low
positive predictive value but, more importantly, a neg-
ative predictive value, as high as 98%, suggesting that
very few cases of SSI are missed when women assess
their own incisional status. Regardless of which
method is used, the overall rate of SSI in an institution
typically increases after postdischarge surveillance
methods are implemented.28
A limitation of the current study is that it is not a
randomized, blinded intervention and thus might not
provide as strong empirical evidence as that provided
by a properly executed randomized controlled clinical
trial. Nonetheless, the data were collected prospec-
tively, and potential selection bias was precluded by in-
cluding all eligible women who underwent CD during
the study period. In addition, a postdischarge surveil-
lance technique with a ,1% rate of loss to follow-up
was used.
Salim et al. e77
CONCLUSIONS
In the present study, the interventions of the multidis-
ciplinary health care providers led to a considerable de-
cline in post-CD infectious morbidity. Direct health care
providers are responsible for ensuring that appropriate
infection prevention and control practices are consis-
tently applied. Future studies are needed to investigate
whether the consequences of staff education and inten-
sive surveillance program have long-lasting effects.
We thank Paula S. Herer, biostatistician at the Emek Medical Center, for assisting with
the statistical analysis.
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