LAS VEGAS – Until recently, residents and surgeons at the University of Cincinnati Medical Center routinely misdiagnosed normal postoperative fever after cesarean section as endometritis, significantly effecting the deep surgical site infection rates reported on websites such as Hospital Compare, according to an investigation by the medical center’s infectious disease experts.
All it took to fix the problem were a few Power Point presentations to make physicians aware of what was going on. Within months, the hospital’s deep-seated c-section infection rate dropped from 2.32 to 0.84 per 100 patients, according to Dr. Madhuri Sopirala, the center’s medical director of infection control, who led the investigation and subsequent educational efforts.
Dr. Madhuri Sopirala
"I don’t believe this is unique to our institution. I am familiar with a lot of other hospitals and practices. This is not uncommon" or limited to c-sections, she said at the annual meeting of the Surgical Infection Society.
"Postoperative fevers happen in a majority of patients," resolve in a day or two, and usually have nothing to do with infection, she noted. Even so, they are often diagnosed and treated as infections out of an abundance of caution.
That’s a problem at a time when surgical site infection rates are among the hospital quality measures reported to the public and, increasingly, affecting the bottom line. Also, "giving antibiotics to patients who don’t need them is not a good thing," Dr. Sopirala added.
The investigation began after she and her colleagues noticed that postcesarean endometritis accounted for a significant proportion of the medical center’s deep surgical site infections.
They found that 78 patients were diagnosed with endometritis after vaginal deliveries or c-sections between January 2011 and June 2012. Forty-four patients were sent home after just a day or two of antibiotics; only 8 patients were readmitted within 30 days.
Most of the 20 post c-section endometritis cases diagnosed between July 2011 and June 2012 got just a few antibiotic doses, too; none of them returned to the hospital.
The numbers just didn’t add up, Dr. Sopirala said. Endometritis is a serious infection; if patients sent home after a dose or two of antibiotics truly had endometritis, more would have been back within a month, seriously ill.
They didn’t come back "because they didn’t need to. It wasn’t really endometritis. These patients most likely had postoperative fever," she said.
"Fever is the most common indication for antibiotics in this country. Whenever a patient has a fever, people give them antibiotics just in case, then find some reason to [justify it]. Endometritis is the most common thing that comes to mind in a patient that’s had a c-section," she said.
Residents and faculty were glad to be made aware of the problem. "The data speak for themselves," Dr. Sopirala said.
Instead of diagnosing postcesarean fevers as endometritis, they "started monitoring temperatures, and could see them coming down on their own. Before, when the fever came down, they assumed it was a response to the antibiotics," she said.
Following the educational efforts, there were no c-section endometritis cases diagnosed at the center between July 2012 and March 2013.
Dr. Sopirala said that she has no disclosures.