SOCIODEMOGRAPHIC PROFILE AND INCIDENCE OF

SURGICAL SITE INFECTIONS AMONG OBSTETRIC AND

GYNECOLOGICAL PATIENTS IN REGION
1 MEDICAL CENTER

Rajbhandari, Subani
So, Darem A.
Vias, James Ryan G.

Adviser: Dr. Diana Maychelle Valeros

A Graduate Research Presented to the Department of

Obstetrics and Gynecology, Region 1 Medical Center,
Dagupan City, Philippines, In Partial Fulfillment of the
Requirements for the Degree

DOCTOR OF MEDICINE
 ACKNOWLEDGMENT

The authors would like to express their outmost appreciation and gratitude who

offered their love, support, and guidance in the realization of this paper.

Dr. Diana Maychelle Valeros, our research adviser, who despite her busy

schedule and life as a resident doctor, has given her all in ensuring that this paper is

complete in substance and enlightenment;

Dr. Rico E. Reyes, the manager of the Department of Obstetrics and Gynecology,

and Dr. Yvonne D. Nacis, chairperson of training of the department, consultants, and

residents for their seemingly unending energy dedicated in enabling us to become more

effective and knowledgeable in the field of Obstetrics and Gynecology;

To our friends and colleagues, who are with us all the way from the very

beginning, Padayon! Kahit nakakabitin ang online clerkship;

To our families, for their support, understanding, and unconditional love;

Above all, to the Almighty God, from Whom all wisdom and knowledge emanates

from. Agyaman kami, Apo.

Subani Rajbhandari

Darem A. So

James Ryan G. Vias

 TABLE OF CONTENTS

PAGE
TITLE PAGE i
LIST OF TABLES ii
LIST OF FIGURES iii
ABSTRACT iv

INTRODUCTION 1
Background of the Study 1
Statement of the Problem 3
Significance of the Study 3
Scope and Delimitations of the Study 4

REVIEW OF RELATED LITERATURE 5

Overview of Surgical Site Infections (SSI) 5
Surgical Site Infections in Obstetrics and Gynecology 8

MATERIALS AND METHODS 12

Research Design 12
Subjects and Locale of the Study 14
Data Gathering Instrument 14
Data Gathering Procedure 14
Statistical Treatment of Data 15

RESULTS AND DISCUSSION 16

CONCLUSION AND RECOMMENDATIONS 23

Conclusion 23
Recommendations 24

REFERENCES 25
APPENDICES 30
Appendix Table 1 30
 LIST OF TABLES

TABLE PAGE

1 Summary and Incidence of SSIs from January to May 2021. 16

2 Frequency and Percentage Distribution of Patients according to Age 17

3 Frequency and Percentage Distribution of Patients according to 18

Parity
4 Frequency and Percentage Distribution of Patients according to 19
Educational Attainment
5 Frequency and Percentage Distribution of Patients according to 19
Place of Residence
6 Frequency and Percentage Distribution of Patients according to 20
Presence or Absence of Comorbidities
7 Distribution of SSI rates according to Surgical Procedures from 21
January to May 2021.

ii
 LIST OF FIGURES

FIGURE PAGE

1 Paradigm of the Study 13

iii
SOCIODEMOGRAPHIC PROFILE AND INCIDENCE OF SURGICAL SITE
INFECTIONS AMONG OBSTETRIC AND GYNECOLOGICAL
PATIENTS IN REGION 1 MEDICAL CENTER
Subani Rajbhandari, Darem A. So, and James Ryan G. Vias
College of Medicine, Lyceum-Northwestern University, Dagupan City

ABSTRACT
This study sought to determine the sociodemographic factors of obstetric and
gynecological patients who have acquired Surgical Site Infections (SSI) following surgery
in the Department of Obstetrics and Gynecology, Region 1 Medical Center, Dagupan City,
Pangasinan, from January to May 2021. The incidence rate of SSIs among the study
population was also determined, as well as the types of surgical procedures which
resulted to surgical site infection following surgery. The following sociodemographic data
were taken: age, parity, educational attainment, place of residence, and presence of
comorbidities.
A total of twenty (20) patients were included in the study. This study found out that
patients belonging to the age group 20-34 years old have the greatest frequency of
patients who acquired SSIs, accounting for 60% of the study population. For parity,
multiparous women accounted for 70% of the study population, whereas patients who
have attained high school accounted for 75%. Residents of rural areas were seen to have
the greater proportion than urban residents, accounting for 80% of the study population.
Furthermore, patients who had no known comorbidities accounted for 75% of the study
population.
The incidence rate and morbidity rate among the study population was at 2.22%.
Among the surgical procedures, SSIs were most seen in patients who have undergone
Cesarean Section (CS) at 50% of all cases, followed by episiorrhaphy at 30%, and
surgeries involving a laparotomy incision accounted for 20% of all the cases.

Keywords: Surgical Site Infection, Incidence Rate, Sociodemographic profile

iv
 CHAPTER I
INTRODUCTION

Background of the Study

Post-surgical site infections are one of the most important hospital associated

infection in low to middle income countries and cause of post-operative morbidity (Pathak

et al., 2017). According to Center for Disease Control and Prevention (CDC), surgical site

infections (SSI) account for more than 38% of nosocomial infections, and prolongs

hospitalization from 2 to 17 days (Mamo et al., 2017). Among complications during

surgery, surgical site infection rates range from 3-15% worldwide and defined as post-

surgical infection happened within 30 days of the procedure. (Zabaglo and Sharman,

2021; Berrios-Torres et al., 2017).

Surgical site infections are brought upon by a complex interplay of both intrinsic

and extrinsic factors related to the patient, surgery, as well as environmental factors inside

and outside the healthcare setting (Woldemicael et al., 2019). One of the intrinsic factors

in consideration are the sociodemographic characteristics of patients, which are useful

determinants of rate of acquiring SSIs among obstetric and gynecological patients. These

include age (Mamo et al., 2017; Pathak et al., 2017), parity (Pathak et al., 2017),

residence (Ayala et al., 2021), educational attainment (Mejia et al., 2019), medical

comorbidities (Gillispie-Bell, 2020), and behavior (Mejia et al., 2019; Gillispie-Bell, 2020).

The development of a surgical site infection causes a substantial increase in the clinical

and economic burden of surgery. The financial burden of surgery is increased due to the

direct costs incurred by prolonged hospitalization of the patient, diagnostic tests, and

treatment as well as it negatively impacts on patient physical and mental health (Bello et

1
al., 2014). Increased patient morbidity, mortality and loss of earnings during recovery are

some of the indirect costs associated with infection. Intangible costs may also be incurred

by the patient, such as pain and anxiety. In addition, patients may experience delayed

wound healing and be more susceptible to secondary complications such as bacteremia.

Distress may also be caused to the patient and family members if the patient is absent

from home and work for a prolonged period (Badia et al., 2017).

In addition to sociodemographic determinants, extrinsic factors such as operating

room practices, aseptic and antiseptic techniques, surgical techniques, and infection

control protocols have major affectations to the outcome of surgical procedures, including

infections (Dinda et al., 2013), wherein the magnitude of SSIs in first-world countries and

low-middle income countries (LMIC) have significant differences in terms of incidence and

control (Khan et al., 2020). First-world countries tend to have lower incidence rates of

SSIs (Kitembo and Chugulu, 2013), while LMICs tend to have greater proportion of SSIs

(Pathak et al., 2017; Curcio et al., 2019).

As such, these factors have raised concerns on how the management of SSIs will

be, especially in a third-world country like the Philippines. The researchers thought of

initially studying the sociodemographic factors that could affect the predisposition and

outcome among surgical obstetric and gynecological patients, which could then serve as

a basis on the prevention and treatment of surgical site infections.

2
Statement of the Problem

The study aimed to determine the incidence and sociodemographic factors of

Obstetric and Gynecologic patients with Surgical Site Infection (SSI) in Region 1 Medical

Center, Dagupan City. Specifically, it sought to answer the following questions:

1. What is the profile of the obstetric and gynecological surgical patients who

acquired SSI in terms of age, parity, educational attainment, place of residence,

and comorbidities?

2. Which sociodemographic factors could affect the likelihood of contracting surgical

site infections?

3. Which surgical procedures have the greatest number of patients acquiring SSIs

following surgery?

4. What is the incidence of SSIs among patients who acquired SSIs postoperatively?

Significance of the Study

In the advent of greater health outcome for both the Obstetric and Gynecologic

patients, researchers are working hard on how to prevent development of surgical

infection and lowering the incidence rate among the said population. This study will help

various groups of population in different ways which are briefly discussed below:

Medical students: This research will help students to be more aware of complications that

might happen post-operatively to an obstetric and gynecologic patient. It will aid them on

managing patient with high risk of having surgical site infections and to guide them on

how to properly care their wound preventing further complications.

3
Doctors: this will help doctors recognize patients who are at risk of having surgical site

infections. This will decrease hospital stay for the patient and lessen the chance of

readmission that can be both beneficial to the doctor and the patient.

Post-operative Patients: Patient will be able to understand doctor`s advice and have an

idea on how to take care of their wound thus preventing the possibility of infection and

further complications.

Future researchers: It will make them aware about current situation and fill in gaps that

leads to a better patient care by focusing their research more on prevention measures

and management of these patients based on their respective risk factors.

Scope and Delimitations of the Study

This study is focused mainly on the sociodemographic profile of surgical patients

who were admitted at Region 1 Medical Center, Dagupan City, Pangasinan, and has

acquired SSI following surgery. The study period was from January to May 2021.

Excluded in the study are non-surgical patients and surgical patients who did not

develop surgical site infections following surgery.

4
 CHAPTER II

REVIEW OF RELATED LITERATURE

Overview of Surgical Site Infections (SSI)

Surgical Site Infections (SSI) are a common complication seen in the healthcare

setting (Zabaglo and Sharman, 2021). It is defined as an infection occurring up to 30 days

after a surgical procedure, which has profound effects from the incision site down to the

deeper tissues beyond the surgical wound (Owens and Stoessel, 2008; Zabaglo and

Sharman, 2021). In addition, an SSI must have either purulent drainage or organisms

isolated from the wound site (Zabaglo and Sharman, 2021). SSIs are further classified by

the Centers for Disease Control and Prevention (CDC) based on depth of involvement:

Superficial Incisional infection, which involves the skin and subcutaneous tissues; Deep

incisional infections, where deeper tissues such as muscle and fascial planes are

involved; and Organ space infection, which is defined as involvement of any organ apart

from the incision site but must be related to the surgical procedure (Berrios-Torres et al.,

2017).

Despite the advances in operating room practices, instrument sterilization

methods, surgical techniques, and protocols for infection control (Dinda et al., 2013), SSIs

still remain a major cause of morbidity and mortality among patients who have undergone

surgery (Lubega et al., 2017). Patients who develop SSIs have longer hospital stays,

develop delayed wound healing, have prolonged pain, discomfort, and disability, and

have an increased risk of mortality (Pittet et al., 2008 as cited by Khan et al., 2020).

5
Moreover, the risk of hospital re-admission are two to five times more likely in those who

developed SSIs, as these infections may recur even after discharge (Lubega et al., 2017).

While SSIs are generally brought upon by a complex interplay of various factors,

such as the surgery, the patients themselves, and microbial and environmental-related

factors (Woldemicael et al., 2019), the incidence rate of SSIs are intimately linked on the

quality of health care facilities, surgical procedure, and level of care provided (Khan et al.,

2020). As such, the incidence of SSIs in the developed and developing countries have

notable differences. Kitembo and Chugulu (2013) stated that patients who have

undergone surgery in developed countries have at least 5% chance of acquiring an SSI,

while Curcio et al., (2019) reported that the rate of SSI development in developing

countries is much greater, which is estimated to be as high as 20%. Moreover, these

infections also account in a large portion of hospital-acquired infections (HAI), wherein

Allegranzi et al., (2011) reported that approximately 31% of HAIs are due to SSIs, and a

sum of around 20% of post-surgical readmissions are due to SSIs. The development of

SSIs in developing countries has been attributed to the inadequate personal protective

equipment among healthcare workers, a lack of training on infection control, and weak

hospital policies on infection control (Awoke et al., 2019).

The higher incidence of SSIs in developing countries not only bring the burden of

various complications and prolonged suffering to patients, but these infections also have

profound negative impacts on healthcare costs, as well as to the socioeconomic and

emotional well-beings of families whose members are afflicted with such infections (Bello

et al., 2014). Furthermore, SSIs also partake in increasing the resistance of pathogenic

6
bacteria to antibiotics, hence adding more burden to the developing antibiotic resistance

problem worldwide (Awoke et al., 2019).

Brunicardi et al., (2019) published that the majority of surgical site infections are

caused by bacteria. Gram-positive, aerobic skin commensals, such Staphylococcus

aureus, S. epidermidis, and Streptococcus pyogenes, and enteric organisms such as

Enterococcus faecalis and E. faecium, partake in a large percentage of SSIs, either alone

or in conjunction with other pathogens. In addition, enterococci can inflict nocosomial

infections, particularly in those who are immunosuppressed and chronically ill. Moreover,

the emergence of Methicillin-resistant Staphylococcus aureus (MRSA) has also been

reported to cause a growing number of SSIs worldwide (Tariq et al., 2017).

Gram-negative bacteria are a group of interest as well in the fields of surgery, as

these bacteria are also frequently found to be causative of various healthcare-associated

infections such as in surgeries involving hollow viscera like appendectomy,

gastroduodenal, biliary tract, and urologic surgeries (Tariq et al., 2017). Species of

interest in this group include Escherichia coli, Pseudomonas aeruginosa, and Klebsiella

pneumoniae (Mezemir et al., 2020; Lubega et al., 2017; Brunicardi et al., 2019). In

addition to bacteria, fungi and viruses also account to be etiological agents of SSIs, but

are relatively uncommon in contrast to bacterial infections. Fungal species of interest

include Candida, and various opportunistic pathogens such as Aspergillus spp.,

Blastomyces dermatitidis, and Cryptococcus neoformans, while viruses of particular

interest include adenoviruses, cytomegalovirus, Epstein-Barr virus, herpes simplex virus,

hepatitis viruses, and human immunodeficiency virus (HIV), to name a few (Brunicardi et

al., 2019).

7
 Management of surgical site infections entails not only on giving the proper

antimicrobial agents that deal with the various infections but to also drive maneuvers that

diminish the presence of pathogens that cause surgical site infections. These mitigating

measures include proper sterilization and asepsis, aggressive source control, and the

appropriate use of antimicrobial agents, (Tariq et al., 2017; Brunicardi et al., 2019).

Saguil et al., (2017) published a set of recommendations on preventing and

managing SSIs in the Philippine setting. Aside from the employment of proper antibiotic

prophylaxis, a number of these recommendations are targeted on proper patient

preparation such as nutritional support, maintenance of normal temperature, proper

glucose control, and maintaining adequate circulating normal volumes, to name a few. In

addition, the authors also gave recommendations on the intra-operative scene, such as

on operative time, proper ventilation in the operating room, and environmental surfaces

and sterilization. Recommendations on the post-operative period were given as well, such

as wound care, antibiotic treatment of SSIs, and infection surveillance program. Measures

like these are employed to mitigate, if not totally prevent, the occurrence of SSIs.

Surgical Site Infections in Obstetrics and Gynecology

Following post-partum hemorrhage, infections account as the second most

common cause of maternal mortality (Van Beneden et al., 2007 as cited by Mamo et al.,

2017). Typical superficial or deep SSIs in obstetric and gynecological procedures typically

present with pain, redness, and swelling at the incision site at least 2 days after surgery,

with or without the presence of purulent drainage. Organ SSIs may present with

8
abdominal or pelvic pain, accompanied by fever and a possible tender mass upon

physical examination (Sarabanchong, 2020).

SSIs in Obstetrics and Gynecology complicates surgeries the same way SSIs do

in other surgical conditions (Pathak et al., 2017), wherein Hysterectomy for gynecological

reasons have an SSI rate of 1.7% (Black et al., 2014), while Cesarean Section (CS)

deliveries have reported low rates of developing SSIs at between 3 to 15% in first-world

nations (Krieger et al., 2016; Mahdi et al., 2014; Shree et al., 2016), and 10 to 20% in

developing nations (WHO, 2016; Pathak et al., 2017). In addition, the risk for acquiring

maternal infection after CS was eight-fold higher versus vaginal delivery (Mamo et al.,

2017).

Sarabanchong (2020) reported that the development of SSIs among obstetric and

gynecological patients is generally dependent on three groups of risk factors: Host risk

factors, Obstetrical risk factors, and Surgical risk factors. Each group of has a specific risk

factors with their respective odds ratio, wherein it revealed that tobacco use, and obesity

account for high odds ratio among the host risk factors, with scores of 1.99-5.32, and

2.23-2.65, respectively. Active smokers are at 40% risk of contracting post-operative

complications such as SSI (ACS, 2017), while obese patients, particularly those who are

undergoing abdominal surgeries such as hysterectomy, are also at high risk due to the

poor tissue perfusion, hence, leading to higher chances of acquiring an SSI (Winfield et

al., 2016). As such, smoking cessation of 4-6 weeks prior to surgery, and appropriate

weight-based administration of antibiotics are highly recommended in order to mitigate

the high risk associated with smoking and obesity (ACS, 2017; Gillispie-Bell, 2020). In

addition, obstetrical risk factors such as presence of chorioamnionitis, labor, and rupture

9
of membranes weigh in the development of SSIs (Sarabanchong, 2020) as normal flora

of the genital tract contaminate the normally sterile amniotic fluid and uterus (Mamo et

al., 2017). Moreover, hyperglycemic status, duration of surgery, and open vs.

laparoscopic surgery, among others, also largely account into the development of SSIs,

wherein odds ratio of 1.4-9.4, 1.84-2.4, and 2.0-3.74, respectively, are reported to be

additional to the aforementioned risk factors. It is particularly important to know that the

complex interplay of these major factors may add up or bring down the chances of

acquiring SSIs following surgery (Woldemicael et al., 2019; Khan et al., 2020).

Various sociodemographic factors are useful determinants of rate of acquiring

SSIs among obstetric and gynecological patients. Mamo et al., (2017) reported a

retrospective study regarding risk factors associated with SSIs in the obstetric wards of

an Ethiopian referral hospital. The authors found a significant association with age,

wherein patients aged younger than nineteen (19) are three times at risk for developing

SSIs in contrast to those who were twenty (20) to forty (40) years old. A similar study of

Pathak et al., (2017) among obstetric and gynecological surgeries in a rural Indian

teaching hospital revealed an increased risk for developing SSIs in patients who are

above forty (40) years of age, grand-multipara, as well as those with significant

comorbidities, such as diabetes mellitus, severe anemia, and cardiovascular disease. In

addition, place of residence also weighs in the development of SSIs, as patients residing

in rural areas are more prone to developing SSIs in contrast to those who are living in

urbanized areas (Ayala et al., 2021). Moreover, patients who have attained higher

education tend to have lesser odds of acquiring SSIs (Mejia et al., 2019).

10
 SSIs in obstetric and gynecological procedures are generally managed by an initial

assessment and identification of various modifiable risk factors in patients. This is

followed by employment of appropriate antibiotics in accordance to wound classification

and/or procedure, management of comorbidities, appropriate operative technique, and

proper surgical site preparation (Sarabanchong, 2020; Saguil et al., 2017).

Treatment of SSIs in obstetric and gynecological surgeries entails a combination

of medical and surgical modes of management with accordance to the depth of the SSI.

Sarabanchong (2020) published a simplified algorithm for such infections. Superficial

SSIs are generally treated with oral antibiotics in the forms of Dicloxacillin, Trimethoprim-

Sulfamethoxazole, and Amoxicillin-clavulanate, plus wound debridement for purulent

drainage. Deep incisional SSIs and organ or space SSIs on the other hand, requires

intravenous antibiotics such as Gentamicin, Clindamycin, Ceftriaxone, Metronidazole,

Piperacillin-Tazobactam, and Vancomycin, wherein combinations of antibiotics are given

as necessary. In addition, wound debridement, and laparoscopic or exploratory

laparotomy are warranted in order to determine the source of infection, e.g., abscess,

most especially in patients that are clinically unstable or septic, or in cases of a ruptured

abscess, perforated viscus, or for cases of necrotizing fasciitis. Moreover, a CT or

ultrasound-guided percutaneous drainage could also be done, especially in the presence

of an abscess measuring more than 8 cm, or if the abscess is not responsive to IV

antibiotics after 48 hours of treatment.

11
 CHAPTER III
MATERIALS AND METHODS

Research Design
A retrospective, descriptive research design was used in the study to investigate

the sociodemographic profiles of patients who acquired surgical site infections following

surgery and were admitted on the months of January to May 2021. Descriptive statistics

was used to describe the profile of the patients in the study.

12
INPUT
PROCESS OUTPUT
1. Sociodemographic
profiles of ob-gyn Basis for its
Descriptive Statistics
patients with SSIs understanding and
of gathered variables
2. Number and types management of
of surgeries resulting patients with SSIs
to SSIs

Figure 1. Paradigm of the study.

13
Subjects and Locale of the Study

The subjects of the study were the patients who acquired surgical site infections

who were admitted in Region 1 Medical Center (R1MC), Dagupan City. The time frame

of the study was from January 2021 to May 2021. There was a total of 20 cases involved.

Data Gathering Instrument

The instrument used for data gathering was a tally sheet based on the profile of

women who had surgical site infections and were admitted in R1MC. The following

variables were taken into account: age, parity, residence, education attainment, and

medical comorbidities. Variables were summed and analyzed.

Data Gathering Procedure

The researchers were tasked to contact Dr. Diana Maychelle Valeros, a resident

physician in the Department of Obstetrics and Gynecology in R1MC. Upon

communication with Dr. Valeros, pertinent information regarding the women’s

sociodemographic profile, medical, and obstetrical history were gathered. The data came

from the summarized table given by the OB-GYN department. Highest research ethical

standards in regard to data privacy and respondent anonymity was complied with

accordance to existing data privacy laws.

14
Statistical Treatment of Data

Analysis of the data was carried out using Microsoft Excel 2016. Frequency count

and percentages were used to answer problems regarding the profile of the patients and

the number of SSIs following surgeries.

The frequency and percentage distribution were determined using the following

formula:

% = (f/n) x 100

Where:

% = percentage of the respondents

f = frequency of the respondents

n = total number of the respondents

15
 CHAPTER IV
RESULTS and DISCUSSION
Table 1. Summary and Incidence of SSIs from January to May 2021.
Month Number of OB- Number of Incidence Rate
GYN surgical patients who had
procedures SSIs
January 167 3 1.79%
February 148 2 1.35%
March 174 6 3.45%
April 198 5 2.52%
May 215 4 1.86%
Total 902 20 2.22%

Table 1 shows the number of surgical procedures in the Department of Obstetrics

and Gynecology in Region 1 Medical Center (R1MC), and the number of Surgical Site

Infections (SSI) tallied per month from January to May 2021. A total of nine-hundred two

(902) surgical procedures were performed in the institution, and a total of twenty (20)

patients had acquired an SSI following operation. Among these patients, sixteen (16)

acquired an SSI following an obstetric procedure, while four (4) of them had an SSI

following a gynecological procedure. The total incidence rate of SSI was at 2.22%.

Surgical Site Infections are a common complication in five (5) to twenty (20)

percent of surgeries worldwide (Kitembo and Chugulu, 2013; Curcio et al., 2019). SSIs

following obstetric and gynecological surgical procedures are seen in 3-15% of obstetric

procedures (Krieger et al., 2016; Pathak et al., 2017; Saeed et al., 2017), and in 1.7-2.7%

of all gynecological surgical procedures (Black et al., 2014; Lachiewicz et al., 2017). Table

1 shows that the incidence of SSIs in the study ranges from 1.35% to 3.45% with a total

16
incidence of 2.22%, depicting a low incidence in reference to the aforementioned data

regarding the incidence of SSIs among obstetric and gynecological procedures.

The morbidity rate in this study was determined to be at 2.22%, which was

identified to be lower than the expected reference range published by multiple studies

(Pathak et al., 2017; Saeed et al., 2017; Lachiewicz et al., 2017). However, the said

finding could be inconclusive as the study period was only done for five months.

Table 2. Frequency and Percentage Distribution of Patients according to Age

Age Frequency (n) Percentage (%)

<19 2 10%
20-34 12 60%
>35 6 30%

Table 2 reports the frequency and percentage distribution of patients based on

age. Among the age groups, SSIs are most frequently seen among post-operative

patients aging twenty (20) to thirty-five (35) years old at 60%, followed by patients who

are more than thirty-five (35) years of age at 30%, while patients who are younger than

nineteen (19) years old are shown to have the least number of patients who have acquired

SSI, garnering a percentage of 10%. Age is a major sociodemographic indicator in the

development of SSIs following obstetric and gynecological procedures. A study published

by Mamo et al., (2017) reported a three-fold increase in acquiring SSIs among patients

younger than nineteen (19) in comparison in patients between the ages of twenty (20)

and thirty-four (34). In addition, Pathak et al., (2017) reported that patients who are above

forty (40) are at a high risk of developing SSIs as well. As seen in table 2, the majority of

patients who had SSIs at are aged twenty (20) to thirty-four (34). The results coincide with

the findings in the study published by Ayala et al., (2021) which revealed a 61.8%

17
incidence of SSIs among patients age twenty-four (24) to thirty-four (34). The study also

supports the findings of Pathak et al., (2017) regarding the higher risks of acquiring SSIs

as the age increases, which could be attributed to various factors that modify wound

healing, cellular growth and repair, as well as changes in the immune and endocrine

responses of the body to injury.

Table 3. Frequency and Percentage Distribution of Patients according to Parity

Parity Frequency Percentage
Nullipara 1 5%
Primipara 5 25%
Multipara 14 70%

Parity, on the other hand, is also seen as an indicator in the development of SSIs

among women in the reproductive age group. As seen in Table 3, SSIs were most seen

in multiparous patients (70%), and are less frequent to the primiparous (25%) and

nulliparous (5%) patients. These results coincide with the findings of Pathak et al., (2017),

wherein six (6) percent of SSIs were patients who are multiparous (OR: 2.93, CI 0.6-14.3).

Ayala et al., (2021) on the other hand, published in their study that there is fifty (50)

percent incidence of acquiring SSI among multiparous patients, higher than those who

are nulliparous and primiparous. Given that multiparous women constitute the greatest

frequency among patients who had SSIs, the significant association of SSIs and parity is

yet to be established (Rano and Patel, 2020), although Vianti (2018) proposed that the

increasing SSIs in multiparous women could be closely associated with increasing age,

as patients who are multiparous tend to be older.

18
Table 4. Frequency and Percentage Distribution of Patients according to Educational
Attainment
Educational Attainment Frequency Percentage
Elementary 4 20%
High School 15 75%
College 1 5%

Educational attainment was also taken to account in the study. Table 4 shows the

frequency and percentage distribution of patients according to educational attainment.

The majority of the patients who had SSI are high school graduates (75%), followed by

those who have attained elementary (20%), and lastly, a patient who had attained college

(5%). While educational attainment is not a significant sociodemographic factor predictive

of SSIs, it is important to take note that patients who are illiterate are at a significant higher

risk of developing SSIs (Mamo et al., 2017).

Table 5. Frequency and Percentage Distribution of Patients according to Place of

Residence.
Place of Residence Frequency Percentage
Urban 4 20%
Rural 16 80%

The patients’ places of residence were also taken into account in the study,

wherein the locations are subdivided into rural and urban areas. In Table 5, it is shown

that 80% of the patients who acquired SSI live in rural areas, wherein majority of them

are residents of Mangaldan, Pangasinan. The study of Mamo et al., (2017) took into

account the residence of patients who had SSIs in an Ethiopian hospital. The results

showed that 56.8% of these patients were from rural areas, while the remainder of 43.2%

are residents of urban areas. The finding of the aforementioned study is consistent with

19
the results of the present study, wherein the rural residents outnumber the number of

patients who live in the urbanized areas.

Table 6. Frequency and Percentage Distribution of Patients according to Presence or

Absence of Comorbidities.
Comorbidities Frequency Percentage
Present 5 25%
Absent 15 75%

Comorbidities are a major risk factor for the development of infections following

surgery. As listed in Table 6, the majority of patients who had SSIs have no comorbidities

while the remainder suffer from an additional medical condition. Among the five (5)

patients with comorbidities, four (4) of them have hypertensive disorder, wherein the three

(3) of them are obstetric patients suffering from pre-eclampsia, while the other one (1) is

a gynecological patient suffering from a long-standing hypertension. The other patient

who had a comorbidity is a gynecological patient who is suffering from Type II Diabetes

Mellitus.

According to a study done by Gedefaw et al., (2018), pregnancy-induced

hypertension is associated with a six-fold increased risk of developing an SSI, in contrast

to those who did not have an associated hypertensive disorder. Gillispie-Bell (2020)

supported this finding and postulated that the incisional infection in hypertensive patients

is due to tissue hypoxia secondary to vasoconstriction. The resulting hypoxia will then

make the wound more susceptible to infections. Diabetic patients, on the other hand, are

at risk of acquiring SSIs at 6.9% (Mejia et al., 2019), attributed to poor peripheral oxygen

supply due to metabolic changes and altered inflammatory response after surgery

(Gedefaw et al., 2018), hence, proper glycemic control and monitoring of surgical patients

20
is highly recommended prior to surgery (Gillispie-Bell, 2020), wherein a preoperative

serum glucose of <200 mg/dL is postulated to reduce the risk of developing an SSI

(Berrios-Torres et al., 2017). Other comorbidities that are highly associated with acquiring

SSIs include obesity (Jasim et al., 2017), immune thrombocytopenia (Mejia et al., 2019),

and chorioamnionitis (Shree et al., 2016).

Table 7. Distribution of SSI Rates according to Surgical Procedures from January to May
2021.
Procedure Incidence Percentage
Episiorrhapy 6 30%
Cesarean Section 10 50%
Laparotomy 4 20%
Total 20

Surgical procedures are a risk factor that can determine the chance of an individual

to have surgical site infection. As shown in Table 7, majority of the patients who had

surgical site infection have undergone cesarean section (CS) with an incidence of 50%.

According to a study done by Alfouzan et al. (2019), CS is one of the most common

obstetrical surgical procedures. It is performed when clinically indicated to facilitate

delivery in complicated cases, hence, preventing maternal and perinatal morbidity and

mortality. Patients who have undergone CS have a 5–20 times higher risk of post-partum

infection as compared to vaginal deliveries, wherein SSIs account for 3-15% of cases

(Zejnullahu et al., 2019). Given the drastic improvements in infection control and antibiotic

prophylaxis, the incidence of SSI following CS is expected to rise, as there is a continuous

upward trend of birth via CS worldwide (Salim et al., 2012; Awad, 2012; Zuarez-Easton

et al., 2017). In addition, SSI following CS could prove troublesome and frustrating for the

21
recovering mother attending to her newborn, as it increases length of hospitalization, as

well as a significant increase in healthcare cost and other socioeconomic implications

(Salim et al., 2012; Zuarez-Easton et al., 2017).

Episiorrhapy comes in second with an incidence rate of 30%. According to

Deshpande et al., (2019), the rate of episiorrhapy following vaginal delivery is found to be

as high as 63.4%. SSIs following episiotomy and repair is owed to the contamination of

the surgical site from the normal flora of the vagina. However, the incidence rate of SSI

following episiotomy and repair is relatively low, estimated to be complicating 0.3-5% of

all cases (Bonet et al., 2017). Maternal risk factors for developing SSI in an episiotomy

wound include obesity, anemia, diabetes mellitus, and hypothyroidism. In addition, wound

dehiscence was more pronounced in labor induction and instrumental delivery

(Deshpande et al., 2019).

Furthermore, surgeries involving a pelvic laparotomy has an incidence rate of 20%.

Lachiewicz et al., (2015) published that occurrence following pelvic laparotomy was at

2.7%. Risk factors for development of SSIs following laparotomy would include

comorbidities such as obesity, diabetes mellitus, malnutrition, and anemia, (Lake et al.,

2013), as well as sociodemographic factors like increasing age, and tobacco use

(Lachiewicz et al., 2015). Nguyen (2018) cited that the single intervention of a closure

tray could decrease rates of SSI for patients undergoing exploratory laparotomy by a

Gynecologic Oncologist.

22
 CHAPTER V

CONCLUSION

This study sought to determine the sociodemographic profile of obstetric and

gynecological patients who acquired surgical site infections following surgery in terms of

age, parity, educational attainment, place of residence, and medical history, and the

incidence of surgical site infections from January to May 2021. This study found that

patients belonging to age twenty (20) to thirty-four (4) have the highest frequency of SSIs,

followed by those who are thirty-five (35) years old and above, and patients who are less

than twenty (20) years old have the least number of SSIs. Multiparous women yielded

higher SSI rates. In terms of educational attainment, there was a 75% percentage

distribution among those who finished high school. Patients from the rural areas garnered

a much higher frequency of 80% versus those living in urban areas at 20%. Furthermore,

surgical site infections are more prominent in patients with no known comorbidities.

However, the risk for acquiring SSIs in individuals with known comorbidities are at a

significant increased risk. The aforementioned sociodemographic factors could affect the

likelihood of acquiring surgical site infections.

The incidence of surgical site infection varied from 1.04% to 2.91% in the months

of January to May 2021, with February having the least incidence rate, and March having

the largest incidence rate. Overall, there were 20 patients who acquired SSIs, wherein

the cumulative incidence rate was at 2.22%. Among the various surgical procedures

performed, Cesarean Section yielded the greatest number of SSIs at 50% of the cases,

followed by Episiorrhapy at 30%, and Laparotomy at 20%.

23
 RECOMMENDATIONS

In the lieu of the findings and conclusions derived in the study, the following

recommendations are as follows:

1. To conduct more extensive researches regarding the intrinsic and extrinsic factors

that contribute to the development of various surgical site infections;

2. To determine the bacteriologic profile of organisms that cause SSIs among

obstetric and gynecological patients in Region 1 Medical Center;

3. To determine the incidence rates of SSIs in other surgical procedures in Region 1

Medical Center;

24
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29
 APPENDICES

Appendix Table 1. Surgical Site Infection Census of Department of Obstetrics and Gynecology, R1MC, from January
to May 2021.

Name/Age/ Ward Date of OPD

Address Education OR Procedure OPD Diagnosis
Sex Final Diagnosis check up
G3P3 (3003) PU term
cephalic livebirth
delivered via LTCS III
with BTL under SAB
for scarred uterus a
BINMALEY, G3P3 (3003) S/P LTCS
27/M HS grad LTCS III with BTL baby boy BW 2970g 16/01/2021
PANGASINAN BL 52cm AS 8,9 BS WITH BTL DAY 38 SSI
39 weeks AGA, Prev
LTCS 2x (2008,
Casilagan, 2015,
R1MC), FPA (BTL)
G2P2 PU, term, G2P2 (2002) S/P LTCS
BUGALLON, cephalic, delivered via
29/F HS grad LTCS II with IUD LTCS II under SAB,
13/01/2021 POST OP DAY 16, WOUND
PANGASINAN
FPA IUD DEHISCENCE, JOCKS ITCH

G2P1 (1011)
Pregnancy uterine
term cephalic
delivered via LTCS I
under SAB for
NRFS (persistent
fetal tachycardia) a
MANGALDAN, G2P1 (1011) S/P LTCS DAY
17/S Senior High LTCS I live baby girl BW 27/01/2021
PANGASINAN 17 SSI
2760 g BL 49 cm
AS 8, 9 BS 39
weeks, AGA;
premature rupture
of membrane x 4
hours, meconium
stained amniotic

30
 fluid, teenage
pregnancy

G2P2 (2002)
Pregnancy Uterine
term cephalic
livebirth delivered
via Low Transverse
Cesarean Section II
under SAB for
arrest in cervical
dilatation secondary
BINMALEY, to pelvic inlet G2P2 (2002) S/P LTCS DAY
29/S 2nd year JS LTCS II with IUD 03/02/2021
PANGASINAN contraction a Baby 16, SSI
boy BW 3300
grams BL 51 cm AS
8/9 BS 40 weeks
AGA; Previous
LTCS 1x (2015,
R1MC for NRFS);
Family Planning
Acceptor (IUD)

G1P1 (1001) PU,

term cephalic
G1P1 (1001) S/P NSD LAST
MANGALDAN, NSD with RMLE livebirth, delivered
36/M HS grad 04/02/2021 JAN. 26, 2021 (DAY 10)
PANGASINAN Repair vaginally a baby
WOUND DECHSCENCE
girl, NSD with
RMLE and repair

G1P1 (1001) PU,

term cephalic G1P1 (1001) S/P NSD
MANGALDAN, NSD with RMLE livebirth, delivered DAY 9, SUPERFICIAL
21/M PANGASINAN
HS grad
Repair
01/03/2021
vaginally a baby WOUND DEHISCENCE
girl, NSD with (RMLE)
RMLE and repair

31
 G0 Ovarian new
growth left
probably
mucinous pleural
effusion T/C
G0 ONG, LEFT,
Pulmonary
MUCINOUS CYST
metastasis, S/P
BANI, ADENOCARCINOMA S/P
28/S HS grad TAHBSO CTT insertion, 01/03/2021
PANGASINAN PELVIC SO LEFT,
anemia; Pelvic
1/19/2021 R1MC, wound
Lap, salpingo-
dehiscence
Oophorectomy,
left omental
biopsy,
appendectomy
blood transfusion
G4P4 (4004)
Abnormal Uterine
Bleeding-L (SM);
Prolapsed
submucous
MANGALDAN, ELEM myoma; DM type G3P3 (3003) S/P THBSO
48/M PANGASINAN
TAHBSO 02/03/2021
grad II anemia Day 14; SSI; DM type II
corrected Pelvic
Lap TAHBSO with
assisted
myomectomy
blood transfusion
G1P1 (1001) PU,
term cephalic
G1P1 (1001) DAY 10 S/P
NSD with livebirth, delivered
BINMALEY, NSD LAST MARCH 1,
31/S HS grad RMLE and vaginally alive 10/03/2021
PANGASINAN 2021; SSI, min wound
repair baby girl, NSD
rmle DEHISCENCE
with RMLE and
repair

32
 G2P2 (2002) PU,
cephalic term G2P2 (2002) S/P LTCS
SAN JACINTO,
25/M HS grad LTCS II livebirth delivered 16/03/2021 LAST MARCH 3, 2021;
PANGASINAN
via LTCS II under SSI
SAB
G4P4 (4004) PU,
term cephalic
G4P3 (3013) S/P NSD
DAGUPAN CITY, ELEM delivered
35/S NSD w/ BTL 26/03/2021 WITH BTL LAST MARCH
PANGASINAN grad vaginally alive
11, 2021, SSI
baby girl; NSD w/
BTL
G2P2 (1102) PU
Preterm Cephalic
Livebirth delivered
via LTCS I under
SAB for NRFS
(Persistent Fetal
Tachycardia) a
LINGAYEN, ELEM baby girl BW 1650 G2P2 (2002) S/P LTCS
32/S LTCS I 4/21/2021
PANGASINAN grad grams BL 46 cm DAY 35; SSI
AS 5/8 BS 33
weeks AGA,
Preeclampsia with
severe features,
HELLP
Syndrome: LTCS
I

33
 G2P2 (2001) PU,
term, cephalic,
delivered via
LTCS II w/ IUD
under SAB for
scarred uterus
alive baby boy
BW-2740 grams,
BL 50cm, AS 8/9, G2P1 (2001) S/P LTCS
MANGALDAN, LTCS II with
38/M HS grad BS 39 weeks. 4/23/2022 WITH IUD LAST MARCH
PANGASINAN IUD
AGA, prev. LTCS 20,2021; SSI
1x (2013 Cuison
Hospital), Pre
eclampsia with
severe features,
FPA (IUD),
Hepatitis B
reactive: LTCS II
w/ IUD
G2P2 (2001)
ONG, bilateral,
endometrioma,
massive adhesion
serosl tear injury,
distal 3rd,
SISON, sigmoid, S/P PELVIC LAP LAST
43/M HS grad TAHBSO 4/6/2021
PANGASINAN hypokalemia mild, FEB 13, 2021, SSI
anemia,: Explor
lap. TAHBSO,
adhesiolysis
primary repair of
serosal tear blood
transfusion

34
 G2P1 (1001) PU
term, Cephalic,
livebirth, delivered
via LTCS I under
SAB for CPD
scarred uterus a
G2P2 (2002) S/P LTCS
DAGUPAN CITY, LTCS II with baby girl BW 2910
26/S HS grad 4/24/2021 LAST MARCH 12, 2021;
PANGASINAN IUD grams, BL-52 cm,
SSI
AS 8/9 BS 40
weeks. AGA
previous LTCS 1x
(2017-R1MC for
CPD), FPA (IUD):
LTCS II w/ IUD
G3P3 (3003) PU
term, cephalic
livebirth delivered
via LTCS III under
SAB for scarred
uterus a baby boy
BW3325g BL G3P3 (3003) S/P LTCS
DAGUPAN CITY, LTCS III with
26/M HS grad 53cm AS 8/9 BS 4/16/2021 W/ BTL LAST APRIL 1,
PANGASINAN BTL
39 weeks AGA, 2021
Prev LTCS 2x
(2010, 2016,
R1MC), FPA
(BTL), PROM,
UTI: LTCS III w/
BTL:SI

35
 G1P1 (1001) PU
term, cephalic,
livebirth, delivered
G1P1 1001 S/P NSD
NSD WITH vaginally a baby
WITH REPAIR OF 2ND
HS REPAIR OF girl, teenage
DAGUPAN CITY, DEGREE PERINEAL
17/S UNDERG 2ND DEGREE pregnancy, 2nd 25/05/2021
PANGASINAN LACERATION LAST MAY
RAD PERINEAL degree perineal
16 2021; WOUND
LACERATION laceration, NSD
DEHISCENCE
w/ repair of 2nd
degree perineal
laceration

G5P5 (5005) PU
term, cephalic,
stillbirth delivered
G5P5 (5005) S/P NSD
vaginally baby
DAY 10 OVERT DM
ELEM boy, CHVD, w/
ROSALES, NSD with repair HYPERTRIGLYCERIDEM
31/M UNDERG superimposed 25/05/2021
PANGASINAN of RMLE IA , WOUND
RAD pre-eclampsia,
DEHISCENCE
fetal macrosomia,
(EPISIORRHAPY SITE)
triglyceridemia,
overt DM, NSD w/
repair of RMLE

G4P3 (3013)
AUB-A,
Hypertension; G4P3 (3013) AUB-A,
Type II DM, S/P Hypertension; Type II DM,
PELVIC LAP,
MANGALDAN, DMPA treatment S/P DMPA treatment x7
56/M HS GRAD TAHBSO, 14/05/2021
PANGASINAN x7 prev. CS 1x prev. CS 1x (1986-R1MC)
ENTEROLYSIS
(1986-R1MC) Pelvic Lap. TAHBSO
Pelvic Lap. (APRIL 13), SSI
TAHBSO,
enterolysis

36
 G1P1 (1001) PU,
term cephalic
delivered via
CALACSA LTCS I under
N, SAB for NRFS
MANGALDAN, G1P1 (1001) S/P LTCS I
MARIEL COLLEGE LTCS I (Fetal 12/05/2021
PANGASINAN DAY 7; SSI SUPERFICIAL
BARROZ Tachycardia +
O 23/M meconium stained
amniotic fluid) to a
live baby boy, UTI
LTCS I

37