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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1126-1132

Surgical site infection in abdominal surgery: A prospective study


1 General Surgery Department, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 General Surgery Department, El Helal Hospital for Health Insurance, Shebeen El-Kom, Egypt

Date of Submission13-Apr-2017
Date of Acceptance09-May-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Ahmed I Swelam
Birket El Saba, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_292_17

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  Abstract 


Objective
The objective of this review was to characterize risk factors for surgical site infection (SSI) within observational studies describing incidence of SSI in a real-world setting.
Data sources
Medline databases (PubMed, Medscape, ScienceDirect and EMF-Portal) and all materials available on the Internet from 1991 to 2016 were used.
Study selection
An initial search identified 328 titles published in 2000–2016; 57 were identified as relevant for data extraction. The articles studied the incidence and risk factors of SSI in general or in specific types of surgeries on variable number of patients.
Data extraction
If the studies did not fulfill inclusion criteria, they were excluded. Study quality assessment included whether ethics approval was gained, eligibility criteria were specified, appropriate controls were used, and adequate information and defined assessment measures were described.
Data synthesis
Comparisons were made by structured review with the results tabulated.
Findings
The median SSI incidence was 3.7%, ranging from 0.1 to 50.4%. Incidence of overall SSI and Staphylococcus aureus SSI were both highest in tumor-related and transplant surgeries. The median time until SSI onset was 17.0 days. Risk factors consistently identified as associated with SSI included comorbidities, advanced age, risk indexes, patient comorbidity, and surgery complexity. Thirteen studies considered diabetes as a risk factor in multivariable analyses; 85% found a significant association with SSI. Longer surgeries were associated with increased SSI risk, with a median odds ratio of 2.3 across 11 studies reporting significant results.
Conclusion
In a broad review of the published literature, the median SSI incidence was 3.7%. Risk factors for SSI were characterized as describing reduced fitness, patient comorbidity, surgery duration, and complexity. Recognition of risk factors frequently associated with SSI allows for optimal preventive measures before surgery.

Keywords: postoperative wound infection, risk factors, surgical site infection


How to cite this article:
Alam El-Din ML, Amar MS, Swelam AI. Surgical site infection in abdominal surgery: A prospective study. Menoufia Med J 2018;31:1126-32

How to cite this URL:
Alam El-Din ML, Amar MS, Swelam AI. Surgical site infection in abdominal surgery: A prospective study. Menoufia Med J [serial online] 2018 [cited 2024 Mar 29];31:1126-32. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1126/252040




  Introduction Top


The term 'surgical site infection' (SSI) was introduced in 1992 to replace the previous term 'surgical wound infection'[1]. Despite modern surgical techniques and the use of antibiotic prophylaxis, SSI is one of the most common complications encountered in surgery. SSI places a significant burden on both the patient and the healthcare system, especially in Africa where resources are limited. SSI occurs in up to 40% of surgical procedures, delaying recovery by 1 week on average and often resulting in the need for further surgical procedures. It is still a major limiting factor in advancing the horizons of surgery in spite of the progress made in its control. SSI is thus a major cause of morbidity, prolonged hospital stay, and increased health costs[2].

SSIs are associated with considerable morbidity and it has been reported that over one-third of postoperative deaths are related, at least in part, to SSI. However, it is important to recognize that SSIs can range from a relatively trivial wound discharge with no other complications to a life-threatening condition. Other clinical outcomes of SSIs include poor scars that are cosmetically unacceptable, such as those that are spreading, hypertrophic, or keloid, persistent pain and itching, restriction of movement, particularly when over joints, and a significant impact on emotional well-being[3].

Numerous patient-related and procedure-related factors influence the risk of SSI, and hence prevention requires a 'bundle' approach, with systematic attention to multiple risk factors, to reduce the risk of bacterial contamination and improve patient defenses. The Centers for Disease Control and Prevention guidelines for the prevention of SSIs emphasize the importance of good patient preparation, aseptic practice, and attention to surgical technique. Antimicrobial prophylaxis is also indicated in specific circumstances[4].

Measures to reduce rates of preventable SSI and their associated adverse outcomes will improve the safety and quality of care while avoiding substantial costs, thereby benefiting all consumers of healthcare. Change in Medicare payment policy eliminating additional payments for healthcare-associated infection underscores the urgent need for hospital leaders to address this important problem[5].

As postoperative SSI is associated with high rates of morbidity and even mortality, this study aimed to identify risk factors of SSI in the published literature. This allows for prevention of SSI and decreases postoperative hospital stay.


  Materials and Methods Top


Data source

Itsa meta analysis no patients consent in that we searched Medline, Embase, the Database of Abstracts of Reviews of Effects, and the Cochrane Database of Systematic Reviews. The search strategy was limited to articles published in the English language between 1 January 2000 and 31 December 2016. This search was supplemented by a PubMed search conducted on 31 December 2016 to include the most recently published articles indexed within Medline. The search strategy included the broad key terms 'Surgical site infection', 'Staphylococcus aureus', and 'Risk factor'. Reference lists of included articles were searched for additional relevant sources. Potential eligibility based on inclusion criteria was assessed in a title review, followed by an abstract review. Articles for which the abstract review suggested potential eligibility were assessed in full-text. For articles that were excluded at any stage, the specific reason for exclusion was documented.

Study selection

Criteria for inclusion, which were applied at all review stages, were as follows:

  1. The study had to be observational and published in a peer-reviewed journal,
  2. The study had to report a relative effect for a risk factor of SSI after surgery, and
  3. If a study had several publications on certain aspects, we used the latest publication giving the most relevant data.


Data extraction

If the studies did not fulfill the above-mentioned criteria, they were excluded. A systematic approach to data extraction was used to produce a descriptive summary of participants, interventions, and study findings. Extracted data included study design, institutional factors, baseline population, and operative characteristics, incidence of SSI [Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), superficial incisional-space, deep incisional-space, and organ-space], time until onset of infection, and risk factor estimates including odds ratios, confidence intervals, and P values for statistical significance.

Quality assessment

The quality of all the studies was assessed. Important factors included study design, attainment of ethics approval, evidence of a power calculation, specified eligibility criteria, appropriate controls, and adequate information, and specified assessment measures. It was expected that confounding factors would be reported and controlled for and appropriate data analysis carried out in addition to an explanation of missing data.

Data synthesis

A structured systematic review was performed with the results tabulated.


  Results Top


Data source

Medline databases (PubMed, Medscape, ScienceDirect, and EMF-Portal) and all materials available on the Internet from 1991 to 2016 were searched using broad key terms 'Surgical site infection', 'Staphylococcus aureus', and 'Risk factor'. A summary of the number of titles, abstracts, and full-text articles reviewed and reasons for exclusion are presented in [Figure 1].
Figure 1: Flow chart of study selection.

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Study selection

In total, 328 potentially relevant publications were identified, and 271 articles were excluded as they did not meet our inclusion criteria. A total of 57 studies were included in the review, as they were deemed eligible by fulfilling inclusion criteria.

Data extraction

Extracted data included study design, institutional factors, baseline population, and operative characteristics, incidence of SSI (S. aureus, MRSA, superficial incisional-space, deep incisional-space, and organ-space), time until onset of infection, and risk factors.

Data synthesis

Statistical analysis of the extracted data included odds ratios, confidence intervals, and P values for statistical significance. Approximately 90% of the studies utilized either a cohort or a case–control design. Although individual study designs varied, all studies described a systematic sampling strategy in which all surgeries meeting predefined inclusion criteria were considered. There were 25 (43.1%) studies from the USA and 20 (35.1%) studies from Europe or Canada. Four studies were based in Eastern Asia, and eight were from other geographical regions. The median sample size of studies was 437 surgeries, with sample sizes ranging from a prospective cohort of 131 surgeries in Saudi Arabia[6] to a national surveillance database of over 70 000 surgeries in the Netherlands[7].

Unadjusted and adjusted odds ratios are presented in [Table 1] and [Table 2] for key risk factors that were either identified a priori as being of particular interest or noted as frequently reported across studies. Variables that were most consistently found to have odds ratios more than 1 for all infections (i.e., SSI, S. aureus SSI, and MRSA SSI) in both unadjusted and adjusted analyses included increasing BMI, more severe derived risk indexes, more severe wound class, diabetes status, and increased surgery duration. Other factors such as increased patient dependence, smoking status, increasing age, S. aureus colonization, and use of medical device were significantly associated with increased risk of all SSIs (i.e., SSI, S. aureus, and MRSA SSI) in adjusted analyses. Although five studies reported statistically significant unadjusted associations and six studies reported statistically significant adjusted associations between SSI and prophylaxis [Table 2], the majority of these represented comparisons across alternative prophylaxis regimens as opposed to comparison of any prophylaxis use versus none. One study reported an association between antibiotic prophylaxis and increased odds of SSI[8]; however, the report was not corroborated by other studies. Twenty-five studies assessed the relationship between derived risk indexes such as the Charlson, National Nosocomial Infections Surveillance (NNIS), or American Society of Anesthesiologists (ASA) indexes, and risk of SSI. A number of estimates failed to achieve statistical significance [Table 2], although a large majority of unadjusted and adjusted point estimates indicated a trend towards increased risk. Most estimates were based on a single cutpoint to create a binary indication of high versus low risk score; however, some estimates were based on the original multilevel scales and indicated a dose–response relationship for the NNIS[7],[9] and Charlson[10] indexes. Comorbidities were consistently found to be associated with SSI incidence. The most frequently considered comorbidity was diabetes, which was included in 13 adjusted analyses, and 85% of these reported a statistically significant association.
Table 1: Characteristics of the study design in 57 studies meeting full-text inclusion criteria

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Table 2: Odds ratio ranges for estimates of key risk factors for all surgical site infections, stratified by unadjusted and adjusted methods

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Other comorbidities for which significant adjusted associations were found included chronic obstructive pulmonary disease[11],[12],[13],[14], coronary heart disease[13], congestive heart failure[15], acute myocardial infarction[16], renal insufficiency[15], hypertension[17], and osteoporosis[18]. The relationship between increasing number of comorbidities and SSI was assessed in several studies. In unadjusted analyses, four studies reported a statistically significant association between increasing number of comorbidities and SSI[18],[19],[20],[21], and three studies reported statistically significant adjusted results[19],[20],[21]. In adjusted analyses, increasing number of comorbidities was associated with an estimated odds ratio for SSI of 1.7 [95% confidence interval (CI): 1.3–2.9] per comorbidity[21], and the presence of at least one comorbidity was associated with an estimated odds ratio for SSI of 2.3 (95% CI: 1.2–4.7)[19] in spinal surgeries and 6.1 (95% CI: 1.3–28.9) in all major surgeries[20]. Ten studies considered risk factors describing patient dependence, which were characterized into a variety of groups, including independence and activities of daily living[10],[22],[23],[24],[25], incontinence[22],[25],[26], and admission from a long-term healthcare facility[10],[24]. The majority of these factors were only considered in unadjusted analyses. Adjusted estimates included an odds ratio for SSI of 4.35 (95% CI: 1.64–11.11) associated with admission from a long-term health facility[24], and an odds ratio for SSI of 2.75 (95% CI: 1.16–6.46) associated with requiring assistance with three or more activities of daily living[22]. Variables describing the complexity and/or duration of surgery were also found to be associated with risk of SSI in 16 studies. Duration was defined either relative to a cutpoint (e.g., 75th percentile, 120, 180 min), as a continuous measure per minute of surgery, or as a multilevel categorical variable. Across definitions, increased duration of surgery was consistently found to be associated with increased risk of SSI. When results were restricted to 16 studies that used a binary cutpoint to compare shorter versus longer surgeries, 15 of 16 estimates suggested an increased risk of SSI for longer surgeries[9],[10],[19],[20],[22],[24],[25],[27],[28],[29],[30],[31],[32],[33],[34]: 11 of these were statistically significant, with estimated odds ratios ranging from 1.2 to 3.8 with a median value of 2.3. Preoperative length of stay was identified as a significantly associated risk factor for SSI in 12 studies[7],[8],[9],[10],[20],[21],[31],[34],[35],[36],[37]. Odds ratios for SSI per additional day of preoperative stay ranged from 1.0 to 2.0, with a median of 1.1[8],[9],[10],[34],[36],[37]. Odds ratios associated with surgeries requiring a previous overnight stay were estimated to be 1.4[35] and 4.6[27]. One study found that preoperative hospitalizations of up to 7 days were not associated with a significant risk of SSI, but that preoperative stays of eight days or longer were associated with an ∼10-fold increased risk of SSI[38].


  Discussion Top


In this broad review of the published literature, a number of risk factors for overall SSI, S. aureus SSI, and MRSA SSI were identified; these included variables describing reduced patient fitness such as comorbidities, advanced age, risk indexes (ASA or NNIS), increased BMI, and patient dependence. Other important markers included increased length of preoperative hospital stay and surgery complexity including increased surgical time. Identified risk factors were biologically plausible, suggesting that patients who are less fit, who have a greater in-hospital exposure time, and/or are undergoing longer and more complex surgeries are at an increased risk for SSI. A statistically significant association between antibiotic prophylaxis and increased risk of SSI observed in one study lacked biological plausibility as a causal relationship given well-documented evidence regarding a protective effect of antibiotics for SSI[39],[40], and increased risks documented in observational studies may be a result of confounding by indication, for example, due to increased antibiotic use in patients deemed to be at high-risk for infection, in more complex surgeries, or in surgeries for which medical errors may have occurred[41],[42]. As has been noted previously, generating estimates across studies is challenging because of variation in study characteristics, variable definition, specific surgeries included, and study quality[43],[44]. As such, overall trends in risk factors were assessed, focusing on direction of effect and achievement of statistical significance, rather than quantitative synthesis across estimates, which are not directly comparable. Where applicable, subsets of studies that characterized risk factors using comparable definitions were pooled to generate summary estimates. In addition to variables reported as risk factors for SSI within individual studies, a study-level comparison of reported cumulative incidence [Table 2] provides further insight into surgical-level risk factors, as some studies focused on specific types of surgery. These results suggest that the highest rates of infection are observed in tumor-related surgeries and transplant surgeries; however, these are based on observed results across relatively small numbers of studies rather than formal statistical comparisons, and can be interpreted only as exploratory evidence. Despite widespread adoption of preventive measures by institutions, SSIs continue to occur, and, although the results presented here do not call into question recommendations for existing prevention options, they do suggest a remaining gap and a potential benefit of additional options to further reduce SSI incidence in high-risk patient subgroups. Given that specific patient-level and operative-level risk factors have been consistently observed across studies, and the availability of formal risk indexes such as ASA and NNIS scores for identifying high-risk patients, those patients with the greatest need for optimal preventive measures can be identified before surgery. Strengths of this review include the comprehensive nature of study eligibility and risk factor consideration. All observational studies reporting risk factors for SSI across all types of surgery were considered for inclusion, and all risk factor estimates were extracted from each study, giving a broad view of risk factors as observed in routine clinical practice across a variety of settings. Given the variation in studies, a number of stratified analyses were performed to compare results against specific study characteristics, including surgery type, geography, and population characteristics; however, broad trends remained consistent in these stratified analyses and further interpretation was limited due to small study numbers; these results are not included here. The comprehensive nature of the review also led to limitations: a broad collection of studies with variability in methodology and risk factors considered were included in the review, which presented challenges in numerical synthesis of results. As such, results are primarily focused on the direction of effect, as opposed to magnitude. A narrower focus on specific risk factors would allow for more detailed exploration of individual trends and magnitude of effect across studies. Results were presented to summarize the entire range of studies, and differences in sample sizes were not accounted for in the presentation of results. Although the variability across studies limited the ability to generate a single quantitative estimate for specific risk factors, it also provides strength in evidence of the direction of effect for factors such as comorbidity burden, patient dependence, and duration and complexity of surgery, which were consistently found to be associated with an increased risk of SSI, across a variety of study designs, study settings, and variable categorizations and definitions.


  Conclusion Top


In a broad review of the published literature, median SSI incidence was 3.7%. Risk factors for SSI were characterized as describing reduced fitness, patient comorbidity, surgery duration, and complexity. Recognition of risk factors frequently associated with SSI allows identification of such patients with the greatest need for optimal preventive measures and pretreatment before surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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