{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T12:52:24Z","timestamp":1770814344070,"version":"3.50.1"},"reference-count":37,"publisher":"Georg Thieme Verlag KG","issue":"03","funder":[{"DOI":"10.13039\/100013965","name":"Eastern Virginia Medical School","doi-asserted-by":"crossref","award":["VHS 241231"],"award-info":[{"award-number":["VHS 241231"]}],"id":[{"id":"10.13039\/100013965","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Am J Perinatol"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>This study aimed to evaluate whether the implementation of a surgical bundle reduces surgical site infections (SSI), hospital readmission rates, and emergency department (ED) visits within 6 weeks in individuals with a body mass index (BMI) of 40\u2009kg\/m2 or greater after cesarean delivery.<\/jats:p>\n                  <jats:p>This was a retrospective study including individuals with morbid obesity undergoing cesarean delivery at 23 weeks of gestation or greater. The preintervention period spanned from January 2017 to December 2020. The postintervention period extended from January 2021 to April 2023. The surgical bundle included standard preprocedure prophylactic antibiotics and a 48-hour course of oral cephalexin and metronidazole. The primary outcome was SSIs while secondary outcomes included hospital readmission or ED visits within 6 weeks postpartum or wound complications (dehiscence, seroma, or hematoma). Adjusted relative risks (aRR) with 95% confidence intervals (95% CI) were calculated using modified Poisson regression, adjusting for potential confounders.<\/jats:p>\n                  <jats:p>Of 2,105 pregnancies, 1,308 (62.1%) underwent cesarean in the preintervention period and 797 (37.9%) in the postintervention period. Compared to the preintervention period, the postintervention period had increased use of azithromycin (30.6 vs. 35.9%; p\u2009=\u20090.012), cephalexin (1.8 vs. 52.8%; p\u2009&lt;\u20090.001), and metronidazole (3.1 vs. 60.4%; p\u2009&lt;\u20090.001). However, compared to the preintervention period, the postintervention period had a similar risk of SSIs (6.6 vs. 5.9%; aRR: 0.92; 95% CI: 0.66\u20131.28), readmission or ED visits (19.8 vs. 19.8%; aRR: 0.94; 95% CI: 0.80\u20131.11), and wound complications (4.7 vs. 6.4%; aRR: 1.37; 95% CI: 0.96\u20131.96). In individuals with labor or ruptured membranes, the postintervention period had increased use of azithromycin (74.9 vs. 82.3%; p\u2009=\u20090.022), cephalexin (2.5 vs. 56.1%; p\u2009&lt;\u20090.001), and metronidazole (4.3 vs. 63.8%; p\u2009&lt;\u20090.001). In this subgroup, outcomes remained insignificant.<\/jats:p>\n                  <jats:p>A morbid obesity surgical bundle increased antibiotic use but did not reduce SSIs, hospital readmission, ED department visits, and wound complications.<\/jats:p>","DOI":"10.1055\/a-2620-7831","type":"journal-article","created":{"date-parts":[[2025,5,26]],"date-time":"2025-05-26T19:37:57Z","timestamp":1748288277000},"page":"366-373","source":"Crossref","is-referenced-by-count":0,"title":["Surgical Bundle to Reduce Infectious Morbidity after Cesarean Delivery in Individuals with Morbid Obesity"],"prefix":"10.1055","volume":"43","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-0568-9892","authenticated-orcid":false,"given":"Martina","family":"Benuzzi","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia"},{"name":"Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Misa","family":"Hayasaka","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1800-9893","authenticated-orcid":false,"given":"Alyssa","family":"Savelli","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"George","family":"Saade","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily","family":"Peters","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2438-1699","authenticated-orcid":false,"given":"Tetsuya","family":"Kawakita","sequence":"additional","affiliation":[{"name":"EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"194","published-online":{"date-parts":[[2025,6,10]]},"reference":[{"issue":"08","key":"ref1","first-page":"1","article-title":"Births: final data for 2017","volume":"67","author":"J A Martin","year":"2018","journal-title":"Natl Vital Stat Rep"},{"key":"ref2","doi-asserted-by":"crossref","first-page":"907","DOI":"10.1097\/01.AOG.0000124568.71597.ce","article-title":"Maternal morbidity associated with vaginal versus cesarean delivery","volume":"103","author":"L J Burrows","year":"2004","journal-title":"Obstet Gynecol"},{"issue":"09","key":"ref3","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1055\/s-0034-1543953","article-title":"Risk Factors for prolonged postpartum length of stay following cesarean delivery","volume":"32","author":"Y J Blumenfeld","year":"2015","journal-title":"Am J Perinatol"},{"issue":"13","key":"ref4","doi-asserted-by":"crossref","first-page":"1231","DOI":"10.1056\/NEJMoa1602044","article-title":"Adjunctive azithromycin prophylaxis for cesarean delivery","volume":"375","author":"A T Tita","year":"2016","journal-title":"N Engl J Med"},{"issue":"03","key":"ref5","doi-asserted-by":"crossref","first-page":"310.e1","DOI":"10.1016\/j.ajog.2010.01.005","article-title":"Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial","volume":"202","author":"D M Haas","year":"2010","journal-title":"Am J Obstet Gynecol"},{"issue":"02","key":"ref6","first-page":"289","article-title":"Pregnancy-related mortality in the United States, 1991-1997","volume":"101","author":"C J Berg","year":"2003","journal-title":"Obstet Gynecol"},{"issue":"03","key":"ref7","doi-asserted-by":"crossref","first-page":"301.e1","DOI":"10.1016\/j.ajog.2008.06.077","article-title":"Timing of perioperative antibiotics for cesarean delivery: a metaanalysis","volume":"199","author":"M M Costantine","year":"2008","journal-title":"Am J Obstet Gynecol"},{"issue":"06","key":"ref8","doi-asserted-by":"crossref","first-page":"1169","DOI":"10.1097\/AOG.0000000000000227","article-title":"Suture compared with staple skin closure after cesarean delivery: a randomized controlled trial","volume":"123","author":"A D Mackeen","year":"2014","journal-title":"Obstet Gynecol"},{"issue":"03","key":"ref9","doi-asserted-by":"crossref","first-page":"388.e1","DOI":"10.1016\/j.ajog.2016.03.035","article-title":"Early wound dressing removal after scheduled cesarean delivery: a randomized controlled trial","volume":"215","author":"D Peleg","year":"2016","journal-title":"Am J Obstet Gynecol"},{"issue":"06","key":"ref10","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1086\/587810","article-title":"Risk factors for surgical site infection after low transverse cesarean section","volume":"29","author":"M A Olsen","year":"2008","journal-title":"Infect Control Hosp Epidemiol"},{"issue":"14","key":"ref11","doi-asserted-by":"crossref","first-page":"1336","DOI":"10.1055\/s-0035-1564883","article-title":"Extreme obesity and postcesarean wound complications in the maternal-fetal medicine unit cesarean registry","volume":"32","author":"M C Smid","year":"2015","journal-title":"Am J Perinatol"},{"key":"ref12","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1097\/AOG.0000000000000384","article-title":"Extreme obesity and postcesarean maternal complications","volume":"124","author":"D M Stamilio","year":"2014","journal-title":"Obstet Gynecol"},{"issue":"03","key":"ref13","doi-asserted-by":"crossref","first-page":"100069","DOI":"10.1016\/j.xagr.2022.100069","article-title":"Incidence and risk factors for surgical wound complications in women with body mass index >30\u2009kg\/m2 following cesarean delivery: a secondary analysis","volume":"2","author":"B M Gillespie","year":"2022","journal-title":"AJOG Glob Rep"},{"key":"ref14","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/s40748-017-0051-3","article-title":"Surgical site infections after cesarean delivery: epidemiology, prevention and treatment","volume":"3","author":"T Kawakita","year":"2017","journal-title":"Matern Health Neonatol Perinatol"},{"issue":"02","key":"ref15","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1097\/AOG.0000000000003091","article-title":"Reducing cesarean delivery surgical site infections: a resident-driven quality initiative","volume":"133","author":"T Kawakita","year":"2019","journal-title":"Obstet Gynecol"},{"issue":"11","key":"ref16","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.1001\/jama.2017.10567","article-title":"Effect of post-cesarean delivery oral cephalexin and metronidazole on surgical site infection among obese women: a randomized clinical trial","volume":"318","author":"A M Valent","year":"2017","journal-title":"JAMA"},{"issue":"12","key":"ref17","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1136\/bmjqs-2015-004411","article-title":"SQUIRE 2.0 (standards for quality improvement reporting excellence): revised publication guidelines from a detailed consensus process","volume":"25","author":"G Ogrinc","year":"2016","journal-title":"BMJ Qual Saf"},{"issue":"02","key":"ref18","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1016\/S0196-6553(99)70088-X","article-title":"Guideline for prevention of surgical site infection, 1999","volume":"27","author":"A J Mangram","year":"1999","journal-title":"Am J Infect Control"},{"issue":"07","key":"ref19","doi-asserted-by":"crossref","first-page":"702","DOI":"10.1093\/aje\/kwh090","article-title":"A modified Poisson regression approach to prospective studies with binary data","volume":"159","author":"G Zou","year":"2004","journal-title":"Am J Epidemiol"},{"issue":"01","key":"ref20","doi-asserted-by":"crossref","first-page":"248","DOI":"10.1186\/s12893-021-01154-x","article-title":"The risk factors and care measures of surgical site infection after cesarean section in China: a retrospective analysis","volume":"21","author":"L Li","year":"2021","journal-title":"BMC Surg"},{"issue":"01","key":"ref21","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1186\/s12874-017-0442-1","article-title":"When and how should multiple imputation be used for handling missing data in randomised clinical trials - a practical guide with flowcharts","volume":"17","author":"J C Jakobsen","year":"2017","journal-title":"BMC Med Res Methodol"},{"issue":"04","key":"ref22","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1097\/AOG.0000000000002249","article-title":"Evidence-based bundles and cesarean delivery surgical site infections: a systematic review and meta-analysis","volume":"130","author":"E B Carter","year":"2017","journal-title":"Obstet Gynecol"},{"issue":"03","key":"ref23","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1016\/j.idh.2020.01.006","article-title":"Reducing surgical site infections post-caesarean section in an Australian hospital, using a bundled care approach","volume":"25","author":"M Bolte","year":"2020","journal-title":"Infect Dis Health"},{"issue":"01","key":"ref24","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1111\/birt.12586","article-title":"Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle","volume":"49","author":"N Sood","year":"2022","journal-title":"Birth"},{"issue":"07","key":"ref25","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1055\/s-0039-3400993","article-title":"A multifaceted surgical site infection prevention bundle for cesarean delivery","volume":"38","author":"R Scholz","year":"2021","journal-title":"Am J Perinatol"},{"issue":"05","key":"ref26","doi-asserted-by":"crossref","first-page":"555","DOI":"10.1016\/j.ajic.2019.09.005","article-title":"Impact of a surgical site infection bundle on cesarean delivery infection rates","volume":"48","author":"C Davidson","year":"2020","journal-title":"Am J Infect Control"},{"issue":"03","key":"ref27","doi-asserted-by":"crossref","first-page":"963","DOI":"10.1002\/ijgo.14605","article-title":"Reduction of adverse outcomes from cesarean section by surgical-site infection prevention care bundles in maternity","volume":"161","author":"M Erritty","year":"2023","journal-title":"Int J Gynaecol Obstet"},{"key":"ref28","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/j.jhin.2023.05.019","article-title":"Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis","volume":"139","author":"M Farid Mojtahedi","year":"2023","journal-title":"J Hosp Infect"},{"issue":"05","key":"ref29","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1111\/j.1600-0412.2011.01090.x","article-title":"Obesity, diabetes, and the risk of infections diagnosed in hospital and post-discharge infections after cesarean section: a prospective cohort study","volume":"90","author":"R A Leth","year":"2011","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"11","key":"ref30","doi-asserted-by":"crossref","first-page":"1324","DOI":"10.1111\/j.1471-0528.2012.03452.x","article-title":"Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study","volume":"119","author":"C Wloch","year":"2012","journal-title":"BJOG"},{"issue":"25","key":"ref31","doi-asserted-by":"crossref","first-page":"5346","DOI":"10.1080\/14767058.2021.1879041","article-title":"Stepwise implementation of vaginal cleansing and azithromycin at cesarean: a quality improvement study","volume":"35","author":"Q N Johanna","year":"2022","journal-title":"J Matern Fetal Neonatal Med"},{"issue":"03","key":"ref32","doi-asserted-by":"crossref","first-page":"e103","DOI":"10.1097\/AOG.0000000000002833","article-title":"ACOG practice bulletin no. 199: use of prophylactic antibiotics in labor and delivery","volume":"132","author":"Committee on Practice Bulletins-Obstetrics","year":"2018","journal-title":"Obstet Gynecol"},{"issue":"03","key":"ref33","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1097\/AOG.0b013e318197c3b6","article-title":"Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review","volume":"113","author":"A TN Tita","year":"2009","journal-title":"Obstet Gynecol"},{"issue":"10","key":"ref34","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1007\/BF01975833","article-title":"Spectrum of activity of azithromycin","volume":"10","author":"J D Williams","year":"1991","journal-title":"Eur J Clin Microbiol Infect Dis"},{"issue":"S 01","key":"ref35","doi-asserted-by":"crossref","first-page":"S16","DOI":"10.1086\/647939","article-title":"Metronidazole is still the drug of choice for treatment of anaerobic infections","volume":"50","author":"S L\u00f6fmark","year":"2010","journal-title":"Clin Infect Dis"},{"issue":"04","key":"ref36","first-page":"483","article-title":"\u201cSingle-shot\u201d-prophylaxe in der abdominalchirurgie. antibiotika mit langer halbwertzeit (ceftriaxon, ornidazol) vs. antibiotika mit kurzer halbwertzeit (cefazolin, metronidazol, clindamycin)","volume":"60","author":"W Schweizer","year":"1994","journal-title":"Helv Chir Acta"},{"issue":"11","key":"ref37","doi-asserted-by":"crossref","first-page":"1012","DOI":"10.1001\/jama.2017.10535","article-title":"Postoperative antimicrobial prophylaxis following cesarean delivery in obese women: an exception to the rule?","volume":"318","author":"D P Calfee","year":"2017","journal-title":"JAMA"}],"container-title":["American Journal of Perinatology"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/a-2620-7831.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T00:12:41Z","timestamp":1770682361000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/a-2620-7831"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,26]]},"references-count":37,"journal-issue":{"issue":"03","published-online":{"date-parts":[[2026,2,9]]},"published-print":{"date-parts":[[2026,2]]}},"URL":"https:\/\/doi.org\/10.1055\/a-2620-7831","archive":["Portico","CLOCKSS"],"relation":{},"ISSN":["0735-1631","1098-8785"],"issn-type":[{"value":"0735-1631","type":"print"},{"value":"1098-8785","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2025,5,26]]},"published":{"date-parts":[[2025,5,26]]}}}