Multi-drug resistant surgical site infections following caesarean delivery: a prospective observational study from urban Uganda

Abstract

Background: Surgical-site infections (SSI) are a feared complication of caesarean section (CS). While the incidence of post-CS SSI is estimated at 5–10% worldwide, increasing evidence suggests that women in low- and middle-income countries (LMIC) may be disproportionally affected. Due to the lack of access to routine microbiology and surveillance, data on bacterial pathogens and resistance are scarce for post-CS SSI from LMIC, and antibiotic treatment is largely empirical. Further research on common pathogens and resistance patterns is urgently needed, considering the rise of antimicrobial resistance (AMR) especially in sub-Saharan Africa. Methods: This prospective observational study aimed to describe the bacterial pathogens, resistance profiles and clinical outcomes of women with post-CS SSI at the largest national maternity hospital in Kampala, Uganda. Women with clinical signs of post-CS SSI were eligible for inclusion. Blood and deep wound swab cultures were taken for bacterial species identification and antibiotic susceptibility testing upon enrolment. Clinical follow-up assessments were conducted on days 2, 4 and at discharge. Results: From May 2021 to January 2022, 70 women were screened for study eligibility, of which 66 were enrolled and completed follow-up. The median age was 25 years (IQR 21–29), and 5 (7.6%) participants were HIV-infected. The median time between CS and diagnosis of SSI was 12.2 days (IQR 8–15). The majority of women required surgical treatment, predominantly debridement (n = 51, 82%). A total of 80 bacterial pathogens were identified from deep wound swabs, of which the majority were Gram-negative (n = 66, 82.5%). The most frequently isolated pathogens were Acinetobacter spp. (n = 26, 32.5%), Escherichia (E.) coli (n = 18, 22.5%), and Klebsiella spp. (n = 15, 18.8%), the majority of which were highly resistant to third-generation cephalosporins (94–100%). Additionally, a large proportion of Acinetobacter spp. isolates were resistant to carbapenems (65.4%), gentamycin (90.9%), and quinolones (85.0%). Blood cultures were negative for bacterial growth in all participants. After a median 10.7 days (IQR 5–14) of in-patient treatment, the majority of study participants made a complete recovery (n = 59, 89.4%). Conclusions: Deep wound swabs from post-CS SSI predominantly identified multidrug resistant Gram-negative pathogens with limited antibiotic treatment options in this setting. Especially the large proportion of carbapenem-resistant Acinetobacter spp. may indicate hospital-acquisition of the infections and warrants the strengthening of infection prevention and control measures, as well as antibiotic stewardship.