Grand Rounds

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

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

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

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

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”

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