Prevalence and predictors of surgical site infection in Tbilisi, Republic of Georgia

A Comparison of Chlorhexidine-Alcohol and Povidone-Iodine-Alcohol on the Incidence of Surgical Site Infection

BACKGROUND

Surgical site infection (SSI) persists as a global challenge, accounting for 20%-25% of all healthcare-associated infections. The SSI rate has been reported to range from 2.5% to 41.9%. Skin preparation with acceptable antiseptic preparations has a high recommendation from the Centers for Disease Control as an SSI preventive measure.

AIM

The aim was to compare the efficacy of 10% povidone-iodine in 70% isopropyl alcohol with 2% chlorhexidine in 70% isopropyl alcohol in preventing SSI.

METHOD

This prospective randomized study included patients who were followed up for 30 days looking for SSI. Swabs were taken from wounds that developed SSI. A culture of all swabs was done.

RESULT

One hundred and fifty-three patients were recruited into the study. Overall, eight (5.23%) of the 153 patients developed SSI. The SSI rate in clean wounds was 2.6%, while the SSI rate in clean-contaminated wounds was 7.9%. No statistically significant difference was found (p=0.141) between the two groups.

Surgical Site Infections at Shirati KMT Hospital in Northeastern Tanzania

Despite improved guidelines for surgical practices and better surgical methods and tools, surgical site infection (SSI) is still a common cause of morbidity and mortality with increased rates in resource-limited nations. In Tanzania, there is limited data on SSI and associated risk factors for developing an effective surveillance system for SSI. In this study, we aimed to establish for the first time the baseline SSI rate and its associated factors at the Shirati KMT Hospital in Northeastern Tanzania. We collected hospital records of 423 patients who had undergone major and minor surgeries between January 1 and June 9, 2019, at the hospital. After accounting for incomplete records and missing information, we analyzed a total of 128 patients and found an SSI rate of 10.9% and performed univariate and multivariate logistic regression analyses for elucidating the relationship between risk factors and SSI. All patients with SSI had undergone major operations. Moreover, we observed trends of increased association of SSI with patients who are 40 or younger, female, and had received antimicrobial prophylaxis or more than one type of antibiotics. In addition, patients who had received an American Society of Anesthesiologists (ASA) score of II or III, as one category, or undergone elective operations or operations lasting longer than 30 minutes were prone to develop SSI. Although these findings were not statistically significant, both univariate and multivariate logistic regression analyses showed a significant correlation between clean contaminated wound class and SSI, consistent with previous reports. The study is the first to elucidate the rate of SSI and its correlated risk factors at the Shirati KMT Hospital. We conclude that, based on the obtained data, clean contaminated wound class is a significant predictor of SSI at the hospital and that an effective surveillance system for SSI should begin with adequate record keeping of all patients' hospitalization and an efficient follow-up system. Moreover, a future study should aim to explore more widespread SSI predictors such as premorbid illness, HIV status, duration of hospitalization prior to operation, and type of surgery.

Core components of infection prevention and control programs at the facility level in Georgia: key challenges and opportunities

Background

The Georgia Ministry of Labor, Health, and Social Affairs is working to strengthen its Infection Prevention and Control (IPC) Program, but until recently has lacked an assessment of performance gaps and implementation challenges faced by hospital staff.

Methods

In 2018, health care hospitals were assessed using a World Health Organization (WHO) adapted tool aimed at implementing the WHO’s IPC Core Components. The study included site assessments at 41 of Georgia’s 273 hospitals, followed by structured interviews with 109 hospital staff, validation observations of IPC practices, and follow up document reviews.

Results

IPC programs for all hospitals were not comprehensive, with many lacking defined objectives, workplans, targets, and budget. All hospitals had at least one dedicated IPC staff member, 66% of hospitals had IPC staff with some formal IPC training; 78% of hospitals had IPC guidelines; and 55% had facility-specific standard operating procedures. None of the hospitals conducted structured monitoring of IPC compliance and only 44% of hospitals used IPC monitoring results to make unit/facility-specific IPC improvement plans. 54% of hospitals had clearly defined priority healthcare-associated infections (HAIs), standard case definitions and data collection methods in their HAI surveillance systems. 85% hospitals had access to a microbiology laboratory. All reported having posters or other tools to promote hand hygiene, 29% had them for injection safety. 68% of hospitals had functioning hand-hygiene stations available at all points of care. 88% had single patient isolation rooms; 15% also had rooms for cohorting patients. 71% reported having appropriate waste management system.

Conclusions

Among the recommended WHO IPC core components, existing programs, infrastructure, IPC staffing, workload and supplies present within Georgian healthcare hospitals should allow for implementation of effective IPC. Development and dissemination of IPC Guidelines, implementation of an effective IPC training system and systematic monitoring of IPC practices will be an important first step towards implementing targeted IPC improvement plans in hospitals.

Surgical Antibiotic Prophylaxis Use and Surgical Site Infection Pattern in Dessie Referral Hospital, Dessie, Northeast of Ethiopia

Background

Surgical site infections are the third (14%-16%) most frequent cause of nosocomial infections among hospitalized patients. They still form a large health problem and result in increased antibiotic usage, increased associated costs, and prolonged hospitalization and contribute to increased patient morbidity and mortality. Therefore, studies on surgical site infections and surgical antibiotic prophylaxis contribute to identifying surgical site infection rate and risk factor associated with it as well as for identifying the gap in surgical antibiotic prophylaxis practice.

Objective

To assess surgical antibiotic prophylaxis practice and surgical site infection among surgical patients.

Method

A hospital-based prospective observational study was conducted in 68 patients who underwent major surgery in Dessie Referral Hospital adult surgical wards between March 24 and April 25/2017. Descriptive and logistic regression analyses were performed to determine infection rate and risk factors for surgical site infections.

Result

Assessment of 68 patients who underwent major surgery revealed an overall surgical site infection rate of 23.4%. Prophylactic antibiotics were administered for 59 operations; of these, 33 (48.6%) had inappropriate timing of administration. A combination of ceftriaxone and metronidazole 28 (47.46%) was frequently used. Factors associated with surgical site infection were wound class, patient comorbid condition, duration of the procedure, the timing of administration, and omitting prophylaxis use.

Conclusion

This study indicated a higher rate of surgical site infection and also revealed that wound class, preexisting medical condition, prolonged duration of surgery, omitting of prophylaxis use, and inappropriate timing of administration were highly associated with surgical site infection.

Functional outcomes after flexor tendon repair of the hand

Objectives

This study aims to evaluate the hand function after flexor tendon repair (FTR) and to investigate factors associated with functional outcomes.

Patients and methods

Between January 2013 and September 2015, a total of 126 patients (84 males, 42 females; mean age 31 years; range, 15 to 62 years) who underwent FTR due to flexor tendon injuries (FTIs) were included. The hand function was assessed using the Jebsen Hand Function Test (JHFT) and Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) at three and six months following FTR.

Results

Of the patients, 94 (75%) and 72 (56%) completed the three-month and six-month assessment visits, respectively. A total of 65 patients (51.1%) had both three and six-month follow-up data. The patients regained a fair amount of power grip strength and more than half of their pinch grip strength compared to the unaffected hand. The results of assessment of hand function at activity and participation levels (JHFT and Quick DASH) showed slightly higher levels of disability. Of 41 patients who were employed prior to injury, 29 (71%) returned to work at six months after surgery. Zone IV injury and language barrier were associated with poor functional outcomes at six months.

Conclusion

Our study results showed that the JHFT and Quick DASH scores of the patients were less than the established norms, although functional outcomes improved over time. Based on these results, we suggest that the presence of zone IV FTI and language barrier are associated with poor functional outcomes.

Risk factors for surgical site infections in abdominal surgery: a study in Nepal

BACKGROUND

Surgical site infection (SSI) remains a major clinical problem for developing countries in terms of morbidity, mortality, and hospital cost. Little is known about the epidemiology of SSI in Nepal. We conducted a study in Nepal to identify the various pre- and intra-operative risk factors for SSIs that are accessible to interventions.

METHODS

The study was a prospective study done on all eligible patients who underwent abdominal surgery in the surgical wards of Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal, from January 2011 to June 2011. We evaluated some patient-related as well as intra-operative variables that could be risk factors for SSIs. We assessed the association between these risk factors and SSI with the Fisher exact test and logistic regression analysis.

RESULTS

Of the 230 patients included in the study, 53 were identified as having a SSI, resulting in an overall rate of SSI of 23%. Multivariable analysis identified the following factors as independent risk factors for SSI: (1) Low hemoglobin concentrations (<12 g/dL) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1-6.1); (2) overweight (OR 7.6; 95% CI 2.1-27.0); and (3) surgery performed by residents (OR 3.4; 95% CI 1.4-8.3).

CONCLUSIONS

Surgical site infection is common among patients undergoing abdominal surgery at TUTH. This study identified some preventable risk factors associated with SSI at TUTH. Identification of such risk factors is expected to help surgeons improve patient care and decrease mortality and morbidity as well as the hospital-care cost of surgical patients.

Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania

Background

Surgical site infection (SSI) continues to be a major source of morbidity and mortality in developing countries despite recent advances in aseptic techniques. There is no baseline information regarding SSI in our setting therefore it was necessary to conduct this study to establish the prevalence, pattern and predictors of surgical site infection at Bugando Medical Centre Mwanza (BMC), Tanzania.

Methods

This was a cross-sectional prospective study involving all patients who underwent major surgery in surgical wards between July 2009 and March 2010. After informed written consent for the study and HIV testing, all patients who met inclusion criteria were consecutively enrolled into the study. Pre-operative, intra-operative and post operative data were collected using standardized data collection form. Wound specimens were collected and processed as per standard operative procedures; and susceptibility testing was done using disc diffusion technique. Data were analyzed using SPSS software version 15 and STATA.

Results

Surgical site infection (SSI) was detected in 65 (26.0%) patients, of whom 56 (86.2%) and 9 (13.8%) had superficial and deep SSI respectively. Among 65 patients with clinical SSI, 56(86.2%) had positive aerobic culture. Staphylococcus aureus was the predominant organism 16/56 (28.6%); of which 3/16 (18.8%) were MRSA. This was followed by Escherichia coli 14/56 (25%) and Klebsiella pneumoniae 10/56 (17.9%). Among the Escherichia coli and Klebsiella pneumoniae isolates 9(64.3%) and 8(80%) were ESBL producers respectively. A total of 37/250 (14.8%) patients were HIV positive with a mean CD4 count of 296 cells/ml. Using multivariate logistic regression analysis, presence of pre-morbid illness (OR = 6.1), use of drain (OR = 15.3), use of iodine alone in skin preparation (OR = 17.6), duration of operation ≥ 3 hours (OR = 3.2) and cigarette smoking (OR = 9.6) significantly predicted surgical site infection (SSI)

Conclusion

SSI is common among patients admitted in surgical wards at BMC and pre-morbid illness, use of drain, iodine alone in skin preparation, prolonged duration of the operation and cigarette smoking were found to predict SSI. Prevention strategies focusing on factors associated with SSI is necessary in order to reduce the rate of SSI in our setting.

Multi-drug-resistant gram-negative bacterial infection in surgical patients hospitalized in the ICU: a cohort study

We sought to identify risk factors for postoperative infections, caused by multi-drug-resistant gram-negative bacteria (MDR-GNB) in surgical patients. This was a retrospective cohort study among patients hospitalized in the intensive care unit (ICU) for more than 5 days, following general surgical operations. Comparison of patients who developed infection caused by MDR-GNB with the remainder of the cohort showed that every minute of operative time, use of special treatments during hospitalization (antineoplastic, immunosuppressive or immunomodulating therapies), every day of metronidazole, and every day of carbapenems use, increased patients' odds to acquire an infection caused by MDR-GNB by 0.7%, 8.9 times, 9%, and 9%, respectively [OR (95% CI): 1.007 (1.003-1.011), p = 0.001; 8.9 (1.8-17.3), p = 0.004; 1.09 (1.04-1.18), p = 0.039; 1.09 (1.01-1.18), p = 0.023, respectively]. The above were adjusted in the multivariable analysis for the confounder of time distribution of infections caused by MDR-GNB. Finally, the secondary comparison, with patients that did not develop any infection, showed that patients who had received antibiotics, within 3 months prior to admission, had 3.8 times higher odds to acquire an infection caused by MDR-GNB [OR (95% CI): 3.8 (1.07-13.2), p = 0.002]. This study depicts certain, potentially modifiable, risk factors for postoperative infections in patients hospitalized in the ICU for more than 5 days.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

BACKGROUND

Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries.

METHODS

We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis.

FINDINGS

Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance.

INTERPRETATION

The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices.

FUNDING

World Health Organization.

Etiology of neonatal blood stream infections in Tbilisi, Republic of Georgia

BACKGROUND

Neonatal blood stream infections (BSI) are a major cause of morbidity and mortality in developing countries. It is crucial to continuously monitor the local epidemiology of neonatal BSI to detect any changes in patterns of infection and susceptibility to various antibiotics.

OBJECTIVES

To examine the etiology of BSI in two neonatal intensive care units (NICUs) in the Republic of Georgia, a resource-poor country, and to determine antibiotic susceptibility of the isolated organisms.

METHODS

A cross-sectional study of all septic infants was conducted in the NICUs of two pediatric hospitals in Tbilisi between September 2003 and September 2004.

RESULTS

A total of 200 infants with clinical signs of sepsis were admitted to two NICUs. Of these, 126 (63%) had confirmed bacteremia. The mortality rate was 34%. A total of 98 (78%) of 126 recovered isolates were Gram-negative organisms and 28 (22%) were Gram-positive. Klebsiella pneumoniae was the most common pathogen, accounting for 36 (29%) of 126 isolates, followed by Enterobacter cloacae accounting for 19 (15%) and Staphylococcus aureus accounting for 15 (12%). The Gram-negative organisms showed a high degree of resistance to commonly used antibiotics such as ampicillin and amoxicillin/clavulanate, and comparatively low resistance to amikacin, ciprofloxacin, carbapenems, and gentamicin; 40% of S. aureus isolates were methicillin-resistant (MRSA). In multivariate analysis only umbilical discharge was a significant risk factor for having a positive blood culture at admission to NICU (prevalence ratio = 2.25, 95% confidence interval 1.82-2.77).

CONCLUSIONS

Neonatal BSI was mainly caused by Gram-negative organisms, which are developing resistance to commonly used antibiotics. Understanding the local epidemiology of neonatal BSI can lead to the development of better medical practices, especially more appropriate choices for empiric antibiotic therapy, and may contribute to improvement of infection control practices.