Title: Surgical Care Bundle: Effect on Post-Caesarean Wound Infection
Version: 1 Date: 19 Feb 2025
Reviewer's report:
Dear Authors,
thanks for this interesting manuscript on SSI and CS. The paper is well written and of outstanding
interest. I would appreciate some clarification. Please find attached my comments.
Best regards
Study Design and Statistical Analysis
The randomization process is not entirely clear. While the authors mention a selection method
using numbered papers, it is important to specify if allocation concealment was ensured to
prevent bias.
The statistical methods need further clarification:
The manuscript lacks detailed information on the statistical tests used for comparisons. Were t-
tests, chi-square tests, or Mann-Whitney U tests used for different variables?
Confidence intervals (CIs) should be reported for key findings, especially the primary outcome
(wound infection rate).
The effect size of the intervention should be reported, as statistical significance alone does not
indicate clinical relevance.
Results Interpretation
The study concludes that the surgical care bundle significantly reduced SSIs, yet it does not
address potential confounding factors. For example:
Were there baseline differences between groups that might have influenced outcomes?
Were perioperative antibiotic use, duration of surgery, or surgeon expertise accounted for?
The clinical implications of the findings should be elaborated upon. While the reduction in
SSIs is statistically significant, does this translate into meaningful cost reductions or improved
recovery times?
We recommend citing https://doi.org/10.1089/gyn.2023.0038
Discussion Needs Strengthening
The discussion section should compare findings more critically with existing literature. Several
cited studies (e.g., Gan et al. [33], Matthew Erritty et al. [24]) discuss care bundles, but a more
in-depth comparison of how this study aligns with or deviates from previous work is needed.
The mechanisms behind the effectiveness of the care bundle should be discussed. Is the reduction
in infection primarily due to antibiotic prophylaxis, skin antisepsis, or wound dressing protocols?
The study suggests that chlorhexidine outperformed other antiseptic methods, yet this is not
explicitly tested in the study design. A stronger emphasis on limitations is necessary.
Limitations Section Needs Expansion
The follow-up period is limited to 48 hours, whereas many SSIs develop within 7–10 days
postoperatively. This is a significant limitation.
The study is single-center, which may limit generalizability.
The sample size (n=100), while calculated appropriately, remains relatively small for a clinical
trial assessing infection outcomes.
The study does not account for long-term maternal morbidity or cost-effectiveness, which could
be valuable endpoints.
Minor Revisions
Clarity and Consistency in Language
Some sections are repetitive and could be streamlined for conciseness.
The introduction states, "Cesarean births can cause SSIs, with estimates ranging from 3 to 16%."
A more precise reference and context for these statistics would strengthen the statement.
The phrase "Women who receive the surgical care bundle are expected to exhibit a lower
occurrence of cesarean section wound infection than those who do not receive" should be revised
for grammatical accuracy (e.g., "...those who do not receive it.").
Terminology and Formatting
Standardize the terminology: "surgical care bundle", "intervention group", and "control group"
should be used consistently.
Tables and figures should have clear, standalone legends explaining their content without
requiring readers to search the text.
References
Ensure that all references are formatted consistently in accordance with journal guidelines.
Some citations appear incomplete or may require updates with DOIs.