Construction and Validation of the Nomogram Prediction Model for Postoperative Infection after Cesarean Section

doi:10.12280/gjfckx.20220806

Abstract

Abstract:

Objective: To investigate the influencing factors of postoperative infection in cesarean section patients and construct a nomogram prediction model. Methods: The clinical data of patients undergoing cesarean section in Shanxi Bethune Hospital from January 2021 to December 2021 were retroanalyzed and devided into infection group (n=60) and no infection group (n=1 086). The influencing factors of postoperative infection in cesarean section patients were selected into the nomogram risk prediction model. The discrimination, calibration, and prediction efficacy of the nomograms prediction model were evaluated. Results: The results of the multivariate Logistic regression analysis showed that having stable work was a protective factor for postoperative infection in cesarean section patients (OR=0.570, 95%CI: 0.331-0.983, P=0.043). Hypertensive disorders in pregnancy (OR=2.356, 95%CI: 1.324-4.192, P=0.004), GBS colonization (OR=3.154, 95%CI: 1.118-8.897, P=0.030), times of vaginal examinations >5 (OR=2.470, 95%CI: 1.146-5.324, P=0.021) and oxytocin induction (OR=2.457, 95%CI: 1.230-4.907, P=0.011) were independent risk factors of postoperative infection in cesarean section patients. The nomogram prediction model was established based on the above factors, whose consistency index (C-index) was 0.721 (95%CI: 0.651-0.791), and 0.051 was selected as the cut-off value, with a sensitivity of 66.7% and a specificity of 72.5%. The Homer-Lemeshow goodness-of-fit test suggested that the prediction model had a better calibration ability ( χ²=2.169, P=0.825). Conclusions: The nomogram prediction model constructed based on work, gestational hypertensive diseases, GBS colonization, times of vaginal examinations, and oxytocin labor induction has good accuracy and differentiation. It can identify the high-risk group after cesarean section to be infected in the early stage according to the predicted risk value, and corresponding preventive measures should be taken to reduce the occurrence of infection. However, further external verification and prospective comparative trials are needed to confirm the reliability of the predictive ability of the model.

Key words: Cesarean section, Postoperative complications, Infections, Root cause analysis, Nomograms, Forecasting

ZHANG Yan-fei, WANG Yi-xuan, ZHANG Shao-hua, CHU Ying, WANG Zan-hong. Construction and Validation of the Nomogram Prediction Model for Postoperative Infection after Cesarean Section[J]. Journal of International Obstetrics and Gynecology, 2023, 50(4): 421-427.

Figures/Tables 8

References 28

[1]	Hirshberg A, Srinivas SK. Epidemiology of maternal morbidity and mortality[J]. Semin Perinatol, 2017, 41(6):332-337. doi: 10.1053/j.semperi.2017.07.007. doi: S0146-0005(17)30079-4 pmid: 28823579
[2]	Jawad MJ, Hassan SM, Obaid AK, et al. Role of pre-cesarean section cefotaxime in ameliorated post-cesarean complication[J]. Wiad Lek, 2022, 75(4 pt 1):818-823. doi: 10.36740/WLek202204113. doi: 10.36740/WLek202204113 pmid: 35633354
[3]	谢幸, 孔北华, 段涛. 妇产科学[M]. 9版. 北京: 人民卫生出版社, 2018:219.
[4]	Li HT, Hellerstein S, Zhou YB, et al. Trends in Cesarean Delivery Rates in China, 2008-2018[J]. JAMA, 2020, 323(1):89-91. doi: 10.1001/jama.2019.17595. doi: 10.1001/jama.2019.17595
[5]	Regmi A, Ojha N, Singh M, et al. Risk Factors Associated with Surgical Site Infection following Cesarean Section in Tertiary Care Hospital, Nepal[J]. Int J Reprod Med, 2022, 2022:4442453. doi: 10.1155/2022/4442453. doi: 10.1155/2022/4442453
[6]	Kvalvik SA, Rasmussen S, Thornhill HF, et al. Risk factors for surgical site infection following cesarean delivery: A hospital-based case-control study[J]. Acta Obstet Gynecol Scand, 2021, 100(12):2167-2175. doi: 10.1111/aogs.14235. doi: 10.1111/aogs.14235
[7]	Li L, Cui H. The risk factors and care measures of surgical site infection after cesarean section in China: a retrospective analysis[J]. BMC Surg, 2021, 21(1):248. doi: 10.1186/s12893-021-01154-x. doi: 10.1186/s12893-021-01154-x pmid: 34011324
[8]	Erritty M, Hale J, Thomas J, et al. Evaluation of independent risk factors associated with surgical site infections from caesarean section[J]. Arch Gynecol Obstet, 2022 Dec 26. doi: 10.1007/s00404-022-06885-7. doi: 10.1007/s00404-022-06885-7
[9]	Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section[J]. Cochrane Database Syst Rev, 2014, 2014(10): CD007482. doi: 10.1002/14651858.CD007482.pub3. doi: 10.1002/14651858.CD007482.pub3
[10]	Sgayer I, Gur T, Glikman D, et al. Routine uterine culture swab during cesarean section and its clinical correlations: A retrospective comparative study[J]. Eur J Obstet Gynecol Reprod Biol, 2020, 249:42-46. doi: 10.1016/j.ejogrb.2020.04.011. doi: S0301-2115(20)30179-2 pmid: 32348949
[11]	Duffy CR, Oberhardt M, Ross N, et al. Perioperative Antibiotics and Other Factors Associated with Postcesarean Infections: A Case-Control Study[J]. Am J Perinatol, 2022 Dec 5. doi: 10.1055/a-1904-9583. doi: 10.1055/a-1904-9583
[12]	Deer E, Herrock O, Campbell N, et al. The role of immune cells and mediators in preeclampsia[J]. Nat Rev Nephrol, 2023, 19(4):257-270. doi: 10.1038/s41581-022-00670-0. doi: 10.1038/s41581-022-00670-0 pmid: 36635411
[13]	He Z, Zhou K, Tang K, et al. Perioperative hypoalbuminemia is a risk factor for wound complications following posterior lumbar interbody fusion[J]. J Orthop Surg Res, 2020, 15(1):538. doi: 10.1186/s13018-020-02051-4. doi: 10.1186/s13018-020-02051-4 pmid: 33203417
[14]	Yuan XY, Liu HZ, Liu JF, et al. Pathogenic mechanism, detection methods and clinical significance of group B Streptococcus[J]. Future Microbiol, 2021, 16:671-685. doi: 10.2217/fmb-2020-0189. doi: 10.2217/fmb-2020-0189
[15]	Liu P, Feng Q, Liang Y, et al. Maternal Group B Streptococcal Rectovaginal Colonization after Intrapartum Antibiotic Prophylaxis[J]. Children (Basel), 2022, 9(12):1848. doi: 10.3390/children9121848. doi: 10.3390/children9121848
[16]	中华医学会围产医学分会, 中华医学会妇产科学分会产科学组. 预防围产期B族链球菌病(中国)专家共识[J]. 中华围产医学杂志, 2021, 24(8):561-566. doi: 10.3760/cma.j.cn113903-20210716-00638. doi: 10.3760/cma.j.cn113903-20210716-00638
[17]	WHO recommendations: Intrapartum care for a positive childbirth experience[M]. Geneva: World Health Organization, 2018.
[18]	Gluck O, Mizrachi Y, Ganer Herman H, et al. The correlation between the number of vaginal examinations during active labor and febrile morbidity, a retrospective cohort study[J]. BMC Pregnancy Childbirth, 2020, 20(1):246. doi: 10.1186/s12884-020-02925-9. doi: 10.1186/s12884-020-02925-9
[19]	Hudson L, Isenberg E. Relationship between educational attainment and labor underutilization[EB/OL]. [2023-07-01]. http://hdl.voced.edu.au/10707/522773.
[20]	Edwards NM, Varnum C, Nelissen R, et al. The association between socioeconomic status and the 30- and 90-day risk of infection after total hip arthroplasty : a registry-based cohort study of 103,901 patients with osteoarthritis[J]. Bone Joint J, 2022, 104-B(2):221-226. doi: 10.1302/0301-620X.104B2.BJJ-2021-1030.R1. doi: 10.1302/0301-620X.104B2.BJJ-2021-1030.R1 pmid: 35094583
[21]	Bakshi SC, Fobare A, Benarroch-Gampel J, et al. Lower Socioeconomic Status Is Associated with Groin Wound Complications after Revascularization for Peripheral Artery Disease[J]. Ann Vasc Surg, 2020, 62:76-82. doi: 10.1016/j.avsg.2019.05.010. doi: S0890-5096(19)30412-1 pmid: 31201969
[22]	Kern-Goldberger AR, Madden N, Baptiste CD, et al. Disparities in obstetric morbidity by maternal level of education[J]. J Matern Fetal Neonatal Med, 2022, 35(24):4682-4686. doi: 10.1080/14767058.2020.1860935. doi: 10.1080/14767058.2020.1860935
[23]	Ngonzi J, Bebell LM, Fajardo Y, et al. Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda[J]. BMC Pregnancy Childbirth, 2018, 18(1):270. doi: 10.1186/s12884-018-1891-1. doi: 10.1186/s12884-018-1891-1
[24]	Moulton LJ, Eric Jelovsek J, Lachiewicz M, et al. A model to predict risk of postpartum infection after Caesarean delivery[J]. J Matern Fetal Neonatal Med, 2018, 31(18):2409-2417. doi: 10.1080/14767058.2017.1344632. doi: 10.1080/14767058.2017.1344632 pmid: 28629241
[25]	樊友莉, 胡苑, 余芳, 等. 剖宫产产妇产褥期感染预测模型建立及验证[J]. 中华医院感染学杂志, 2021, 31(23):3642-3646. doi: 10.11816/cn.ni.2021-210236. doi: 10.11816/cn.ni.2021-210236
[26]	Duffy CR, Garcia-So J, Ajemian B, et al. A randomized trial of the bactericidal effects of chlorhexidine vs povidone-iodine vaginal preparation[J]. Am J Obstet Gynecol MFM, 2020, 2(3):100114. doi: 10.1016/j.ajogmf.2020.100114. doi: 10.1016/j.ajogmf.2020.100114
[27]	Ruzic MF, Blanchard CT, Cozzi GD, et al. Adjunctive Azithromycin Prophylaxis for Prelabor Cesarean Birth[J]. Obstet Gynecol, 2023, 141(2):403-413. doi: 10.1097/AOG.0000000000005037. doi: 10.1097/AOG.0000000000005037 pmid: 36649335
[28]	Gillespie BM, Webster J, Ellwood D, et al. Closed incision negative pressure wound therapy versus standard dressings in obese women undergoing caesarean section: multicentre parallel group randomised controlled trial[J]. BMJ, 2021, 373:n893. doi: 10.1136/bmj.n893. doi: 10.1136/bmj.n893

组别	n	年龄（岁）	BMI （kg/m²）	婚姻状况		工作		居住地		既往剖宫产次数（次）
组别	n	年龄（岁）	BMI （kg/m²）	未婚	已婚	无	有	本地	外地	0	≥1
感染组	60	30.28±4.72	29.43±3.85	0（0.0）	60（100.0）	34（56.7）	26（43.3）	31（51.7）	29（48.3）	47（78.3）	13（21.7）
未感染组	1 086	30.88±4.37	28.77±3.94	10（0.9）	1 076（99.1）	459（42.3）	627（57.7）	677（62.3）	409（37.7）	666（61.3）	420（38.7）
t或χ²		1.481	-1.255	-		4.811		2.743		6.996
P		0.476	0.101	0.583^a		0.028		0.098		0.008

组别	n	年龄（岁）	BMI （kg/m²）	婚姻状况		工作		居住地		既往剖宫产次数（次）
组别	n	年龄（岁）	BMI （kg/m²）	未婚	已婚	无	有	本地	外地	0	≥1
感染组	60	30.28±4.72	29.43±3.85	0（0.0）	60（100.0）	34（56.7）	26（43.3）	31（51.7）	29（48.3）	47（78.3）	13（21.7）
未感染组	1 086	30.88±4.37	28.77±3.94	10（0.9）	1 076（99.1）	459（42.3）	627（57.7）	677（62.3）	409（37.7）	666（61.3）	420（38.7）
t或χ²		1.481	-1.255	-		4.811		2.743		6.996
P		0.476	0.101	0.583^a		0.028		0.098		0.008

组别	n	术前阴道炎		糖尿病		妊娠期高血压疾病		GBS定植
组别	n	无	有	无	有	无	有	无	有
感染组	60	58（96.7）	2（3.3）	50（83.3）	10（16.7）	37（61.7）	23（38.3）	55（91.7）	5（8.3）
未感染组	1 086	1 064（98.0）	22（2.0）	865（79.7）	221（20.3）	821（75.6）	265（24.4）	1 060（97.6）	26（2.4）
χ²		0.051		0.479		5.865		5.531
P		0.822^b		0.489		0.015		0.019^b

组别	n	术前阴道炎		糖尿病		妊娠期高血压疾病		GBS定植
组别	n	无	有	无	有	无	有	无	有
感染组	60	58（96.7）	2（3.3）	50（83.3）	10（16.7）	37（61.7）	23（38.3）	55（91.7）	5（8.3）
未感染组	1 086	1 064（98.0）	22（2.0）	865（79.7）	221（20.3）	821（75.6）	265（24.4）	1 060（97.6）	26（2.4）
χ²		0.051		0.479		5.865		5.531
P		0.822^b		0.489		0.015		0.019^b

组别		n		缩宫素引产				胎膜破裂				宫口开全				放置宫颈球囊
组别		n		无		有		否		是		否		是		否		是
感染组		60		32（53.3）		28（46.7）		33（55.0）		27（45.0）		56（93.3）		4（6.7）		58（96.7）		2（3.3）
未感染组		1 086		859（79.1）		227（20.9）		828（76.2）		258（23.8）		1 076（99.1）		10（0.9）		1 050（96.7）		36（3.3）
χ²				21.816				13.733				-				0.000
P				<0.001				<0.001				0.005^a				1.000^b
组别	n		阴道检查次数（次）				手术时间（min）				术中出血量（mL）				围手术期输血
组别	n		≤5		>5		<60		≥60		<300		≥300		否		是
感染组	60		42（70.0）		18（30.0）		32（53.3）		28（46.7）		38（63.3）		22（36.7）		52（86.7）		8（13.3）
未感染组	1 086		978（90.1）		108（9.9）		499（45.9）		587（54.1）		555（51.1）		531（48.9）		1 014（93.4）		72（6.6）
χ²			23.370				1.247				3.405				2.970
P			<0.001				0.264				0.065				0.085^b