Prevention of post-caesarean section wound infection: single or multiple drug chemoprophylaxis? A cost effective analysis

Abstract

INTRODUCTION: Caesarean section deliveries are common worldwide ranging between 5% and 35%, with highest rates observed in developed countries(Makinde, 1987). However, increasing rates are being observed in developing countries as well. In Mulago, the caesarean section rate rose from 7% in 1972(Mulago hospital annual report,1972) to 15.8% in 2002 and 14.7% in 2003(Mulago hospital records, 2002 and 2003). In Kawolo hospital, the caesarean section rate is 30 %(kawolo hospital records, 2003) almost twice that observed in Mulago hospital. Caesarean section deliveries carry a 5-20 times higher risk of post-partum infection compared to vaginal deliveries(Henderson et al, 1995). This may be surgicalwound infection, endometritis, pelvic peritonitis or pelvic abscess. Post operative wound infection accounts for 5-34% of nosocomial infections worldwide(Mayon-White;1998 Henderson et al,2000; Woodfield et al, 2003 and many others have documented use of antibiotic chemoprophylaxis to reduce post operative wound infection. OBJECTIVE: The general objective is to compare the post-caesarean wound infection and duration of hospitalization among mothers delivered by caesarean section who receive chemoprophylaxis with a single doze of ceftrixone and those who receive multiple drug chemoprophylaxis, and compare the cost of treatment in the two groups. STUDY DESIGN: Multicentre randomized clinical trial, single blind. STUDY SIGHT: Department of Obstetrics and gynaecology, mulago hospital and Kawolo hospital maternity ward. STUDY POPULATION: Mothers delivered by caesarean section in mulago and Kawolo hospitals, met the inclusion criteria and consented to take part in the study. METHODS: 236 mothers scheduled for delivery by caesarean section in the two hospitals and met the inclusion criteria, were randomly allocated to two chemoprophylactic arms. The single drug chemoprophylactic arm consisted of administering one doze intravenous ceftriaxone after clamping the code and no other antibiotics were administered during the post-operative period. In the multiple drug chemoprophylactic arm, drug treatment was started one hour after the operation and consisted 2 MU were given intravenously every six hours for forty eight hours, followed with three days of amoxicillin and metronidazole to make five antibiotic days. Patients were followed till discharge for wound infection. The cost of drug acquision, lodging, doctors and nurses’ care, utilities, equipment and laboratory costs were determined. RESULTS: There were no statistically significant differences in the socio-demographic characteristics between the two groups. Over 90% of mothers in each arm had emergency caesarean section. The wound infection rate was 8.4% in the multiple drug chemoprophylactic arm while no one developed wound infection in single drug chemoprophylactic arm. Patients in the multiple drug chemoprophylactic arm were more likely to stay longer in hospital compared to those in the single drug chemoprophylactic arm (p< 0.0001). The cost effectiveness ratio in the multiple drug chemoprophylactic arm was 1.2 times higher compared to chemoprophylaxis with a single doze of ceftriaxone. Through use of a singe doze of ceftriaxone chemoprophylaxis, mulago hospital would save up to Ushs 232,203,746 annually while kawolo hospital would save Ushs 42 million annually. CONCLUSION: Single doze chemoprophylaxis is more effective in reduction of wound infection than multiple drug chemoprophylaxis. Chemoprophylaxis with a single doze of ceftriaxone is more cost-effective compared to multiple drug chemoprophylaxis. Use of ceftriaxone chemoprophylaxis in caesarean section leads to net savings for the hospital.