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

Comparison of abdominal depth with subcutaneous fat thickness in predicting surgical site infection among patients undergoing hepatopancreatobiliary surgery: a prospective observational study

Introduction

Surgical site infection (SSI) is a significant cause of postoperative morbidity resulting in an increased hospital stay and cost. Various measures have been used to predict SSI such as subcutaneous fat thickness (SCFT) and abdominal depth (AD) in case of abdominal surgeries. The objective of the study was to compare SCFT with AD to predict SSI in HPB surgeries.

Methods

A prospective observational study was conducted from February 2020 to February 2021, which included 76 patients who underwent elective open hepatopancreatobiliary surgeries. SCFT and AD at the level of the umbilicus were measured preoperatively using the computed tomography abdomen. The occurrence of SSI was evaluated in correlation with SCFT and AD. SCFT and AD were compared using the receiver operating characteristic curve for prediction of SSI.

Results

Twenty-five (32.3%) patients who underwent elective HPB surgeries developed SSI. 72% of the SSI were superficial. In multivariate analysis, only SCFT was associated with SSI, which was statistically significant. It was compared with AD using the receiver operating characteristic curve where SCFT proved to be better at predicting SSI (AUC=0.884) with cut-off =2.13 cm, sensitivity 84%, and specificity 86%), compared to AD with an AUC of 0.449.

Conclusion

SSI is the common cause of increased morbidity following hepato-pancreato-biliary surgeries with risk factors including SCFT and AD. Approximately one-third of patient developed SSI, with most the common being superficial SSI. SCFT at the incision site was associated with an increased rate of SSI and the better predictor for SSI as compared with the AD.

Assessment of risk factors associated with surgical site infection following abdominal surgery: a systematic review

Objective

Surgical site infections (SSIs) are among the most common healthcare-associated infections occurring following 1%-3% of all surgical procedures. Their rates are the highest following abdominal surgery. They are still associated with increased morbidity and healthcare costs despite the advancement in the medical field. Many risk factors for SSIs following abdominal surgery have been identified. The aim of this study is to comprehensively assess these risk factors as published in peer-reviewed journals.

Design

A systematic review was conducted with accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Setting

The databases for search were PubMed and Cochrane Library, in addition to reference lists. Studies were retrieved and assessed for their quality. Data were extracted in a designed form, and a stratified synthesis of data was conducted to report the significant risk factors.

Participants

Patients undergoing general abdominal surgery.

Intervention

The intervention of general abdominal surgery.

Main outcome measures

To identify and assess the risk factors for SSI following abdominal surgery.

Results

Literature search yielded 813 articles, and the final screening process identified 11 eligible studies. The total number of patients is 11 996. The rates of SSI ranged from 4.09% to 26.7%. Nine studies were assessed to be of high quality, the remaining two studies have moderate quality. Stratified synthesis of data was performed for risk factors using summary measures (OR/risk ratio, 95% CI, and p value). Male sex and increased body mass index (BMI) were identified as significant demographic risk factors, and long operative time was among the major significant procedure-related risk factors.

Conclusions

Male sex, increased BMI, diabetes, smoking, American Society of Anesthesiologists classification of >2, low albumin level, low haemoglobin level, preoperative hospital stay, long operative time, emergency procedure, open surgical approach, increased wound class, intraoperative blood loss, perioperative infection, perioperative blood transfusion, and use of drains are potential independent risk factors for SSI following abdominal surgery.

Surgical Site Infection in Obstetric and Gynecological Surgeries: A Prospective Observational Study

Introduction An infection at an incisional site that develops within 30 days after surgery, or within a year if a prosthetic is implanted, is referred to as a surgical site infection (SSI). They are mainly caused by exogenous and/or endogenous microbes that penetrate the surgical site during surgery (primary infection) or after the procedure (secondary infection). The prevention of SSI should be the ultimate goal of the surgery team and hospital administration. Methodology The prospective observational study of SSI consisted of 920 patients who were admitted and underwent surgery between April 2021 and September 2022. After a complete examination, a detailed proforma for the collection of data pertaining to patients in this study was prepared, and patients were included as per the inclusion and exclusion criteria. Results The study demonstrated significant results in terms of the association of body mass index (BMI), hemoglobin, and blood sugar level with the SSI status (p<0.05) and nonsignificant results in terms of emergency/elective surgery, type of surgery, and type of incision (p>0.05). Conclusion The overall rate of SSI was 9.2% in the present study. The major reasons involved are inadequate infrastructure facilities, different antibiotics policies, and non-uniform pre-, intra-, and post-operative measures that add woes and result in an increased incidence of SSI. In the present study that was undertaken at a teaching and tertiary care center, the SSI incidence is comparatively lower, but with the implementation of correct knowledge and technique, the rate can further be reduced to a large extent.

Healthcare workers’ knowledge and attitudes towards sterilization and reuse of medical devices in primary and secondary care public hospitals in Nepal: A multi-centre cross-sectional survey

Background

Healthcare facilities reprocess and sterilize reusable medical devices before each invasive clinical procedure, such as surgery, to prevent person-to-person or environmental transmission of pathogens through medical devices. We conducted a nationwide multi-centre cross-sectional survey in primary and secondary-care public hospitals in Nepal to assess the knowledge and attitudes of healthcare workers towards sterilization and reuse of medical devices.

Methods

We carried out a multi-centre cross-sectional survey comprising eleven primary-care (two district-level and nine district hospitals) and two secondary-care (zonal hospitals) public hospitals which covered all seven provinces of Nepal. Survey questionnaires were distributed to 234 healthcare workers including doctors, nurses, paramedics, and office assistants (involved in medical device reprocessing); 219 (93.6%) returned the completed questionnaire. Descriptive analyses of demographic information, knowledge and attitude responses of survey participants were performed. Logistic regression and ordinal regression models for complex samples were used to investigate associations between responses and independent variables.

Results

Except for a few areas, more than 70% of healthcare workers had proper knowledge about different aspects of sterilization and reuse of medical devices. Paramedics and office assistants were less likely to have the correct knowledge in different aspects compared to nurses. Permanent staff were more likely to give correct answers to some knowledge questions compared to temporary staff. Previous infection control training was positively associated with correct responses to some knowledge items. Most of the healthcare workers had positive attitudes towards different aspects of sterilization and reuse of medical devices, and nurses were more likely to have positive attitudes compared with other staff categories.

Conclusions

Most of the healthcare workers had correct knowledge and positive attitudes towards most areas of sterilization and reuse of medical devices. However, they need proper education and training in some areas such as sterilization procedures, storage of sterilized devices, prion decontamination and standard precautions.

Thickness of subcutaneous fat is a risk factor for incisional surgical site infection in acute appendicitis surgery: a prospective study

BACKGROUND

Incisional surgical site infection (SSI) is a significant source of postoperative morbidity resulting in increased length of stay and cost. In this study, our aim was to evaluate the association between thickness of subcutaneous fat (TSF) and incisional SSI among patients undergoing open appendectomy in low-resource settings.

METHODS

90 patients with acute uncomplicated appendicitis who underwent emergency open appendectomy from December 2017 to August 2018 were included in this prospective study. TSF was measured preoperatively using ultrasound. TSF and other possible predictors of incisional SSI, including body mass index and other clinical characteristics, were assessed by univariate and multivariable logistic regression analysis. Receiver operating characteristic (ROC) curve analysis evaluated the predictive value of TSF and the optimum cut-off value for TSF was determined using the Youden index.

RESULTS

The prevalence of incisional SSI was 13.3% (12/90). TSF was independently associated with incisional SSI (P < 0.001). Additionally, history of smoking (P = 0.048) was also associated with incisional SSI. A model of incisional SSI using a cut-off of 23.0 mm for TSF was moderately accurate (area under curve 0.83, confidence interval 0.70-0.97; sensitivity 83.3%; specificity 76.9%).

CONCLUSIONS

The study demonstrated that TSF, as evaluated by ultrasound, is a predictor in the development of incisional SSI in patients with acute appendicitis undergoing open appendectomy. These findings suggest that ultrasound is useful both for the evaluation of TSF and the prediction of incisional SSI risk factor in low-resource settings.

Risk factors for surgical site infections using a data-driven approach

Objective

The objective of this study was to identify risk factors for surgical site infection from digestive, thoracic and orthopaedic system surgeries using clinical and data-driven cut-off values. A second objective was to compare the identified risk factors in this study to risk factors identified in literature.

Summary background data

Retrospective data of 3 250 surgical procedures performed in large tertiary care hospital in The Netherlands during January 2013 to June 2014 were used.

Methods

Potential risk factors were identified using a literature scan and univariate analysis. A multivariate forward-step logistic regression model was used to identify risk factors. Standard medical cut-off values were compared with cut-offs determined from the data.

Results

For digestive, orthopaedic and thoracic system surgical procedures, the risk factors identified were preoperative temperature of ≥38°C and antibiotics used at the time of surgery. C-reactive protein and the duration of the surgery were identified as a risk factors for digestive surgical procedures. Being an adult (age ≥18) was identified as a protective effect for thoracic surgical procedures. Data-driven cut-off values were identified for temperature, age and CRP which can explain the SSI outcome up to 19.5% better than generic cut-off values.

Conclusions

This study identified risk factors for digestive, orthopaedic and thoracic system surgical procedures and illustrated how data-driven cut-offs can add value in the process. Future studies should investigate if data-driven cut-offs can add value to explain the outcome being modelled and not solely rely on standard medical cut-off values to identify risk factors.

Compliance of primary and secondary care public hospitals with standard practices for reprocessing and steam sterilization of reusable medical devices in Nepal: findings from nation-wide multicenter clustered audits

BACKGROUND

Reusable medical devices in healthcare facilities are decontaminated and reprocessed following standard practices before each clinical procedure. Reprocessing of critical medical devices (those used for invasive clinical procedures) comprises several processes including sterilization, which provides the highest level of decontamination. Steam sterilization is the most used sterilization procedure across the globe. Noncompliance with standards addressing reprocessing of medical devices may lead to inadequate sterilization and thus increase the risk of person-to-person or environmental transmission of pathogens in healthcare facilities. We conducted nationwide multicenter clustered audits to understand the compliance of primary- and secondary-care public hospitals in Nepal with the standard practices for medical device reprocessing, including steam sterilization.

METHODS

We developed an audit tool to assess compliance of hospitals with the standard practices for medical device reprocessing including steam sterilization. Altogether, 189 medical device reprocessing cycles which included steam sterilization were assessed in 13 primary and secondary care public hospitals in Nepal using the audit tool. Percentage compliance was calculated for each standard practice. Mean percentage compliances were obtained for overall primary and secondary care hospitals and for each hospital type, specific hospital and process involved.

RESULTS

For all primary and secondary care hospitals in Nepal, the mean percentage compliance with the standard practices for medical device reprocessing including steam sterilization was 25.9% (95% CI 21.0-30.8%). The lower the level of care provided by the hospitals, the lower was the mean percentage compliance, and the difference in the means across the hospital types was statistically significant (p < 0.01). The mean percentage compliance of individual hospitals ranged from 14.7 to 46.0%. The hospitals had better compliance with the practices for cleaning of used devices and transport and storage of sterilized devices compared with the practices for other processes of the medical device reprocessing cycle.

CONCLUSION

The primary and secondary care hospitals in Nepal had poor compliance with the standard practices for steam sterilization and reprocessing of medical devices. Interventions to improve compliance of the hospitals are immediately required to minimize the risks of person-to-person or environmental transmission of pathogens through inadequately reprocessed medical devices.

Incidence and Bacterial Etiologies of Surgical Site Infections in a Public Hospital, Addis Ababa, Ethiopia

Background:

Surgical Site Infections (SSIs) are among the frequently reported healthcare-acquired infections worldwide. Successful treatment of SSIs is affected by the continuous evolvement of drug-resistant microbes. This study investigated the incidence of SSIs, identifying the major etiologic agents and their drug resistance patterns in Yekatit 12 Hospital, Ethiopia.

Methods:

A cross-sectional study was conducted on 649 patients who underwent surgery at Yekatit 12 hospital from April 2016 to April 2017. Socio-demographic and clinical data were collected from each patient on admission. After surgery, they were followed for SSI occurrence. SSI was initially diagnosed by a senior surgeon based on standard clinical criteria and then confirmed by culture. Isolates were tested for drug resistance according to the clinical and laboratory standards institute guideline.

Results:

Of the 649 study participants, 56% were females. Their age ranged from 9 months to 88 years with a median age of 37 years. The incidence of culture-confirmed SSI was 10.2% (66/649) where 73 isolates were recovered. About two-third of the isolates were Gram-positive bacteria. Staphylococcus aureus was the most frequently isolated (27/73, 37%) followed by Coagulase-negative staphylococci (18/73, 24.7%), Escherichia coli (11/73, 15.1%) and Klebsiella species (10/73, 13.7%). About 89% and 44% of S. aureus isolates were resistant to penicillin and trimethoprim-sulfamethoxazole, respectively. MRSA constituted 11% of the S. aureus isolates. All the Gram-negative isolates were resistant to ampicillin and trimethoprim-sulfamethoxazole but susceptible to amikacin and meropenem. Klebsiella species showed 70-100% resistance to ceftazidime, cefuroxime, augmentin, chloramphenicol, ciprofloxacin, cefepime and gentamicin. About 82% of E. coli isolates were resistant for chloramphenicol, cefepime, ceftazidime, augmentin, cefuroxime and 64% for gentamicin and ciprofloxacin.

Conclusion:

The incidence of surgical site infection in Yekatit 12 hospital is 10.2%. Most of the SSIs were due to Gram-positive bacteria. Gram-negative isolates showed high resistance to the most commonly prescribed drugs. No resistance was found for meropenem indicating the absence of carbapenem-resistant bacteria. SSI treatments should be guided by culture and drug resistance test. Better infection prevention practices and continuous surveillance of antimicrobial resistance in the hospital are recommended for better patient care.

Effectiveness of steam sterilization of reusable medical devices in primary and secondary care public hospitals in Nepal and factors associated with ineffective sterilization: A nation-wide cross-sectional study

Background

Inadequate sterilization of reusable medical devices can lead to healthcare associated infections (HAIs) through person-to-person or environmental transmission of pathogens. Autoclaving (steam sterilization) is most commonly used for sterilizing medical devices in healthcare facilities. We conducted a nation-wide cross-sectional study to evaluate the effectiveness of steam sterilization practices in primary and secondary care public hospitals in Nepal and to identify factors associated with ineffective sterilization.

Methods

Using a stratified clustered random sampling, 13 primary- and secondary-care public hospitals in Nepal were selected. 189 steam sterilization cycles from these hospitals were evaluated for their effectiveness using self-contained biological indicators, class-5 chemical indicators, autoclave indicator tape and physical parameters. Information about the hospitals and the types of autoclaves being used was also collected. Data were analysed to estimate the proportion of ineffective steam sterilization cycles. Logistic regression was used to identify factors associated with ineffective sterilization.

Findings

In primary and secondary care public hospitals in Nepal, 71.0% (95% CI 46.8% - 87.2%) of the autoclave cycles were ineffective (i.e. showed positive results) when tested with biological indicators and 69.8% (95% CI 44.4% - 87.0%) showed ‘reject’ results with class 5 chemical indicators. There was no statistically significant difference in proportions showing positive or reject results by hospital types for either biological (p = 0.51) or class 5 chemical (p = 0.87) indicators. Autoclave type and pressure achieved during sterilization were statistically significantly associated with steam sterilization failures, adjusted for holding period, evenness of pressure and barrier system used.

Conclusion

Primary and secondary care hospitals in Nepal have a high proportion of steam sterilization failure, indicating a risk of person-to-person transmission of pathogens through reusable medical devices. There is an urgent need to improve steam sterilization processes in these hospitals.

Bacterial Aetiology and Antibiotic Susceptibility Profile of Post-Operative Sepsis among Surgical Patients in a Tertiary Hospital in Rural Eastern Uganda

Background:

Post-operative wound sepsis remains a surgical challenge of public health concern constituting approximately 20% of the health care-associated nosocomial infections. This study aimed at determining the prevalence and antimicrobial resistance patterns of bacterial pathogens isolated from post-operative wound infections at Mbale Regional Referral Hospital.

Materials and Methods:

This was a descriptive cross-sectional study conducted from June to October 2015. Study participant samples were sub-cultured upon reception in the Microbiology laboratory and the isolated bacterial pathogens were analysed. Phenotypic antimicrobial susceptibility profiles were determined using the Kirby-Bauer method. Interpretation of the zone diameters was done following the Clinical and Laboratory Standards Institute guidelines. Phenotypic screening for Methicillin-resistant Staphylococcus aureus (MRSA) was performed using oxacillin (1 μg). D-test was also performed for phenotypic screening of inducible clindamycin resistant Staphylococcus aureus, Data were entered into Microsoft Excel and analysed using IBM SPSS statistics (version 16).

Results:

Overall post-operative sepsis was 69/80 (86.2%) with Staphylococcus aureus as the most predominant organism 41/104 (39.4%) followed by Escherichia coli 22/104 (21.2%) and Klebsiella species 15/104 (14.4%). Of the 41/104 isolated Staphylococcus aureus, 27/41(65.9%) were MRSA strains and 5/41 (12.2%) were inducible clindamycin resistant Staphylococcus aureus strains. The isolated Staphylococcus aureus was resistant to multiple drugs though susceptible to vancomycin and clindamycin. In addition, none of the isolated Enterococci species was vancomycin resistant. Although most of the isolated Gram-negative organisms were sensitive to imipenem, resistance was observed for tetracycline, trimethoprim/sulphamethoxazole, and ceftriaxone.

Conclusion:

Staphylococcus aureus was the most common causative agent associated with postoperative sepsis with most of the strains being MRSA. Multi-drug resistance was observed in 63/104 (60.6%) of the isolated organisms in our study. Hence the need to better develop and strengthen antimicrobial stewardship programs as well as to understand the carriage of antimicrobial resistance genes among these organisms.

Incidence and Etiology of Surgical Site Infections among Emergency Postoperative Patients in Mbarara Regional Referral Hospital, South Western Uganda

Background. This prospective hospital based study was conducted to determine the incidence, risk factors, and causative agents of surgical site infection their susceptibility to among 114 emergency postoperative patients at the Mbarara Regional Referral Hospital between September 2014 and January 2015. Methods. Consented patients were consecutively enrolled and their preoperative, intraoperative, and postoperative data were collected. Follow-ups were done in the surgical outpatient clinics. Wound specimens were collected and processed as per Sops; susceptibility testing was done using the Kirby-Bauer disc diffusion technique. Data was analyzed using STATA 11.0. Results. Overall SSI incidence was 16.4%: 5.9% superficial and 47.1% deep and organ space SSIs each. Klebsiella pneumoniae was the most predominant organism (50%) followed by Staphylococcus aureus (27.8%). E. coli and P. aeruginosa both accounted for 11.1%. Wound class (p = 0.009), anaemia (p = 0.024), low serum albumin (p = 0.046), and property of suture material used (p = 0.006) were significantly associated with SSIs. All organisms had 100% resistance to ampicillin, tetracycline, septrin, and erythromycin. Ciprofloxacin and ceftriaxone are highly sensitive to all organisms. Conclusion. The incidence of SSI in this hospital is very high. Klebsiella pneumoniae is the predominant cause. Ciprofloxacin are very potent antibiotics against organisms that cause SSI.