What is the treatment for a cesarean (C) section incision infection?

Treatment of Cesarean Section Incision Infection

The primary treatment for a cesarean section incision infection is prompt and wide opening of the surgical incision to evacuate infected material, with antibiotics indicated only when systemic inflammatory response syndrome (SIRS) criteria, signs of organ failure, or immunocompromise are present. 1

Diagnosis

• Surgical site infection (SSI) following cesarean section is diagnosed based on the presence of purulent incisional drainage, local signs including pain, tenderness, swelling, redness, and induration 1
• Cesarean delivery incisions are typically classified as clean (class I) if performed before rupture of membranes and without chorioamnionitis, or clean-contaminated (class II) if performed after membrane rupture or with chorioamnionitis 2
• SSI rates following cesarean section range from 3-15%, making it a common cause of postoperative morbidity 3
• Obesity (BMI ≥30) is a significant risk factor for developing SSI after cesarean section (OR 4.1) 4

Primary Treatment

• For all incisional SSIs, the primary intervention is to open the incision, evacuate infected material, and continue dressing changes until the wound heals by secondary intention 1
• Prompt opening of the incision is crucial as delayed drainage can lead to progression of infection 1
• Antibiotics are NOT routinely indicated for incisional SSIs without systemic signs of infection 2, 1

When to Add Antibiotics

Antibiotics should be added to surgical drainage when any of the following are present:

• SIRS criteria or signs of organ failure such as hypotension, oliguria, decreased mental alertness 2
• Immunocompromised patient status 2
• Temperature >38.5°C or heart rate >110 beats/minute 1
• Erythema extending >5 cm from the wound edge 1

Antibiotic Selection

When antibiotics are indicated, the appropriate regimen should be selected based on the likely pathogens:

• For operations involving genital tract (such as cesarean section), recommended options include:
  • Single-drug options: piperacillin-tazobactam, ertapenem, or other broad-spectrum agents 1
  • Combination options: ceftriaxone + metronidazole or ciprofloxacin + metronidazole 1
• If MRSA is suspected, vancomycin 15 mg/kg every 12h IV should be added 1
• A short course (24-48 hours) is usually sufficient after adequate drainage 1

Prevention Strategies for Future Cesarean Deliveries

To prevent SSI in future cesarean deliveries:

• Administer intravenous antibiotics within 60 minutes before the cesarean delivery skin incision 2
• Use a first-generation cephalosporin (cefazolin) for all women; in women in labor or with ruptured membranes, add azithromycin for additional reduction in postoperative infections 2
• For obese women (BMI ≥30), increase cefazolin dosing to 3g (rather than standard 2g), which has been shown to reduce SSI risk (OR 0.309) 4
• Use chlorhexidine-alcohol for abdominal skin cleansing rather than aqueous povidone-iodine solution 2
• Consider vaginal preparation with povidone-iodine solution before cesarean delivery 2
• Use electric clippers rather than razors if hair removal is necessary 5

Special Considerations

• Failure to recognize deeper infection can lead to inadequate treatment; any deep SSI that does not resolve as expected should be investigated as a possible manifestation of a deeper organ/space infection 1
• Patients with higher BMI have different pathogen distributions in their infections compared to non-obese patients, which may affect antibiotic selection 4
• Certain ethnic groups may have higher risk of SSI following cesarean section, including Māori (OR 2.1) and Samoan women (OR 3.0), which may warrant additional preventive measures 4

Follow-up Care

• Continue dressing changes until the wound heals by secondary intention 1
• Educate patients on proper wound care techniques for self-management after discharge 6
• Monitor for signs of deeper infection or inadequate healing that might indicate the need for additional intervention 1