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. 2024 Jan 25;19(1):e0286165. doi: 10.1371/journal.pone.0286165

Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

Kalpana Basany 1,*, Sirshendu Chaudhuri 2, Lakshmi Shailaja P 3, Varun Agiwal 2, Neelima Angaali 4, Nirupama A Y 2, Shailendra D 5, Catherine Haggerty 6, P S Reddy 1,7
Editor: Arghya Das8
PMCID: PMC10810521  PMID: 38271389

Abstract

Background

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

Main objectives

To estimate the incidence of surgical site infections (SSI’s) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India.

Methods

A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity.

Results

The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%).

Conclusion

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Introduction

Caesarean section (CS) is a considered to be a life-saving operative intervention for women and new-borns in certain antepartum conditions. Globally, CS is the most common major surgical intervention in pregnancies [1]. As per the World Health Organization (WHO), CS rate between 10–15% is considered optimum at the population level. Globally, the reported rate of CS is 21.1% and varies between 4.1% in West and Central Africa and 44.3% in the Latin America and the Caribbean region and increasing by 4% annually [2, 3]. In India, the overall CS rate has increased from 8.5% to 21.5% in the last 15 years [4]. According to the last national-level survey, a substantial variation exists between the states- from as low as 5.2% in Nagaland to as high as 60.7% in Telangana [4].

As a surgical procedure, caesarean delivery may be accompanied by several complications including surgical site infections (SSI) [5]. SSIs increase the morbidity and mortality of the mothers and babies and increases the length of hospital stay and thereby the cost of care [6, 7]. To prevent SSI, the WHO recommend using a single dose antibiotic, mostly the first generation cephalosporins or pencillin before 30 to minutes of incision for all women undergoing CS [8].

According to reports, the incidence of post-CS SSI worldwide is between 0.63% and 9.85%. [9–13] whereas in India, it ranges from 3.1% to 24.2% [7, 14–16]. However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries.

Therefore, the present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO [8] in a tertiary care teaching hospital in Medchal, Telangana state, India. Prior to 2017, the hospital’s practice involved administering post-operative antibiotics to all patients undergoing a caesarean section (CS). However, after adapting the single-dose antibiotic prophylaxis, the administration of post-operative antibiotics was limited to cases where there was clinical or microbiological evidence of infection, specifically in cases of surgical site infections (SSI’s). Additionally, we looked at the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

Methods

Setting

The study was carried out at MediCiti Institute of Medical Sciences which is a tertiary care teaching hospital at Ghanpur village, located about 25km from the city of Hyderabad, in the Indian state of Telangana. The hospital has 570 inpatient beds out of which 60 were allocated to department of Obstetrics and Gynaecology. The caesarean section rate was 46% during the study period.

Study design

Prospective study.

Study duration

The study was conducted between June 2017 & December 2019.

Study population

All women who underwent CS in the hospital during the study period were eligible for the study. We classified CS into two types—emergency and elective. And comparative analysis was made between emergency and elective caesarean section for various parameters (Table 1). An emergency CS is where there is either maternal or foetal compromise or where there is immediate threat to the life of women or foetus. Rest of the caesarean deliveries were grouped under elective CS. We excluded those women who delivered at other hospitals and came to the study hospital with surgical infection, those who died during CS or immediately after CS, and those who did not consent to participate.

Table 1. Profile of the study participants based on caesarean section.

Variables Emergency CS, n = 1232 (%) Elective CS, n = 783(%) P-value
Age, years      
< = 25 908(73.7) 507(64.8) <0.001
>25 324(26.3) 280(35.5)
BMI*, Kg/m2 (n = 1,356)      
Underweight 147(11.9) 80(10.2) 0.075
Normal 374(30.4) 230(29.4)
Overweight 147(11.9) 74(9.5)
Obesity 171(13.9) 133(17)
Current pregnancy registered 1086(88.1) 717(91.6) 0.015
Number of prenatal visits to hospital≥ 4 times 968(78.6) 645(82.4) 0.411
Presence of anaemia 94(7.6) 87(11.1) 0.008
Presence of hypertension 207(16.8) 94(12) 0.003
Presence of hypothyroidism 171(13.9) 97(12.4) 0.337
Presence of gestational diabetes 48(3.9) 33(4.2) 0.723
Previous caesarean section 437(35.5) 687(87.7) <0.001
Duration of labour (Hours) (n = 2,015)      
Non-labour 118 (9.6) 783 (100) <0.001
<6 597(48.4) 0
6–12 381(30.9) 0
>12 136(11) 0
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Sample size

For estimating 2% or less incidence of SSI after CS, we estimated our minimum required sample size to be 1,500 women who undergo CS; considering α = 0.05, β = 0.8, & margin of error = 0.01.

Antibiotic policy of the hospital

A single dose of prophylactic antibiotic was administered 30 min to one hour before the caesarean section. As a prophylaxis, we used injection cefazolin 1 gram. When cefazolin was unavailable, injection ampicillin 1 gram, or injection cefotaxime 1 gram was given. Post-operative antibiotics were not prescribed unless there was any clinical or bacteriological evidence of infection.

Definition of variables

SSI was defined as "An infection of the superficial or deep skin incision, or of an organ or space, occurring up to 30 days after surgery” [17]. There are two types of SSI- superficial and deep. SSI was defined as per the CDC- National Healthcare Safety Network guidelines.

All the suspected infections were confirmed either clinically by the treating gynaecologist or microbiologically by the culture results.

Body mass index (BMI) was calculated by weight in Kg divided by height in meter2. If height and weight measures were missed in the first trimester, or the participants recruited in the second trimester or later, BMI was excluded in the analysis. BMI was categorized according to underweight (BMI < 18.5 kg/m2), normal (BMI 18.5 to 22.93 kg/m2), overweight (BMI 23 to 24.9 kg/m2, and obese (BMI ≥25 kg/m2) [18]. After admission, all women were assessed for co-morbid medical conditions like diabetes, hypertension, and thyroid disorders.

Data collection

All pertinent clinical details were collected from the participants hospital record using structured questionnaire by a dedicated study nurse. The questionnaire and the dataset were uploaded as supplementary files.

Post discharge follow up

The hospital policy was to discharge the patient after suture removal on 6th or 7th postoperative day. The duration of hospital stay is from the day of admission to hospital to till the day of discharge from hospital. At the time of discharge from the hospital, the women were educated about the signs and symptoms of wound infection and were asked to report to the study nurse on noticing any signs and symptoms. The participants’ contact number(s) were collected before discharge. Post-discharge, the information on signs and symptoms were also collected by weekly telephone calls till the end of 30th day from the date of operation by the study nurse. A standard script and a questionnaire in local language was used to enquire about the general health and wound infection. If suspected to have SSI, the women were followed up at the outpatient department (OPD).

Laboratory diagnosis

In women where there was pus or discharge from the wound, two swabs were taken. Direct microscopy was done using the first swab, a smear was made on a clean glass slide and stained by Gram’s stain. The second swab was inoculated onto plates of 5% sheep blood agar & Mac Conkey agar by rolling the swab over the agar and streaking from the primary inoculums, using a sterile bacteriological loop. If growth was seen after 24hrs, standard biochemical reactions were performed to isolate the organism. Antibiotic susceptibility testing (Antibiogram) of above isolates was performed by Kirby-Bauer disc diffusion method, using Muller Hinton agar plates according to Central Laboratory Standards Institute guidelines (CLSI). The same microbiological procedure was followed for those who were discharged and followed up in the OPD.

Statistical analysis

The data was analyzed by STATA version 14.0. Descriptive statistics in terms of mean and standard deviation (SD) or median and interquartile range (IQR) were used to characterize the participants. Incidence of SSI was calculated in terms of percentage with 95% confidence interval (CI). Unpaired t-test was applied to test the difference in mean between two groups whereas association between two categorical variables was found out using chi-square test. Univariate logistic regression model was conducted to assess the determinants with a p-value lower than 0.2 were selected for inclusion in the final regression model, which was then analyzed using multiple logistic regression method. Risk of the predictors was estimated by adjusted relative risk (a RR) with 95% CI. A p-value <0.05 was considered significant for all statistical tests. Descriptive statistics were used to report the bacteriological profile of the SSI. Authors have access to deidentified data.

Human subject protection

The study was approved by the MediCiti Ethics Committee of the institute which states that “on consideration of the study papers submitted, permission is also accorded for publication of any paper on the studying subjects.” Besides, written informed consent was taken from all the participants.

Results

We recruited a total number of 2,038 participants in the study. We excluded 23 participants due to missing information. Finally, 2,015 participants’ information were available for analysis. The mean age of the participants was 24.1 years (SD 3.2 years), and majority were multigravida (n = 1,274, 63.2%) (Table 2). Seven hundred eleven (35.3%) participants had at least one known comorbidity Twelve hundred and thirty two (61.1%) participants underwent emergency CS. The average hospital stay was 9.4 days (SD 3.2 days).

Table 2. Clinical profile of the participants, Medchal, Telangana, India (n = 2,015).

Variables Frequency (%)
Age, years
< = 25 1,415 (70.2)
>25 600 (29.8)
BMI*, Kg/m2 (n = 1,356)
Underweight 227 (16.7)
Normal 604 (44.5)
Overweight 221 (16.3)
Obesity 304 (22.4)
Current pregnancy registered 1803 (89.5)
Number of prenatal visits to hospital≥ 4 times 1613 (80.1)
Presence of anaemia (< 11gm%) 181 (9.0)
Presence of hypertension BP ≥140 /90 mmHg) 301 (14.9)
Presence of hypothyroidism 268 (13.3)
Presence of gestational diabetes 81 (4.0)
Previous caesarean section 1,124 (55.8)
Duration of labour (Hours) (n = 2,015)
Non-labour 901 (44.7)
<6 597 (29.6)
6–12 381 (18.9)
>12 136 (6.8)
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*First trimester BMI is unavailable for 659 participants

Incidence of SSI

Surgical site infection was developed in 92 (4.6%, 95% CI: 3.7% to 5.6%) out of 2015 participants. Out of this 91 (98.9%) had superficial and 1 (1.1%) had deep infection. Eighty-four (91.3%) participants developed infection during the hospital stay and eight (8.7%) at home. The infection rate was higher among women underwent emergency CS (n = 70, 5.7%; 95% CI: 4.5 to 7.1) compared to those who underwent elective CS (n = 22, 2.8%; 95% CI: 1.8 to 4.2).

The median time to develop SSI was 7 days (IQR 6 to 7 days). The average hospital stay was 11.8 days (SD 3.7 days) in women who developed SSI and 9.3 (SD 3.1) days without SSI and mean difference was 2.5 days (95% CI: 1.9 to 3.2 days; p <0.001).

Risk factors

Adjusted relative risk (a RR) of SSI was 2.3 times higher (95% CI: 1.1 to 4.8; Power 100%) among young age (< = 25 years) and 2.5 times higher (95% CI: 1.4 to 4.6; Power 99.9%) among obese women. Women who underwent emergency LSCS (a RR 3.0 95% CI: 1.1 to 8.8, p = 0.06) had a higher SSI rate, though statistically not significant (Table 3).

Table 3. Associated socio-demographic and clinical factors for developing the SSI.

Variable Reference group Study group Univariate Logistic Regression Multivariate Logistic Regression
RR (95% CI) P-value a RR (95% CI) P-value
Age (years) >25 < = 25 1.8 (1.1–3.0) 0.030 2.3 (1.1–4.8) * 0.026
BMI Normal Underweight 0.7 (0.3–1.8) 0.479 0.7 (0.3–1.7) 0.413
Overweight 1.4 (0.7–2.9) 0.388 1.3 (0.6–2.8) 0.465
Obesity 2.4 (1.3–4.3) 0.004 2.5 (1.4–4.6)* 0.003
Parity Primi Multi 0.5 (0.3–0.7) <0.001 0.6 (0.3–1.2) 0.147
Duration of labor (hours) Non-labor <6 1.5 (0.9–2.6) 0.142 0.5 (0.2–1.2) 0.127
6–12 2.1 (1.2–3.8) 0.009 0.6 (0.2–1.7) 0.328
>12 3.3 (1.7–6.6) 0.001 0.8 (0.3–2.6) 0.765
Type of LSCS Elective Emergency 2.1 (1.3–3.4) 0.003 3.0 (1.1–8.8) 0.041
No. of persons in OT <5 5–10 0.3 (0.1–0.7) 0.005 0.4 (0.1–1.1) 0.078
11–15 0.3 (0.1–0.6) 0.002 0.4 (0.1–1.3) 0.145
>15 0.2 (0.02–1.4) 0.100 0.4 (0.04–4.1) 0.456
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Bacteriological profile

A total number of 66 wound discharge samples were sent for bacteriological assessment, out of which growth yielded in 50 (75.8%) samples, seven samples (14.0%) grew multiple organisms thereby yielding a total of 57 isolates. We found, Klebsiella sp. (n = 13, 22.8%), and Escherichia coli (n = 12, 21.1%) and Staphylococcus aureus (n = 7, 12.3%) being the most common organisms (Table 4).

Table 4. Sensitivity and resistance pattern of the organisms.

Methicilin sensitive Staphylococcus aureus (n = 7) Klebsiella (n = 13) E. Coli (n = 12) Citobacter (n = 4) Acinetobacter (n = 3) Proteus mirabilis (n = 1) Providencia (n = 1)
Sensitivity (Number of isolates)
Amoxyclav 2 3 1 3 1
Cefepime 1 9 2 1 1
Ceftazidime and Clavulanic acid 13
Ceftriaxone 4 1 2
Ciprofloxacin 8 1 2 1 1 1
Co-Trimoxazole 3 8 3 4 2
Doxycycline 2 2 1 2 1 1
Erythromycin 3
Gentamycin 3 1 1
Imipenem 10 10 3 1 1
Linezolid 6
Levofloxacin 5
Methicillin 7
Nitrofurantoin 1 6
Norfloxacin 3 2 1
Piperacillin/Tazobactum 1 13 11 4 3 1 1
Vancomycin 7
Resistance (Number of isolates)
Amoxycillin 2 1 3 1
Amoxyclav 2 10 2 3 2 1
Amikacin 5 3 2 1 1
Ampicillin 2 11 2 2 1 1
Aztreonam 1 3 3 4
Cefepime 4 3 3 1
Cefotaxime 5 2 1
Ceftriaxone 3 3
Ciprofloxacin 1 2 2
Co-Trimoxazole 2 3 1 1 1
Nitrofurantoin 2 1
Penicillin 6
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Staphylococcus aureus was commonly sensitive to linezolid (6 isolates, 85.7%), and levofloxacin). All the isolates were sensitive to methicillin and vancomycin (Table 4). The isolates were commonly resistant to penicillin (six isolates, 85.7%) (Table 4). Among the gram-negative organisms, Klebsiella was the commonest organism. It was sensitive to ceftazidime and clavulanic acid combination (13 isolates, 100%), imipenem (10 isolates, 76.9%), and cefepime (9 isolates, 69.2%) and commonly resistant to ampicillin (11 isolates, 84.6%) and amoxycillin/clavulanic acid combination (10 isolates, 76.9%).

Discussion

In this large prospective study, the incidence of SSI was 4.6% with a single dose prophylactic antibiotic as per the WHO guidelines, detected within 30 days post-operative period as per CDC criteria. A single dose of prophylactic antibiotic, injection cefazolin was given and if not available, injection cefotaxime was given 30 minutes to one hour before skin incision for both elective and emergency caesarean sections. The incidence of SSI is low compared to most Indian studies, which have reported a burden ranging from 3.12% to as high as 24.2% over the last decade [7, 14–16, 19–21]. Most of these studies did not follow the WHO guidelines on pre-operative antibiotic use, and some even used multiple antibiotics in multiple doses before or after surgery [15, 19–21]. Therefore, we recommend adherence to the guidelines unless there is evidence-based justification to deviate from them.

We found that obesity is a strong risk factor for developing SSI. A meta-analysis has revealed that obese pregnant women have a higher risk of wound infections in all settings [22]. To prevent SSI in obese women, various guidelines recommend higher dose of antibiotics based on several studies [23–25]. However, these guidelines were advocated after commencement of our study. Based on these facts, we have changed our institutional policy to include double dose of antibiotic prophylaxis for obese women. We expect that this practice will further reduce the SSI burden in our setting.

Our study found that the younger (aged <25 years) are at high risk of developing SSI after CS. In India, inconsistent results are found in the literature in this regard [10, 14, 20, 26]. We found higher risk with emergency CS with borderline significance; but most studies in literature have confirmed a higher risk of SSI with emergency CS [16, 27, 28].

In the present study, Staphylococcus aureus, a gram-positive organism, was the commonest organism isolated from caesarean wound infections. The other common organisms that were isolated include Klebsiella and E.coli, both being gram-negative organisms. The finding is consistent with the findings from other Indian studies which has reported co infections with both gram negative and gram-positive organisms [14–16, 20].

The strengths of the present study were that it was done prospectively, single dose antibiotic was prescribed as per the WHO guidelines, and the women were followed for 30 days post-operation as per the CDC criteria. Another strength of this study is that the proforma was filled by study nurses only, to rule out reporting bias. However, the study was based on a single centre, and thus, the results might not be generalizable to the other contexts.

Conclusion

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was 4.6% with 99% being superficial infections. Young women and obese women were at high risk of developing SSI. Our finding also indicates the need for continuous vigilance on SSI control measures at the hospital-level.

Supporting information

S1 Questionnaire

(PDF)

Click here for additional data file. (602.7KB, pdf)
S1 Data

(XLSX)

Click here for additional data file. (840.2KB, xlsx)

Acknowledgments

We are very grateful to our Study Nurses Ms Harati, Mrs Rosamma, study Co-ordinators Mrs. Deepa and Mrs Mamta and our IT team Mr. Purushotham Reddy and Mr. Narender.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.World Health Organization. WHO Statement on Caesarean Section Rates [Internet]. 2015. [cited 2023 Jan 2]. Available from: https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf [Google Scholar]
  • 2.Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. The Lancet. 2018. Oct 13;392(10155):1341–8. doi: 10.1016/S0140-6736(18)31928-7 [DOI] [PubMed] [Google Scholar]
  • 3.Lancet T. Stemming the global caesarean section epidemic. The Lancet. 2018. Oct 13;392(10155):1279. doi: 10.1016/S0140-6736(18)32394-8 [DOI] [PubMed] [Google Scholar]
  • 4.Roy N, Mishra PK, Mishra VK, Chattu VK, Varandani S, Batham SK. Changing scenario of C-section delivery in India: Understanding the maternal health concern and its associated predictors. J Family Med Prim Care. 2021. Nov;10(11):4182–8. doi: 10.4103/jfmpc.jfmpc_585_21 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Larsson C, Djuvfelt E, Lindam A, Tunón K, Nordin P. Surgical complications after caesarean section: A population-based cohort study. PLoS One. 2021. Oct 5;16(10):e0258222. doi: 10.1371/journal.pone.0258222 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007. Feb 13;176(4):455–60. doi: 10.1503/cmaj.060870 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Hirani S, Trivedi NA, Chauhan J, Chauhan Y. A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India. PLOS ONE. 2022. Jun 3;17(6):e0269530. doi: 10.1371/journal.pone.0269530 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.World Health Organization. WHO recommendations for prevention and treatment of maternal peripartum infections. World Health Organization; 2015. [PubMed] [Google Scholar]
  • 9.Shree R, Park S, Beigi R, Dunn S, Krans E. Surgical Site Infection following Cesarean Delivery: Patient, Provider, and Procedure-Specific Risk Factors. Amer J Perinatol. 2015. Sep 7;33(02):157–64. doi: 10.1055/s-0035-1563548 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Saeed KB, Corcoran P, Greene RA. Incisional surgical site infection following cesarean section: A national retrospective cohort study. Eur J Obstet Gynecol Reprod Biol. 2019. Sep;240:256–60. doi: 10.1016/j.ejogrb.2019.07.020 [DOI] [PubMed] [Google Scholar]
  • 11.Zejnullahu VA, Isjanovska R, Sejfija Z, Zejnullahu VA. Surgical site infections after cesarean sections at the University Clinical Center of Kosovo: rates, microbiological profile and risk factors. BMC Infect Dis. 2019. Aug 28;19(1):752. doi: 10.1186/s12879-019-4383-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Kvalvik SA, Rasmussen S, Thornhill HF, Baghestan E. Risk factors for surgical site infection following cesarean delivery: A hospital-based case–control study. Acta Obstetricia et Gynecologica Scandinavica. 2021;100(12):2167–75. doi: 10.1111/aogs.14235 [DOI] [PubMed] [Google Scholar]
  • 13.Ferraro F, Piselli P, Pittalis S, Ruscitti LE, Cimaglia C, Ippolito G, et al. Surgical site infection after caesarean section: space for post-discharge surveillance improvements and reliable comparisons. New Microbiol. 2016. Apr;39(2):134–8. [PubMed] [Google Scholar]
  • 14.De D, Saxena S, Mehta G, Yadav R, Dutta R. Risk Factor Analysis and Microbial Etiology of Surgical Site Infections following Lower Segment Caesarean Section. International Journal of Antibiotics. 2013. Sep 1;2013:e283025. [Google Scholar]
  • 15.Gupta S, Manchanda V, Sachdev P, Kumar Saini R, Joy M. Study of incidence and risk factors of surgical site infections in lower segment caesarean section cases of tertiary care hospital of north India. Indian J Med Microbiol. 2021. Jan;39(1):1–5. doi: 10.1016/j.ijmmb.2020.11.005 [DOI] [PubMed] [Google Scholar]
  • 16.Panwar D, Jodha BS, Prakash P. Study of surgical site infection: An obstetrical surgical morbidity at a tertiary level hospital | Panwar | Clinical Surgery Research Communications. 2021. Sep 29 [cited 2023 Jan 2]; Available from: http://www.antpublisher.com/index.php/CSRC/article/view/391 [Google Scholar]
  • 17.Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999. Apr;20(4):250–78; quiz 279–80. doi: 10.1086/501620 [DOI] [PubMed] [Google Scholar]
  • 18.Misra A. Ethnic-Specific Criteria for Classification of Body Mass Index: A Perspective for Asian Indians and American Diabetes Association Position Statement. Diabetes Technol Ther. 2015. Sep 1;17(9):667–71. doi: 10.1089/dia.2015.0007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Vijayan CP, Mohandas S, Nath AG. Surgical Site Infection Following Cesarean Section in a Teaching Hospital. INTERNATIONAL JOURNAL OF SCIENTIFIC STUDY. 2016;3(12):97–101. [Google Scholar]
  • 20.Thakur N, Kujur A. Microbiological and antibiotic sensitivity pattern of surgical site infection following caesarean section in a tertiary care center of Chhattisgarh. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2021. Jun 28;10(7):2638–46. [Google Scholar]
  • 21.Dahiya P, Gupta V, Pundir S, Chawla D. Study of Incidence and Risk Factors for Surgical Site Infection after Cesarean Section at First Referral Unit. 2016;3(4). [Google Scholar]
  • 22.Słabuszewska-Jóźwiak A, Szymański JK, Jóźwiak Ł, Sarecka-Hujar B. A Systematic Review and Meta-Analysis of Wound Complications after a Caesarean Section in Obese Women. J Clin Med. 2021. Feb 10;10(4):675. doi: 10.3390/jcm10040675 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Coleman J, Murtha A, Silverman NS. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstetrics & Gynecology. 2018. Sep;132(3):e103. doi: 10.1097/AOG.0000000000002833 [DOI] [PubMed] [Google Scholar]
  • 24.Malhotra J, Mittal P, Rajaram S, Bharti R. FOGSI Focus Surgical Skills [Internet]. First. 2018. [cited 2023 Mar 9]. Available from: https://www.fogsi.org/wp-content/uploads/fogsi-focus/FOGSI-Focus-Surgical-Skills.pdf [Google Scholar]
  • 25.World Health Organization. WHO recommendation on prophylactic antibiotics for women undergoing caesarean section [Internet]. 2021. [cited 2023 Mar 9]. Available from: https://apps.who.int/iris/bitstream/handle/10665/341865/9789240028012-eng.pdf [PubMed] [Google Scholar]
  • 26.Sangwan A, Malhotra V. Assessment of risk factors for surgical site infection following caesarean section. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2019. Oct 23;8(11):4518–24. [Google Scholar]
  • 27.Chhetry M, Subedi S, Banerjee B. Risk factors for post caesarean surgical site infection at a tertiary care center in Eastern Nepal. J Coll Med Sci-Nepal. 2017. Oct 19;13(3):314–7. [Google Scholar]
  • 28.Shrestha S, Shrestha R, Shrestha B, Dongol A. Incidence and risk factors of surgical site infection following cesarean section at Dhulikhel Hospital. Kathmandu Univ Med J (KUMJ). 2014;12(46):113–6. doi: 10.3126/kumj.v12i2.13656 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Arghya Das

12 Jun 2023

PONE-D-23-11380Dear Editor: -

Prospective cohort study of Surgical Site Infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, IndiaPLOS ONE

Dear Dr. Kalpana,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 27 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Arghya Das, MD

Academic Editor

PLOS ONE

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Additional Editor Comments:

Page 2, Line 34: “…………..profiles and the antimicrobial sensitivity and resistance pattern………..”

Comment: Replace ‘antimicrobial sensitivity and resistance pattern’ with ‘antimicrobial susceptibility’ only. Please use the word ‘susceptibility’ instead of ‘sensitivity’ throughout the manuscript.

Page 2, Line 49: “Of these, 92 participants……..”

Comment: Delete ‘Of these’ and start the sentence with ’Ninety-two participants’.

Page 2-3, Lines 54-55: “Microbial growth was observed in 75.8% 3 55 (n=50/66) samples”

Comment: Please rephrase the above sentence like “Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples”. Please mention the statistical figures in and out of the parentheses within a sentence uniformly throughout the manuscript.

Page 3, Lines 55-56: The most common organisms identified were Staphylococcus aureus 56 (n=23, 46.0%), Klebsiella sp. (n=13, 26.0%), and Escherichia coli (n=12, 24.0%).

Comment: From the above sentence, it appears to be that the percentages of the organisms were calculated considering the total number of samples with a positive growth as denominator. Since multiple organisms have been isolated from 7 samples (as mentioned under Results), it will be helpful if the percentages are calculated considering total number of isolates in the denominator. Please also make relevant changes in the text under ‘Results’ section.

Page 3, Lines 58-61: Conclusion: Given the low rate of SSI following Caesarean deliveries subjected to single-dose antibiotic prophylaxis and the increased risk noted with obesity, it is rationale to practice the latest recommendations of WHO including higher dose for obese patients, unless there is compelling evidence to do otherwise in any context.

Comment: It is strongly advisable that the author should rewrite the conclusion of both Abstract and the main text based on the objective of the study only i.e. rate of CS and significant risk factors. Any recommendation based on the findings, may be included under the Discussion only.

Page 4, Lines 83-84: To prevent SSI, the WHO recommend using a single dose antibiotic, mostly the first generation cephalosporins, before 30 to minutes of incision for all women undergoing CS.

Comment: As per the reference cited, the recommendation for as single dose antibiotics is first generation cephalosporins or penicillin. Authors are advised to recheck the same and make required changes.

Page 5, Lines 107: We classified CS into two types- emergency and elective.

Comment: In general, emergency procedures have more risk for post-operative infections than elective procedures. As more than 60% of the patients underwent emergency CS it will be better if some comparative analysis is done based on the parameters described in the manuscript between emergency and elective CS.

Page 5, Line 113: For estimating 2% or less incidence of SSI after CS

Comment: Please clarify on the incidence of SSI after CS for calculating sample size. Or cite suitable reference.

Page 5, Lines 116-119: When Cefazolin was unavailable, injection Ampicillin 1 gram, OR injection Cefotaxim 1 gram was given.

Comment: Check the spelling of antibiotics. Few are written wrongly in the manuscript. Within a sentence, the name of the antibiotics should be written in lower case letters only.

As per the above-mentioned sentence, a third generation of cephalosporin was sometimes chosen if cefazolin, a first-generation cephalosporin, was not available. Is this also a part of hospital’s antibiotic policy?

Also mention under discussion why choosing a higher generation cephalosporins instead of first generation cephalosporins only will not cause any difference in rate of SSI in the study.

Page 6, Lines 121-124: Definition of variables: SSI was defined as- "An infection of the superficial or deep skin incision, or of an organ or space, occurring up to 30 days after surgery.” [17] There are two types of SSI- superficial and deep. As per the CDC definition, "A superficial SSI is infection identified during hospital stay or within 30 days……..

Comment: It is not clear what exact criteria were adopted for defining SSI. From the later sentences of the above paragraph, it seems to be that the authors have adopted CDC surveillance definitions. If NHSN-CDC surveillance definitions were considered to define the cases in the study, that should be directly cited as reference. Moreover, considering the detailed nature of the definitions of the guidelines it should be enough to state that “SSI for the present study was defined as per the CDC-NHSN guidelines”.

Page 7, Lines 150-151:  Data collection: All pertinent clinical details were collected by from the participants hospital record using structured questionnaire by a dedicated study nurse.

Comment: Please upload the structured questionnaire as supplementary file. Please also mention about the source of the questionnaire under the ‘Methods’ section.

Page 7, Lines 152-171: The hospital policy was to discharge the patient after suture removal………………….. microbiological procedure was followed for those who were discharged and followed up in the OPD.

Comment: Please provide some headings for the above paragraphs like “Laboratory diagnosis of SSI”, “Post-discharge Follow up”.

Page 10, Lines 200-202: The average hospital stay was 11.8 days (SD 3.7 days) in women who developed SSI and 9.3 (SD 3.1) days without SSI and mean difference was 2.5 days (95% CI: 1.9 to 3.2 days; p <0.001).

Comment: Please indicate under Statistical Methods in the Methods section about the specific test that was used for comparing the continuous quantitative variables.

Page 11, Lines 215-216: The only gram-positive organism, Staphylococcus, was commonly sensitive to- Linezolid (20 isolates, 87%)….

Comment: Authors need to recheck and confirm the susceptibility profile of staphylococcal isolates against linezolid. Linezolid resistance in Staphylococcus is still very low in India. No speciation has also been done for Staphylococcus. Please differentiate between Staphylococcus aureus and coagulase-negative staphylococcus in the manuscript.

Page 12, Lines 221-222: ……….. and Cefepime (9 isolates, 69.2%) and commonly resistant to Ampicillin (11 isolates, 222 84.6%) and Amoxycillin/Clavulanic acid combination (10 isolates, 76.9%).

Comment: It seems to be that the intrinsic resistance was not considered for some of the organisms in the study. Those with intrinsic resistance against some particular organism, need not to be analysed for resistance/susceptibility profile against that particular organisms. Authors are strongly encouraged to seek help from clinical microbiologists or ID specialists for these technical issues.

Page 16, Lines 246-247: Therefore, we recommend adherence to the guidelines unless there is evidence-based justification to deviate from them.

Comment: The statement may be overly correct, as the authors themselves did not uniformly followed the WHO guidelines (choice of antibiotics) for all the subjects.

Page 17, Lines 262-263: The finding is consistent with the findings from other Indian studies which has reported mixed infections with gram negative and gram-positive organisms. [14–16,20]

Comment: The authors should rephrase the above sentence as mixed infections term may be misleading and often refers to co-infections by both types of organisms mentioned above.

Page 17, Lines 266-267: Another strength of this study is that the proforma was filled by study nurses only, to rule out reporting bias.

Comment: Authors should also mention about the questionnaire filled up by the nurses under the ‘Methods’ section.

Table 1

Comment: Please define anaemia (as per Hb% etc) and hypertension (SBP, DBP, etc) within the table.

Table 2

Comment: Please mention the p values for individual variables with regards to the multivariable analysis. It’s also not clear whether authors choose to perform multivariable analysis for those variables which had a significant value in univariate analysis. Please clarify under the Statistical Methods

Tables 3 and 4

Comment: Both the tables may not be required. Either resistance or susceptibility profile may be presented. Moreover, the colour coding of the cells seem arbitrary without mentioning the level of susceptibility/resistance. Authors should remake the tables with mentioning of percentages instead of absolute numbers. Please seek help from a clinical microbiologist for depicting the susceptibility profile. Name of the organisms should be properly written following standard nomenclature.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Authors congratulation for the work that has been put in this paper , however few points needs more crisper reprenetaion like isolates and their antibiogram contain two table very big one , MRSA and MSSA have not been differantiated ,thir is no mention on inherant ressitant that might lead to the query for many who might not be aware of the things

Similiary in the risk factor table the refferance group needs to be defined clearly

and in discussion/result the Antibiotic that were used for surgical prophylaxis ,their timimg if it is discuused thotoghly would justify the title that has been used for the paper

Reviewer #2: The findings of the study have been presented in a rational and scientific manner using standard English. It is the opinion of the reviewer that sample size calculation formula, and its reference be added to the manuscript.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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Attachment

Submitted filename: Manuscript Revised.docx

Click here for additional data file. (77.7KB, docx)
PLoS One. 2024 Jan 25;19(1):e0286165. doi: 10.1371/journal.pone.0286165.r002

Author response to Decision Letter 0

7 Aug 2023

Response to Reviewers

Page 2, Line 34: “………….profiles and the antimicrobial sensitivity and resistance pattern………..”

Comment: Replace ‘antimicrobial sensitivity and resistance pattern’ with ‘antimicrobial susceptibility’ only. Please use the word ‘susceptibility’ instead of ‘sensitivity’ throughout the manuscript.

Response: Agree with the suggestion, replaced with the word ‘ susceptibility’.

Page 2, Line 49: “Of these, 92 participants……..”

Comment: Delete ‘Of these’ and start the sentence with ’Ninety-two participants’.

Response: Agree with the suggestion , changed.

Page 2-3, Lines 54-55: “Microbial growth was observed in 75.8% 3 55 (n=50/66) samples”

Comment: Please rephrase the above sentence like “Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples”. Please mention the statistical figures in and out of the parentheses within a sentence uniformly throughout the manuscript.

Response: As suggested by the reviewers,the sentence was rephrased. The statistical figures were mentioned uniformly throughout the manuscript.

Page 3, Lines 55-56: The most common organisms identified were Staphylococcus aureus 56 (n=23, 46.0%), Klebsiella sp. (n=13, 26.0%), and Escherichia coli (n=12, 24.0%).

Comment: From the above sentence, it appears to be that the percentages of the organisms were calculated considering the total number of samples with a positive growth as denominator. Since multiple organisms have been isolated from 7 samples (as mentioned under Results), it will be helpful if the percentages are calculated considering total number of isolates in the denominator. Please also make relevant changes in the text under ‘Results’ section

Response: Thanks for the suggestion. We have done the calculation accordingly. Also, as suggested by the other reviewer, we have also reported the number of Staphylococcus aureus isolates and number of Coagulase negative Staphylococcus isolates.

Page 3, Lines 58-61: Conclusion: Given the low rate of SSI following Caesarean deliveries subjected to single-dose antibiotic prophylaxis and the increased risk noted with obesity, it is rationale to practice the latest recommendations of WHO including higher dose for obese patients, unless there is compelling evidence to do otherwise in any context.

Comment: It is strongly advisable that the author should rewrite the conclusion of both Abstract and the main text based on the objective of the study only i.e. rate of CS and significant risk factors. Any recommendation based on the findings, may be included under the Discussion only.

Response: As suggested, conclusion was changed.

Page 4, Lines 83-84: To prevent SSI, the WHO recommend using a single dose antibiotic, mostly the first generation cephalosporins, before 30 to minutes of incision for all women undergoing CS.

Comment: As per the reference cited, the recommendation for as single dose antibiotics is first generation cephalosporins or penicillin. Authors are advised to recheck the same and make required changes

Response: Rechecked the reference no.8. Changes made

Page 5, Lines 107: We classified CS into two types- emergency and elective.

Comment: In general, emergency procedures have more risk for post-operative infections than elective procedures. As more than 60% of the patients underwent emergency CS it will be better if some comparative analysis is done based on the parameters described in the manuscript between emergency and elective CS

Response: As advised by the reviewers, comparative analysis was done between elective and emergency CS

Page 5, Line 113: For estimating 2% or less incidence of SSI after CS

Comment: Please clarify on the incidence of SSI after CS for calculating sample size. Or cite suitable reference.

Response: We thank the reviewer for the comment. According to the study conducted by Vijayan et al (2016), we determined that a minimum sample size of approximately 1500 women undergoing caesarean section would be necessary to estimate a 4.1% incidence of surgical site infections (SSI). This estimation took into account a significance level (α) of 0.05, a power (β) of 0.8, and a margin of error of 0.01.

Reference: Vijayan CP, Mohandas S, Nath AG, Surgical site infection following caesarean section in a teaching hospital. International Journal of Scientific Study. 2016;3(12);97-101.

Page 5, Lines 116-119: When Cefazolin was unavailable, injection Ampicillin 1 gram, OR injection Cefotaxim 1 gram was given.

Comment: Check the spelling of antibiotics. Few are written wrongly in the manuscript. Within a sentence, the name of the antibiotics should be written in lower case letters only.

As per the above-mentioned sentence, a third generation of cephalosporin was sometimes chosen if cefazolin, a first-generation cephalosporin, was not available. Is this also a part of hospital’s antibiotic policy?

Also mention under discussion why choosing a higher generation cephalosporins instead of first generation cephalosporins only will not cause any difference in rate of SSI in the study.

Response: Spelling of cefotaxime changed. Yes, it is the hospital policy to use third generation cephalosporin if first generation of cephalosporin was not available.

Page 6, Lines 121-124: Definition of variables: SSI was defined as- "An infection of the superficial or deep skin incision, or of an organ or space, occurring up to 30 days after surgery.” [17] There are two types of SSI- superficial and deep. As per the CDC definition, "A superficial SSI is infection identified during hospital stay or within 30 days……..

Comment: It is not clear what exact criteria were adopted for defining SSI. From the later sentences of the above paragraph, it seems to be that the authors have adopted CDC surveillance definitions. If NHSN-CDC surveillance definitions were considered to define the cases in the study, that should be directly cited as reference. Moreover, considering the detailed nature of the definitions of the guidelines it should be enough to state that “SSI for the present study was defined as per the CDC-NHSN guidelines”.

Response: As suggested , definition of SSI was changed accordingly, reference given

Page 7, Lines 150-151: Data collection: All pertinent clinical details were collected by from the participants hospital record using structured questionnaire by a dedicated study nurse.

Comment: Please upload the structured questionnaire as supplementary file. Please also mention about the source of the questionnaire under the ‘Methods’ section.

Response: The questionnaire was uploaded as supplementary file.

Page 7, Lines 152-171: The hospital policy was to discharge the patient after suture removal………………….. microbiological procedure was followed for those who were discharged and followed up in the OPD.

Comment: Please provide some headings for the above paragraphs like “Laboratory diagnosis of SSI”, “Post-discharge Follow up”.

Response: As advised by the reviewers, headings were provided.

Page 10, Lines 200-202: The average hospital stay was 11.8 days (SD 3.7 days) in women who developed SSI and 9.3 (SD 3.1) days without SSI and mean difference was 2.5 days (95% CI: 1.9 to 3.2 days; p <0.001).

Comment: Please indicate under Statistical Methods in the Methods section about the specific test that was used for comparing the continuous quantitative variables.

Response: We agree with the reviewers. As suggested, mentioned in the statistical methods

Page 11, Lines 215-216: The only gram-positive organism, Staphylococcus, was commonly sensitive to- Linezolid (20 isolates, 87%)….

Comment: Authors need to recheck and confirm the susceptibility profile of staphylococcal isolates against linezolid. Linezolid resistance in Staphylococcus is still very low in India. No speciation has also been done for Staphylococcus. Please differentiate between Staphylococcus aureus and coagulase-negative staphylococcus in the manuscript.

Response: We thank the author for the comment. We have discussed the same with the clinical Microbiologist and reanalyzed the figures. There were 7 isolates of Staphylococcus aureus and we have reported the sensitivity and resistance based on these 7 isolates. We have differentiated between the two organisms, viz. Staphylococcus aureus and coagulase-negative staphylococcus.

Page 12, Lines 221-222: ……….. and Cefepime (9 isolates, 69.2%) and commonly resistant to Ampicillin (11 isolates, 222 84.6%) and Amoxycillin/Clavulanic acid combination (10 isolates, 76.9%).

Comment: It seems to be that the intrinsic resistance was not considered for some of the organisms in the study. Those with intrinsic resistance against some particular organism, need not to be analysed for resistance/susceptibility profile against that particular organisms. Authors are strongly encouraged to seek help from clinical microbiologists or ID specialists for these technical issues

Response: We have discussed with the Clinical Microbiologist and considered the intrinsic resistance and removed those antibiotics. We have merged table 3 and table 4 as suggested by the other reviewers also.

Page 16, Lines 246-247: Therefore, we recommend adherence to the guidelines unless there is evidence-based justification to deviate from them.

Comment: The statement may be overly correct, as the authors themselves did not uniformly followed the WHO guidelines (choice of antibiotics) for all the subjects.

Response: Yes. We understand that and we have reported that practicality to avoid any biased statement.

Page 17, Lines 262-263: The finding is consistent with the findings from other Indian studies which has reported mixed infections with gram negative and gram-positive organisms. [14–16,20]

Comment: The authors should rephrase the above sentence as mixed infections term may be misleading and often refers to co-infections by both types of organisms mentioned above

Response: The sentence has been rephrased.

Page 17, Lines 266-267: Another strength of this study is that the proforma was filled by study nurses only, to rule out reporting bias.

Comment: Authors should also mention about the questionnaire filled up by the nurses under the ‘Methods’ section

Response: As suggested by the reviewers , mentioned under the ‘Methods’ section

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (19.1KB, docx)

Decision Letter 1

Arghya Das

11 Sep 2023

PONE-D-23-11380R1

Prospective cohort study of Surgical Site Infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, IndiaPLOS ONE

Dear Dr. Basany,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 26 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Arghya Das, MD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The exponentiated coefficients for logistic regression model are interpreted as odds ratios whereas for log-binomial regression they are relative risk ratios. The authors have mentioned that they have conducted logistic regression but mentioned relative risks instead of odds ratio. This needs clarification.

Please edit the title of the manuscript while resubmission and delete "Dear Editor".

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: No

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: No

Reviewer #4: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: No

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: The statistical analysis is not in accordance with the research question. The study variables are not well defined. The research question is whether there is a reduction in the SSI following single antibiotic prophylaxis but the analysis is on various risk factors rather.

The study population is not homogenous which includes both elective and emergency caesarean section group.

The elective section group included by the author also has patients in prolonged labour which is incorrect.

There is no comparator group. The institute's previous SSI atleast should be mentioned. The manuscript needs to be rewritten addressing all these inputs.

Reviewer #4: Page 12, Lines 219-220: ……….. and Cefepime (9 isolates, 69.2%) and commonly resistant to Ampicillin (11 isolates, 84.6%) and Amoxycillin/Clavulanic acid combination (10 isolates, 76.9%).

Comment: It seems that these lines depicting resistance/susceptibility profile of Ampicillin in Klebsiella species has not been modified as suggested by other reviewers. Authors are suggested to check the intrinsic resistance profile of Klebsiella species and accordingly make changes in the manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: Yes: J. Yavana Suriya

Reviewer #4: Yes: ANWITA MISHRA M.D

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Jan 25;19(1):e0286165. doi: 10.1371/journal.pone.0286165.r004

Author response to Decision Letter 1

19 Oct 2023

Responses to the reviewer’s comments

Editors comment:

1. The exponentiated coefficients for logistic regression model are interpreted as odds ratios whereas for log-binomial regression they are relative risk ratios. The authors have mentioned that they have conducted logistic regression but mentioned relative risks instead of odds ratio. This needs clarification.

Response: We thank the editor for pointing it out. We have revised the terminology used from ‘logistic regression’ to ‘binomial regression”. Vide line number 174-176.

Editors comment:

2. Please edit the title of the manuscript while resubmission and delete "Dear Editor".

Response: Thanks. We will ensure that while resubmitting the manuscript.

Reviewers # 3 comments

3. The statistical analysis is not in accordance with the research question. The research question is whether there is a reduction in the SSI following single antibiotic prophylaxis but the analysis is on various risk factors rather.

Response: We thank the reviewer for the comment. Please note that our primary objective was- to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO [8] in a tertiary care teaching hospital in Medchal, Telangana state, India. (Vide- line number 93-95).

Besides, we had two more secondary objectives- “Additionally, we looked at the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.” (Vide line number 99-101)

In our results, we have articulated the results in the same line- the incidence of SSI, the risk factors and the susceptibility pattern of the culture positive isolates.

All the authors have gone through the results and we strongly feel that the statistical analysis is in accordance with the research objectives.

4. The study variables are not well defined.

Response: We have added the definitions of all other variables those were missed out in the previous draft with appropriate references. (Vide line number 139 to 145). Please note that we have revised the sequence of references as well while incorporating the additional references.

5. The study population is not homogenous which includes both elective and emergency caesarean section group.

Response: We thank the author for the comment. Please note that in a hospital setting, we expect both elective and emergency caesarean section group. Hence, we believe that the population is homogeneous. In addition, we strongly feel that type of surgery may be directly related to SSI. Hence, we have reported the primary outcome of interest (SSI incidence) separately for both these groups to ensure clarity in the results.

6. The elective section group included by the author also has patients in prolonged labour which is incorrect.

Response: We agree with the reviewer and we have done the necessary correction in table 3.

7. There is no comparator group. The institute's previous SSI at least should be mentioned.

Response: As our primary outcome was to calculate the SSI incidence, we did not require a comparator group. Also, taking a historical control has it’s own challenges, especially the robustness of the information. Hence, we feel that taking a comparator group might not help improving the interpretation of the present finding. However, to calculate the risk, we have used the comparator group.

Reviewers #4 comment

8. It seems that these lines depicting resistance/susceptibility profile of Ampicillin in Klebsiella species has not been modified as suggested by other reviewers. Authors are suggested to check the intrinsic resistance profile of Klebsiella species and accordingly make changes in the manuscript.

Response: We thank the reviewer for pointing it out. Comment of the earlier reviewer was “It seems to be that the intrinsic resistance was not considered for some of the organisms in the study. Those with intrinsic resistance against some particular organism, need not to be analysed for resistance/susceptibility profile against that particular organisms. Authors are strongly encouraged to seek help from clinical microbiologists or ID specialists for these technical issues.”

Though we changed mostly based on the comment, we might have missed a few inadvertently. We have now incorporated the changes as suggested after discussing with the clinical microbiologist. The changes are as follows:

• The ampicillin resistance pattern for Klebsiella has been removed from the table and from the text. (Vide table 4, line number 227-8 in the text)

• For Staphylococcus aureus (Table 4), we have removed Methicillin as the Methicillin susceptibility/resistance was screened by cefoxitin). We have also removed Aztreonam and Vancomycin resistance/susceptibility pattern for Staphylococcus aureus. (Vide table 4, line number 223).

Attachment

Submitted filename: Responses to the Reviewers.docx

Click here for additional data file. (16.1KB, docx)

Decision Letter 2

Arghya Das

2 Nov 2023

PONE-D-23-11380R2Prospective cohort study of Surgical Site Infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, IndiaPLOS ONE

Dear Dr. Basany,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 17 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Arghya Das, MD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The manuscript has been satisfactorily revised. Addressing few minor issues would make the manuscript flawless.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

Reviewer #4: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: No

Reviewer #4: Yes

**********

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Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: 1) Labouring patients are included in the elective section group in the table.

2) Grammatical and punctuation errors needs to be corrected.

3) The names of the antibiotics like methicillin, ceftazidime, etc. and terms like caesarean delivery, elective need not be capitalised.

Reviewer #4: Authors have mentioned that all the isolates of Staphylococcus were sensitive to Methicillin (Table 4). (line number 223), but have not shown the same in table 4. As per CLSI guidelines, though Methicillin susceptibility/resistance was screened by cefoxitin, it should be mentioned in the table and the isolate should be reported in results as Methicillin sensitive Staphylococcus aureus (MSSA).

**********

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Reviewer #3: Yes: Yavana Suriya.J

Reviewer #4: Yes: ANWITA MISHRA M.D

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Jan 25;19(1):e0286165. doi: 10.1371/journal.pone.0286165.r006

Author response to Decision Letter 2

12 Dec 2023

Responses to reviewers

Reviewers # 3 comments

1. Labouring patients are included in the elective section group in the table

Response: We thank the reviewer for pointing it out. We have gone through the data source carefully and learned that an inadvertent error took place from our end , and we misclassified a few participants as elective section group, whereas, they should have been included in the emergency CS group. Hence, we have updated the data and reanalyzed it and updated the results and the discussion section as per the need. We have also replaced the previous data that we submitted to PLOS One with the updated data.

2. Grammatical and punctuation errors needs to be corrected

Response: Thank you the reviewer for pointing out. We have addressed them.

3. The names of the antibiotics like methicillin, ceftazidime, etc. and terms like caesarean delivery, elective need not be capitalised

Response: As suggested, we have changed into small letters.

.

Reviewers #4 comment

Authors have mentioned that all the isolates of Staphylococcus were sensitive to Methicillin (Table 4). (line number 223), but have not shown the same in table 4. As per CLSI guidelines, though Methicillin susceptibility/resistance was screened by cefoxitin, it should be mentioned in the table and the isolate should be reported in results as Methicillin sensitive Staphylococcus aureus (MSSA)

Response: We thank the reviewer for the comment. We have made necessary changes in the table.

Attachment

Submitted filename: Responses to the Reviewers - Copy.docx

Click here for additional data file. (14.9KB, docx)

Decision Letter 3

Arghya Das

18 Dec 2023

PONE-D-23-11380R3Prospective cohort study of Surgical Site Infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, IndiaPLOS ONE

Dear Dr. Basany,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Feb 01 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Arghya Das, MD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Authors have made few changes in the statistical figures but similar changes have not been made in the Abstract.

As per Table 1, the total number of patients for whom data on labour was available are 2015. But the same has been mentioned as 2010 in Table 3.

In Table 3, the percentage of participants in the Emergency CS group with <6 hours duration of labour has been wrongly mentioned.

In Table 3, the number of participants in the Elective CS group (non-labour) should be 783 not 78.3

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2024 Jan 25;19(1):e0286165. doi: 10.1371/journal.pone.0286165.r008

Author response to Decision Letter 3

19 Dec 2023

Responses to Editor comments

1. Authors have made few changes in the statistical figures but similar changes have not been made in the Abstract

Response: Thank the Editor for pointing out. Statistical figures have been changed.

2. As per Table 1, the total number of patients for whom data on labour was available are 2015. But the same has been mentioned as 2010 in Table 3.

Response: As suggested, the changes have been made.

3. In Table 3, the percentage of participants in the Emergency CS group with <6 hours duration of labour has been wrongly mentioned

Response: Thank the Editor for pointing out. We corrected the percentage.

4. In Table 3, the number of participants in the Elective CS group (non-labour) should be 783 not 78.3

Response: In Table 3, the number of participants in the Elective CS group was mentioned as 783.

Attachment

Submitted filename: Responses to reviewers.docx

Click here for additional data file. (14.2KB, docx)

Decision Letter 4

Arghya Das

22 Dec 2023

Prospective cohort study of Surgical Site Infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

PONE-D-23-11380R4

Dear Dr. Basany,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Arghya Das, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

A small correction for the number of Staphylococcus isolates and its percentage needs to be made in the Abstract. This discrepancy is present between what is mentioned in the main text (number of S. aureus n=7) and in the Abstract (number of S. aureus isolates n=23). This correction has not been made since revision of the earlier version of manuscripts. Authors should change it during the authors proofing stage.

Reviewers' comments:

Acceptance letter

Arghya Das

17 Jan 2024

PONE-D-23-11380R4

PLOS ONE

Dear Dr. Basany,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Arghya Das

Academic Editor

PLOS ONE

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