Emergency Cesarean Section Preoperative Antibiotic Prophylaxis – Opportunities for improvement

Authors:
Alex Kaizer, Dante Yeh, Gabriela Cortese, Heather Young, Robyn Bronshtein, Stefka Fabbri

Body of Abstract:
Background: Surgical Care Improvement Project (SCIP) recommends intravenous prophylactic antibiotics (abx) to be given within 60 minutes before incision to reduce the risk of surgical site infection (SSI). In non-elective cesarean sections, time constraints present challenges to timely abx administration. The aim of this quality improvement study was to assess SCIP compliance in emergent cesareans to identify opportunities for improvement.

Methods: This retrospective study included patients undergoing emergent cesarean at our institution between May 2016 and Dec 2023. Cases of emergent cesarean in the context of major trauma were excluded. Maternal demographic, obstetric, medical, and labor outcomes were abstracted from the medical record. The primary outcome was the incidence of timely (within 60 minutes of incision) administration of abx. Secondary outcomes included maternal ICU admission, hospital length of stay (LOS), loss to follow-up, SSI, and 30-day outcomes such as readmission, reoperation, and Emergency Department (ED) visit. Logistic regression analyses were performed using select variables to identify predictors of SCIP compliance.

Results: A total of 891 patients were included in the study and the majority were non-Caucasian with public insurance (Table). The most common indication for cesarean delivery was non-reassuring fetal status and the most common form of anesthesia was epidural. Antibiotics were administered in 96% of cases, but only 72% were given within 60 minutes before skin incision (SCIP compliance). Chlorhexidine-alcohol was most commonly used for abdominal skin preparation. There were significant differences between the SCIP Not Compliant vs. Compliant group (Table), but multiple logistic regression identified only ASA Class 3 (OR 0.69 95% CI 0.49-0.97, p=.034), ASA Classes 4/5 (OR 0.22 95% CI 0.04-0.96, p=.047), and prolapsed cord as indication for C-section (OR 0.22 95% CI 0.10-0.49, p<.001) as predictors of SCIP Not Compliant. Race and Insurance Status were not significant predictors of SCIP compliance. Maternal morbidity was low, with only 2% ICU admission and median hospital LOS 4 days. A large proportion (32%) were lost to follow-up. The SSI rate was low (1%) and patients infrequently needed interventions. Conclusion: At our safety net hospital, we identified multiple opportunities for improvement, including timeliness of preoperative abx administration, abdominal skin preparation agent, and post-discharge follow-up. SCIP non-compliance was significantly associated with indications for emergent cesarean and higher ASA class. Post-operative SSI rates were low, though a selection bias may be present due to high loss-to-follow-up. Further research is necessary to develop strategies to improve compliance.