Evaluation of antimicrobial prophylaxis use and rate of surgical site infection in surgical ward of Wachemo University Nigist Eleni Mohammed Memorial Hospital, Southern Ethiopia: prospective cohort study

Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting

Background

Surgical site infection (SSI), albeit infrequent, drastically impacts the quality of care. This article endeavors to investigate the predictive factors of SSIs following surgical interventions that involve the gastrointestinal (GI) tract within a single institution in a resource-limited setting.

Methods

Over seven years from June 2015 to June 2022, patients who underwent GI surgery and developed SSI were retrospectively matched with an unaffected case-control cohort of patients. Standardized techniques for wound culture, laboratory evaluation of bacterial isolates, and antibiotic susceptibility tests were employed. Logistic regression analysis was utilized to investigate the predictive factors associated with 30-day postoperative SSI occurrence.

Results

A total of 525 patients who underwent GI surgical procedures were included, among whom, 86 (16.4%) developed SSI and the majority of SSIs were superficial (74.4%). Escherichia coli was the most commonly isolated bacterium (54.4%), and a high percentage of multidrug-resistant organisms were observed (63.8%). In multivariate Cox regression analysis, illiteracy (Odds ratio [OR]:40.31; 95% confidence interval [CI]: 9.54-170.26), smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI:1.62-26.09), longer operation duration (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and extending antibiotic prophylaxis duration (OR: 3.01; 95% CI: 1.28-7.10) were the independent risk factors for SSI (all p < 0.05).

Conclusions

This study highlights significant predictors of SSI, including illiteracy, smoking, diabetes, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operative time, emergency operations, and extending antibiotic prophylaxis duration. Identifying these risk factors can help surgeons adopt appropriate measures to reduce postoperative SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI.

Prevalence and factors associated with surgical site infections among mothers after cesarean section at Mbarara Regional Referral Hospital, Uganda: an observational retrospective study

Background

The risk of infection following cesarean delivery is 5-20 times higher than that following normal delivery, contributing to 10% of pregnancy-related mortality. In 2019, Mbarara Regional Referral Hospital (MRRH) performed cesarean section for 40% of deliveries, surpassing the WHO's recommended 15%-20%. The availability and provision of effective prophylactic antibiotics are crucial in preventing surgical site infections (SSIs).

Objectives

To determine the prevalence and predictors of SSIs among mothers after cesarean section, length of hospital stay, and antibiotic use at MRRH.

Design

This was an observational retrospective study conducted in the maternity ward of the MRRH.

Methods

Data on the diagnosis of SSI, length of hospital stay, and antibiotic use were extracted and entered into EpiData software version 3.1 and analyzed using STATA version 15. We conducted logistic regression analysis to identify factors independently associated with SSIs. We also compared the length of hospital stay.

Results

The prevalence of post-cesarean SSIs was 7.9% (95% CI: 6.3%-9.9%). Mothers aged 25 years and younger were less likely to develop SSIs (adjusted odds ratio (aOR): 0.53, 95% CI: 0.30-0.93; p = 0.027). Those with more than six pregnancies were more likely to develop SSIs (aOR: 3.4; 95% CI: 1.35-8.58; p = 0.009). The median length of stay was 8 days for mothers who developed an SSI (interquartile range (IQR): 5, 16) and 3 (IQR: 3, 4) days for those who did not (p < 0.001). Prophylactic antibiotics were prescribed to 83.4% of the women (95% CI: 80.7-85.8). Ampicillin (88.2%) was the most prescribed prophylactic antibiotic, and metronidazole was the most prescribed postoperatively (97.8%) and at discharge (77.6%).

Conclusion

The current prevalence of post-cesarean SSIs is higher in Uganda than in developed countries. Older age and having had more than six pregnancies are independent predictors of SSIs, and post-cesarean SSI significantly prolonged hospital stay.

Surgical site infection and antimicrobial prophylaxis prescribing profile, and its determinants among hospitalized patients in Northeast Ethiopia: a hospital based cross-sectional study

The inappropriate use of surgical antimicrobial prophylaxis is a common cause for increased risk of morbidity and mortality from surgical site infection in patients who underwent surgical procedures. The study aimed to evaluate surgical antimicrobial prophylaxis prescribing patterns, Surgical Site Infection (SSI), and its determinants in the surgical ward of Debre Berhan Comprehensive Specialized Hospital, northeast Ethiopia. A prospective cross-sectional study was conducted from October 1st 2022 to January 31st, 2023. Data collected from patient medical record cards and patient interviews were entered and analyzed using SPSS V26.0. The determinants of surgical site infection were determined from the multivariable logistic regression. P-value ≤ 0.05 was considered statistically significant. Ceftriaxone (70.5%) followed by a combination of ceftriaxone with metronidazole (21.90%) was the most frequently used prophylactic antibiotic. One hundred fifty-nine (78%) of patients were exposed to inappropriately used prophylactic antimicrobials and 62.2% of these were exposed to inappropriately selected antibiotics. One hundred twenty-six (61.9%) patients developed Surgical Site Infection (SSI). Duration of procedure longer than an hour and inappropriate use of antimicrobial prophylaxiswere the independent predictors for the occurrence of surgical site infections. Patients whose operation was lasted in longer than an hour were 3.39 times more likely to develop SSI compared to those whose operation was completed in less than an hour, AOR = 3.39 (95% CI: 1.24-9.30). Similarly, controlling the effect of other covariate variables, individuals who were given inappropriate antimicrobial prophylaxis were 6.67 times more likely to develop SSI compared to those given appropriate prophylaxis, AOR = 6.67 (95% CI: 1.05-42.49). The high rate of SSI requires due attention from clinicians as well as health policymakers. Duration of surgical procedure greater than an hour and inappropriate antimicrobial prophylaxis use was the independent predictor of surgical site infections.

A randomised control trial using soap in the prevention of surgical site infection in Tanzania

BACKGROUND

Surgical site infections (SSIs) are common and serious complications of surgery. Guidelines on preventing SSIs have been developed, but the role of preoperative bathing with plain soap among paediatric population is unclear. We aimed to assess the effectiveness of pre-operative bathing using plain soap in preventing SSIs among paediatric surgical patients.

MATERIALS AND METHODS

An open-label, randomised trial was conducted at Muhimbili National Hospital in Tanzania. Preoperatively, patients in the intervention group washed their body using plain soap, while those in the control group did not. The primary outcome was SSI postoperatively. Statistical tests included χ2, Wilcoxon rank sum, and univariate and multivariable logistic regression.

RESULTS

Of the 252 patients recruited,114 were randomised to the intervention arm. In the control arm, 40.6% (56/138) of participants developed SSIs compared to 11.4% (13/114) in the intervention arm (p < 0.01). After adjusting for confounding factors in multivariable analysis, the intervention reduced the odds of an SSI by 80% (OR: 0.20 [95% CI: 0.10, 0.41]; p < 0.01). Preoperative antibiotics were deemed to be an effect modifier of the association between the intervention and SSI (p = 0.05). The intervention significantly reduced the odds of an SSI by 88% among participants not given preoperative antibiotics (OR: 0.12 [95% CI: 0.05, 0.30]; p < 0.01).

CONCLUSION

This study has shown that preoperative bathing with soap significantly reduces SSIs in paediatric surgical patients. It is a simple, cost effective and sustainable intervention.

LEVEL OF EVIDENCE

Level II.

Optimizing Nanopore Sequencing for Rapid Detection of Microbial Species and Antimicrobial Resistance in Patients at Risk of Surgical Site Infections

Surgical site infections (SSI) are a significant burden to patients and health care systems. We evaluated the use of Nanopore sequencing (NS) to rapidly detect microbial species and antimicrobial resistance (AMR) genes present in intraoperative bile aspirates. Bile aspirates from 42 patients undergoing pancreatic head resection were included. Three methods of DNA extraction using mechanical cell lysis or protease cell lysis were compared to determine the optimum method of DNA extraction. The impact of host DNA depletion, sequence run duration, and use of different AMR gene databases was also assessed. To determine clinical value, NS results were compared to standard culture (SC) results. NS identified microbial species in all culture positive samples. Mechanical lysis improved NS detection of cultured species from 60% to 76%, enabled detection of fungal species, and increased AMR predictions. Host DNA depletion improved detection of streptococcal species and AMR correlation with SC. Selection of AMR database influenced the number of AMR hits and resistance profile of 13 antibiotics. AMR prediction using CARD and ResFinder 4.1 correctly predicted 79% and 81% of the bile antibiogram, respectively. Sequence run duration positively correlated with detection of AMR genes. A minimum of 6 h was required to characterize the biliary microbes, resulting in a turnaround time of 14 h. Rapid identification of microbial species and AMR genes can be achieved by NS. NS results correlated with SC, suggesting that NS may be useful in guiding early antimicrobial therapy postsurgery. IMPORTANCE Surgical site infections (SSI) are a significant burden to patients and health care systems. They increase mortality rates, length of hospital stays, and associated health care costs. To reduce the risk of SSI, surgical patients are administered broad-spectrum antibiotics that are later adapted to target microbial species detected at the site of surgical incision. Use of broad-spectrum antibiotics can be harmful to the patient. We wanted to develop a rapid method of detecting microbial species and their antimicrobial resistance phenotypes. We developed a method of detecting microbial species and predicting resistance phenotypes using Nanopore sequencing. Results generated using Nanopore sequencing were similar to current methods of detection but were obtained in a significantly shorter amount of time. This suggests that Nanopore sequencing could be used to tailor antibiotics in surgical patients and reduce use of broad-spectrum antibiotics.

Discordance to ASHP Therapeutic Guidelines Increases the Risk of Surgical Site Infection

Clean surgery without contamination does not require prophylactic antibiotics, but there are high-risk surgical procedures that may cause infection and/or involve vital organs such as the heart, brain, and lungs, and these indeed require the use of antibiotics. This study aimed to determine the quantity of antibiotic use based on the defined daily dose (DDD) per 100 bed days and the quality of antibiotic use based on the percentage of concordance with The American Society of Health-System Pharmacists (ASHP) therapeutic guidelines (i.e., route of administration, time of administration, selection, dose, and duration). This includes the profiles of surgical site infection (SSI) in surgical patients from January through June 2019. The study subjects were 487 surgical patients from two hospitals who met the inclusion criteria. There were 322 patients out of 487 patients who had a clean surgical procedure. Ceftriaxone (J01DD04) was the most used antibiotic, with a total DDD/100 bed days value in hospitals A and B, respectively: pre-surgery: 14.71, 77.65, during surgery: 22.57, 87.31, and postsurgery: 38.34, 93.65. In addition, 35% of antibiotics were given more than 120 min before incision. The lowest concordance to ASHP therapeutic guideline in hospital A (17.6%) and B (1.9%) was antibiotic selection. Two patients experienced SSI with bacterial growths of Proteus spp., Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli. The usage of prophylactic antibiotics for surgical procedures was high and varied between hospitals. Hospital B had significantly lower concordance to antibiotic therapeutic guidelines, resulting to a higher infection rate, compared with hospital A. ASHP adherence components were then further investigated, after which antibiotic dosing interval and injection time was found to be a significant predictor for positive bacterial growth based on logit–logistic regression. Further interventions and strategies to implement antibiotic stewardship is needed to improve antibiotic prescriptions and their use.

Gram-Negative Bacteria Isolates and Their Antibiotic-Resistance Patterns in Patients with Wound Infection in Ethiopia: A Systematic Review and Meta-Analysis

BACKGROUND

Antibiotic resistance (ABR) restricts the armamentarium of health-care providers against infectious diseases due to the emergence of multidrug resistance (MDR), especially in Gram-negative bacteria. This study aimed to determine pooled estimates of Gram-negative bacteria, their resistance profiles, and rates of MDR in patients with wound infection in Ethiopia.

METHODS

Electronic databases such as PubMed/MEDLINE, EMBASE, Science Direct, Web of Science, and Google Scholar were searched. Original articles, available online from 1988 to 2020, addressing the prevalence and resistance patterns of Gram-negative bacteria in patients with wound infection and written in English were screened. The data were extracted using a format prepared in Microsoft Excel and exported to STATA 14.0 for the outcome analyses.

RESULTS

The data of 15,647 wound samples, from 36 studies conducted in 5 regions of the country, were pooled. The overall pooled estimate of Gram-negative bacteria was 59% [95% CI: 52-65%, I2 = 96.41%, p < 0.001]. The pooled estimate of Escherichia colirecovered from isolates of 5205 wound samples was 17% [95% CI: 14-20%], followed by Pseudomonas aeruginosa, 11% [95% CI: 9-14%], Klebsiella pneumonia, 11% [95% CI: 9-13%], Proteus mirabilis, 8% [95% CI: 6-10%], Acinetobacter species, 4% [95% CI: 2-6%], Enterobacter species, 4% [95% CI: 3-5%], and Citrobacter species, 3% [95% CI: 2-4%]. Multidrug resistance prevalence estimates of E. coli, K. pneumonia, P. aeruginosa, P. mirabilis, Citrobacter species, Enterobacter species and Acinetobacter species were 76% [95% CI: 66-86%], 84% [95% CI: 78-91%], 66% [95% CI:43-88%], 83% [95% CI:75-91%], 87% [95% CI:78-96%], 68% [95% CI:50-87%] and 71% [95% CI:46-96%], respectively.

CONCLUSION

There was high resistance in Gram-negative bacteria from wound specimens to commonly used antibiotics in Ethiopia. The data warrant the need of regular epidemiological surveillance of antimicrobial resistance and implementation of an efficient infection control program.

Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia

Objective:

Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC).

Design:

Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization’s SSI prevention recommendations.

Setting:

A tertiary-care hospital in Jimma, Ethiopia.

Participants:

Surgical nurses, surgeons, and anesthetists at JUMC.

Results:

Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring.

Conclusions:

Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC.

The Association Between Incorrect Use of Antibiotic Prophylaxis and in-Hospital Surgical Site Infections - A Prospective Observational Study

Background

Surgical site infection (SSI) is the most prevalent in developing countries where 61–90% of cases develop in-hospital. The study aimed to assess the correctness of antibiotic prophylaxis (AP) use, the incidence of in-hospital SSI, and its determinants.

Patients and Methods

A 3-month hospital-based prospective observational study design was used on general surgery patients. The criteria for identification of SSI were performed based on the Center for Disease Control and Prevention’s (CDC’s) definition of SSI. The correctness of AP was performed based on the American Society of Health System Pharmacist 2013 guideline (ASHP). Multiple stepwise backward logistic regression analysis was used at p-value <0.05 to predict SSI.

Results

Of 269 adult patients, the type of admission was almost equal between emergency and elective surgery. The mean (± SD) age of the study participants was 41.95±17.764. Only 19.7% of the study participants used AP correctly. The incidence rate of in-hospital SSI was 16.7% (45/269), which corresponds to 45/4736 or 9.5/1000 person-days. Independent predictors for SSI were American Society of Anesthesiology (ASA) class III–IV (p-value <0.0001), patients with age-adjusted Charlson co-morbidity index (CCI) of ≥1 score (p value=0.008), and incorrect use of AP (p-value =0.025).

Conclusion

Incorrect antibiotic prophylaxis use contributed to an increased risk of SSI, which needs urgent attention in the present study area.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis

BACKGROUND

The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work.

METHODS

MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted.

RESULTS

This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis.

CONCLUSIONS

There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Surgical site infection and its associated factors in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Despite being a preventable complication of surgical procedures, surgical site infections (SSIs) continue to threaten public health with significant impacts on the patients and the health-care human and financial resources. With millions affected globally, there is significant variation in the primary studies on the prevalence of SSIs in Ethiopia. Therefore, this study aimed to estimate the pooled prevalence of SSI and its associated factors among postoperative patients in Ethiopia.

METHODS

PubMed, Scopus, Psyinfo, African Journals Online, and Google Scholar were searched for studies that looked at SSI in postoperative patients. A funnel plot and Egger's regression test were used to determine publication bias. The I2 statistic was used to check heterogeneity between the studies. DerSimonian and Laird random-effects model was applied to estimate the pooled effect size, odds ratios (ORs), and 95% confidence interval (CIs) across studies. The subgroup analysis was conducted by region, sample size, and year of publication. Sensitivity analysis was deployed to determine the effect of a single study on the overall estimation. Analysis was done using STATA™ Version 14 software.

RESULT

A total of 24 studies with 13,136 study participants were included in this study. The estimated pooled prevalence of SSI in Ethiopia was 12.3% (95% CI: 10.19, 14.42). Duration of surgery > 1 h (AOR = 1.78; 95% CI: 1.08-2.94), diabetes mellitus (AOR = 3.25; 95% CI: 1.51-6.99), American Society of Anaesthesiologists score > 1 (AOR = 2.51; 95% CI: 1.07-5.91), previous surgery (AOR = 2.5; 95% CI: 1.77-3.53), clean-contaminated wound (AOR = 2.15; 95% CI: 1.52-3.04), and preoperative hospital stay > 7 day (AOR = 5.76; 95% CI: 1.15-28.86), were significantly associated with SSI.

CONCLUSION

The prevalence of SSI among postoperative patients in Ethiopia remains high with a pooled prevalence of 12.3% in 24 extracted studies. Therefore, situation based interventions and region context-specific preventive strategies should be developed to reduce the prevalence of SSI among postoperative patients.