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Grand Rounds

Cesarean Surgical Site Infection Rates: Does a Wound Dressing Matter?

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BACKGROUND AND PURPOSE:

  • Current guidelines recommend dressings be used to cover incisions following cesarean to prevent surgical site infections (SSIs)
    • Evidence limited as to benefit of dressings
  • NICE recommends that cesarean wounds be covered for a minimum of 48 hours even though there is limited evidence that dressings reduce SSIs or improve cosmesis
  • Tan et al. (BJOG, 2020) compared caesarean wounds that were exposed vs covered with a dressing

METHODS:

  • Randomized controlled trial (RCT)
  • Participants
    • Women who delivered via cesarean section (planned or unplanned)
    • Transverse suprapubic skin incision
    • Exclusive use of subcuticular suture skin closure
    • Patients requiring pressure dressing were excluded
  • Interventions: Patients were randomized to the following (1:1)
    • Exposed: wound was left entirely exposed
    • Dressed control: wound was dressed with a low adhesive dressing and removed the next day
  • Study design
    • Dressing could be removed if heavy seepage | Additional coverage with gauze or another dressing was left to clinician
    • Superficial SSIs: Assessed by provider inspection through hospital discharge | Telephone questionnaires on days 14 and 28
    • Patient satisfaction: Obtained prior to discharge using an 11-point VisualNRS (0 very dissatisfied to 10 very satisfied)
  • Primary outcome
    • Superficial SSI rate through 28 days
    • Patient satisfaction
  • Power analysis
    • 80% power (alpha 0.05)
    • 334 participants would be required assuming 10% dropout

RESULTS:

  • 331 patients were randomized
    • Exposed: 165 patients
    • Dressed: 166 patients
  • Patient characteristics similar between exposed and dressed groups including BMI (30.1 vs 29.4)
  • There was no significant difference in superficial SSI rates at 28 days between the two groups (P=0.45)
    • Exposed: 1.3% (2/153)
    • Dressed: 3.2% (5/157)
    • Relative risk (RR) 0.4 (95% CI, 0.1 to 2.1)
  • There was no significant difference in medium patient satisfaction scores prior to discharge (P=0.81)
    • Exposed: 7
    • Dressed: 7
  • In wound-exposed patients, preference for wound exposure increased
    • Preference for wound exposure at recruitment: 35.5%
    • Preference for wound exposure at day 28: 57.5%
  • In wound-dressed patients, preference for wound dressing significantly decreased
    • Preference for wound dressing at recruitment: 48.5%
    • Preference for wound dressing at day 28: 34.4%
  • There were no significant differences between the groups for
    • Post-hospital discharge self-reported wound issues of infection
    • Antibiotic use
    • Redness and inflammation
    • Swollen, painful, and fluid leakage of wounds through day 28
  • Additional dressing or gauze use for wound care
    • Post op day 1: Wound-exposed patients were more likely to require a dressing (26.6% vs 10.2%; P<0.001) but less likely to require additional gauze (10.3% vs 19.3%; P=0.03)
    • Overall inpatient stay: There was no significant differences in the use of additional dressing or gauze use

CONCLUSION:

  • Leaving incisions site wounds exposed following cesarean does not appear to affect SSI rates, compared to using the standard dressing for wound coverage | Patients in the wound-exposed arm may be more satisfied at 28 days
  • However, since the actual infection rate (3.2%) in the wound dressed arm was so much lower than anticipated from the pilot data (9.3%) the study was underpowered
  • The data supports cesarean wounds being left exposed but “more research is needed”

Learn More – Primary Sources:

A randomised trial of caesarean wound coverage: exposed versus dressed

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Related ObG Topics:

Cesarean Delivery Best Practices & Guidelines – The ERAS Committee Recommendations
What is the Best Practices Prevention Bundle for Post Cesarean Infection?
Can Evidence-Based Interventions Reduce C-section Complications?
Does Tissue Adhesive Decrease Cesarean Wound Infection?

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