European Journal of Cardiovascular Medicine

Surgical site infections (SSIs) represent the most common postoperative complication following cesarean sections (C/S), contributing significantly to increased maternal morbidity, prolonged hospital stays, and elevated healthcare costs worldwide. The global burden of SSIs after C/S is substantial, with a recent systematic review and meta-analysis estimating an overall incidence of 7.0% (95% CI: 6.0%–8.0%). This burden, however, is not evenly distributed. The incidence in Low- and Middle-Income Countries (LMICs) is considerably higher at 8.0% (95% CI: 6.0%–10.0%) compared to 5.0% (95% CI: 4.0%–7.0%) in High-Income Countries. In Pakistan, SSIs remain a concerning issue, with rates in LMICs like Pakistan ranging from 8-30%. A study conducted at a major teaching hospital in the Khyber Pakhtunkhwa province, which borders the current study region, reported an SSI incidence of 12.6% following cesarean sections. The microbiological profile of these infections is critical for guiding effective empirical antibiotic therapy. Staphylococcus aureus is consistently identified as one of the predominant pathogens. Globally, the incidence of postoperative S. aureus infections varies by procedure, but it remains a leading cause of SSIs . In the context of cesarean sections, a large retrospective study in Australia found that methicillin-susceptible Staphylococcus aureus (MSSA) accounted for 30.4% of isolates, and methicillin-resistant Staphylococcus aureus (MRSA) for a further 14.7%. Similarly, a study from Peshawar, Pakistan, reported S. aureus as the most common pathogen, found in 39.1% of post-cesarean SSI cases. Given the high SSI rates in LMICs and the prominent role of S. aureus, understanding local pathogen profiles and their antibiotic sensitivity patterns is essential for optimizing patient care and infection control strategies. Therefore, this study was conducted to determine the wound infection rates and antibiotic sensitivity of pathogens in patients undergoing emergency cesarean sections at our institution.

The study was a descriptive cross-sectional study that was carried out at the Department of Obstetrics and Gynecology, Khalifa Gulnawaz Teaching Hospital (MTI Bannu), Pakistan, between May 2025 and November 2025, to determine the wound infection rates and antibiotic sensitivity of patients undergoing emergency cesarean sections (C/S). The sample size of 120 subjects was estimated through the use of the WHO sample size calculator, according to the anticipated wound infection rate of 8.5, a 95% interval, and a 5 percent margin of error and participants were chosen by means of consecutive non-probability sampling. Women aged 15-45 years undergoing emergency C/S were included. Exclusion criteria included diabetes, malignancies, BMI >29 kg/m², immunocompromised status, patients on prolonged use of steroids, patients on steroids or antibiotics in the last week and elective C/S cases were used as inclusion and exclusion criteria.The Ethical and Research Committee at MTI Bannu approved the Ethics and had the reference number No. 21 /DiR&MJ/BMC/2025, dated 28/02/2025. All the participants gave informed consent and a comprehensive clinical history and physical examination were performed. This was done by qualified consultant gynaecologists applying aseptic procedures of emergency C/S. Follow up of post operation up to 7 days was done and samples of infected wounds were sent to be cultured. The pathogens which were identified were Staphylococcus aureus, Coagulase Negative Staphylococci, Group B Streptococci, Enterobacter, Enterococcus, Pseudomonas, and E. coli and the antibiotic sensitivity testing was done using Cephradine, Ceftriaxone, Cefixime, Amoxicillin, Gentamicin, Metronidazole, Levofloxacin and Tazobactam. Data were analysed by use of the SPSS version 10.0 where descriptive statistics were used to analyse continuous variables and Chi-square test was used to analyse categorical data .

The research involved 80 participants, 25 percent wound infection as was witnessed among 20 out of 80 patients. The bacteria infection was high, Staphylococcus aureus was present in 6 patients (30%), Coagulase Negative Staphylococci in 4 patients (25%). Other bacterial infections were Group B Streptococci, Enterobacter and Enterococcus and had a prevalence in each case of 12.5(2/16). The most common organisms were Pseudomonas and E. coli (12.5% (2 out of 16) each), and Enterococcus (4 patients (25%)). Staphylococcus aureus had 50% sensitivity to Cephradine and Amoxicillin (p = 0.046), 75% sensitivity to Ceftriaxone and Cefixime (p = 0.248). The sensitivity of gentamycin and Levofloxacin was low 25. The data were stratified by age which showed that wound infection was much higher in 31-45 years age group (26.7%) than in age group of 15-30 years (4.4%) (p = 0.000). The same tendency is noticed in parity and gravida where the individuals with more than 2 children and those with a gravida of greater than 3 reported a significantly higher infection rate (26.5% vs. 3.5%). In the analysis of the prevalence of Staphylococcus aureus among the ages, they found the infection rate is 50 percent among the 15-30 years group and 25 percent among the 31-45 years group, but the p-value of 0.386 showed that there is no statistically significant difference between the two groups. Other bacteria like Coagulase Negative Staphylococci, Group B Streptococci and Enterococcus are not significantly different between the age groups and did not have any statistically significant association (p > 0.05). Enterococcus infections were higher in the 31-45 years group (25%) than in the younger ageing group (0%), however, the difference was not found to be statistically significant (p = 0.273). To conclude, the age, parity, and gravida played an important role in wound infections as older patients and those with high parity or gravida were more likely to be infected. But certain bacterial infections like those caused by Staphylococcus aureus, did not show any distinct age correlation though there was a variation in the rate of infection among the various age groups. The susceptibility to the antibiotics was also different as Cephradine, Ceftriaxone and Cefixime had greater sensitivity with respect to the rest of the antibiotics such as the Gentamycin and Levofloxacin.

Table: Stratification Data (Wound Infection, Bacteria, and Sensitivity) for 80 Patients

The results of this research provide valuable insights into the correlation between age, parity, gravida, and postpartum wound infection rates following emergency cesarean sections. The study demonstrated a significantly higher wound infection rate in the 31-45 years age bracket (26.7%) compared to the 15-30 years age bracket (4.4%), with a highly significant p-value (0.000). This observation aligns with multiple studies that have identified advanced maternal age as an independent risk factor for postoperative infections, likely attributable to age-related physiological changes in immune function and tissue repair mechanisms [.9]. Specifically, immunosenescence, coupled with the higher prevalence of comorbid conditions in older women, may impair wound healing and increase susceptibility to surgical site infections during the postoperative period [.10]. Furthermore, the research found that increased parity and gravidity were associated with elevated wound infection rates, wherein 26.5% of women with parity greater than 2 and gravidity greater than 3 developed wound infections compared to only 3.5% of women with lower parity and gravidity. This finding corroborates earlier studies that have identified multiple pregnancies as a potential risk factor for cesarean section complications and wound infections, possibly due to factors such as uterine scarring, prolonged labor duration, and cumulative immunological alterations associated with repeated pregnancies [.11]. The significantly higher infection rates observed in women with multiple pregnancies underscore the importance of enhanced perioperative vigilance in this demographic, as they may demonstrate increased susceptibility to infectious complications following cesarean delivery [.12]. The predominance of Staphylococcus aureus, identified in 30 cases of wound infections, represents the strongest corroboration of existing literature that establishes S. aureus as the most prevalent pathogen in post-cesarean surgical site infections [.13]. This finding is consistent with global epidemiological data reporting S. aureus as the leading causative organism in obstetric postoperative infections, with studies from Oman reporting S. aureus in 31.27% of cases and Ethiopian studies reporting 21.2% [.14]. In the present study, Staphylococcus aureus demonstrated 50% sensitivity to Cephradine and Amoxicillin, suggesting that these antibiotics retain utility in treating infections caused by this pathogen. However, the superior efficacy of Ceftriaxone and Cefixime (both exhibiting 75% sensitivity) indicates that third-generation cephalosporins may represent more effective therapeutic options [.15]. Conversely, Gentamicin and Levofloxacin demonstrated markedly low sensitivity (25%), raising concerns regarding their empirical use in hospital-acquired infections and highlighting the growing challenge of antimicrobial resistance [.16]. An interesting observation emerged from the age-stratified analysis of pathogen distribution. The 15-30 years age group recorded 50% of Staphylococcus aureus infections compared to 25% in the 31-45 years group. However, the p-value of 0.386 was not statistically significant, indicating no significant association between age and the occurrence of this specific pathogen. These findings suggest that age alone may not be the primary determinant of Staphylococcus aureus wound infections, and other factors—including personal hygiene practices, pre-existing medical conditions, and the nature of surgical intervention—may contribute more substantially to infection rates [.17]. Similarly, Coagulase Negative Staphylococci, Enterococcus, and Pseudomonas were less prevalent across both age groups, with no significant differences in prevalence (p > 0.05). This observation aligns with previous research indicating that Enterococcus infections are typically associated with vaginal colonization, particularly in women with higher parity or gravidity, although the present study did not demonstrate a statistically significant association [.18]. Pseudomonas presence was detected in only 12.5% of cases and showed no significant relationship with age [.19]. The antibiotic sensitivity testing results underscore the critical importance of antimicrobial stewardship in obstetric care. The observed sensitivity patterns—50% for Cephradine, Amoxicillin, and Tazobactam against Staphylococcus aureus, compared to 75% sensitivity for Ceftriaxone and Cefixime—suggest that third-generation cephalosporins may serve more effectively as first-line therapy for S. aureus infections [.20]. The reduced susceptibility to Gentamicin and Levofloxacin (25%) represents a concerning trend that reflects the broader global challenge of antimicrobial resistance in healthcare settings [.21]. These findings emphasize the urgent need for updated treatment guidelines incorporating local antibiotic sensitivity data to optimize patient outcomes and preserve antimicrobial efficacy [.22]. When examining the prevalence of other bacterial species, the study did not identify significant differences in the distribution of Group B Streptococci, Enterobacter, or E. coli between the 15-30 years and 31-45 years age groups. This observation is consistent with previous research indicating that Group B Streptococci and Enterobacter are fewer common precipitators of wound infections compared to Staphylococcus aureus, although they may contribute to infectious morbidity in high-risk patient populations [.23]. The presence of E. coli as a causative pathogen in a subset of cases aligns with findings from other studies in similar settings, where Gram-negative organisms have been increasingly implicated in post-cesarean infections [.24].

This study establishes that age, parity, and gravidity represent significant determinants of wound infections following emergency cesarean sections. The elevated infection rates observed among older women and those with increased parity or gravidity are consistent with existing literature and highlight the need for targeted perioperative care in these populations [.9]. Furthermore, the results identify Staphylococcus aureus as the predominant pathogen in post-cesarean wound infections, with Ceftriaxone and Cefixime demonstrating the most favourable sensitivity profiles against this organism the concerning levels of antibiotic resistance observed, particularly to Gentamicin and Levofloxacin, underscore the critical importance of antimicrobial stewardship and regular surveillance of local sensitivity patterns. Future research should prioritize multicentre trials, long-term follow-up studies to assess neonatal outcomes, and more comprehensive investigations of antibiotic resistance mechanisms to optimize infection prevention and management protocols in obstetric departments

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