INCIDENCE OF SURGICAL SITES INFECTION AFTER ABDOMINAL SURGERIES

INCIDENCE OF SURGICAL SITES INFECTION AFTER ABDOMINAL SURGERIES

By

Ahmed A. Elyan, El-Sayed M. Abd El-Wahab, Basma A. Mohamed

General Surgery Department, Faculty of Medicine (Girls), ALAzharUniversity

Corresponding author: Ahmed A. Elyan, E-mail: ahmedelyan2010@yahoo.com

ABSTRACT

Background: Surgical site infections (SSIs) are one of the most frequent complications in abdominal surgery. It is associated with prolonged hospital stay, a compromised quality of life and an increase in mortality and in costs.

Objective: To assess the prevalence, risk factors and causative organism of surgical sites infection after abdominal surgeries.

Patients and methods: Five hundred patients who underwent an abdominal surgery were included in this prospective observational comparative study. The study population was divided into two equal groups: Group (A): Non- comorbidities group and Group (B): Comorbidities group. Patients underwent abdominal surgeries in Ismailia general Hospital and Al-Zahra’a University Hospital. The study was conducted at Ismailia GeneralHospital from November 2020 to June 2021. All patients who were subjected to full medical history, general and systemic examination and laboratory investigation

Results: There was an insignificant difference between the groups according to the demographic data. The results showed significant difference between the groups according to the frequency of surgical wound classification, and according to total leukocitic count, C. reactive protein and the fasting blood sugar results (P value >0.001) after the surgery. The result of the treatment followed with the infected site among the study groups after the abdominal procedure showed significant difference between the groups according to the treatment (P value = 0.001).

Conclusion: Although surgical site infections cannot be completely eliminated, a reduction in the infection rate to a minimal level could have significant benefits, by reducing postoperative morbidity and mortality, and wastage of health care resources. A pre-existing medical illness, the wound class, and wound contamination strongly predisposed to wound infection.

Keywords: Inflammation, Infection, Abdominal surgeries.

INTRODUCTION

     Infections that occur in the wound created by an invasive surgical procedure are generally referred to as surgical site infections (SSIs). SSIs are one of the most important causes of healthcare-associated infections (HCAIs). Surgical site infections and its management are costly to both patients and the health facilities. Surgical site infections definitions can vary because they range from a relatively trivial wound discharge without complications to serious conditions that are fatal. Therefore, to encourage a uniform and standard approach among data collectors, the Center for Disease Control and Prevention (CDC) brought out definitions for each category (Merollini et al., 2013).

     Surgical site infections (SSIs) are one of the most frequent complications in abdominal surgery. It is associated with prolonged hospital stay, a compromised quality of life and an increase in mortality and in costs (Lyden and Dellinger, 2016).

     The SSIs appears when the bacterial inoculum exceeds the immune system’s ability to control it. Contamination in abdominal surgery originates from the skin or organs that have been targeted during surgery (Tovar and Josep, 2014).

     Additional costs attributable to SSI have been reported depending on the type of surgery and the severity of the infection. The main additional costs are related to re-operation, extra nursing care and interventions, and drug treatment costs. The indirect costs, due to loss of productivity, patient dissatisfaction and litigation, and reduced quality of life, have been studied less extensively (Umscheid et al., 2011).

     The present work aimed to assess the prevalence, risk factors and causative organism of surgical sites infection after abdominal surgeries.

PATIENTS AND METHODS

     Between November 2020 and June 2021, a prospective study was performed on 500 patients at Al-Zahra’a University hospital and Ismailia GeneralHospital. All patients underwent different abdominal surgeries with and without comorbidities. The study aimed to assess the prevalence, risk factors and causative organism of surgical sites infection after abdominal surgeries.

     All patients who included in the study were subjected to full medical history, general and systemic examination and laboratory investigations. The study population was divided into two equal groups: Group (A): Non- comorbidities group, and Group (B): Comorbidities group, who underwent an abdominal surgery.

All patients’ undergone different abdominal surgery with and without comorbidities will be underwent the following:

1.   Full history taking (before surgery):

•     Personal history.

•     Complaint.

•     History of presenting illness.

•     Past history.

•     Family history.

•     Socio-economic history.

2.   General and systematic examination:

•     Preoperative examination: General Examination.

•     Postoperative examination (every week): Wound assessment early and late.

3.   Laboratory investigations:

•     Complete blood count (CBC).

•     Kidney function tests.

•     Liver function tests.

•     Coagulation profile.

•     Fasting blood glucose.

•     Electrolytes.

4.   Swab from surgical site postoperative if there is signs of infection (redness, hotness, swelling, discharge).

5.   Culture and sensitivity of the collected swabs.

Statistical analysis:

     Collected data was coded, entered and analyzed using Microsoft Office Excel (2007) software. Data was then imported into Statistical Package for the Social Sciences (SPSS) version 20.0 (IBM SPSS Ver. 20.0) and MedCalc version 12.1.3.0 software for (SPSS INC. CHICAGO IL USA) analysis. Baseline characteristics of the study population were presented as frequencies and percentages (%) in qualitative data or mean values and standard deviations (SD) in quantitative data. Differences between frequencies were compared by Chi-square or Fisher exact tests. Differences between means were compared by t-test. Pearson correlation coefficient test was used to evaluate the inter-correlations between the studied variables. Analysis of variance (ANOVA) test followed by logistic regression analysis model of the dependent variable and other studied variables (independent predictors) were performed. P value of < 0.05 was considered significant.

RESULTS

     Our study showed that the mean of age of the study population was 40.45 ± 10.42 years with range of 18 to 89 years old. Most of our study populations (51.4%) were females (Table 1).

Table (1):   Demographic characteristics of the study groups

     Inguinal hernia was the most frequent procedure among the study population (21.4%). The results showed no significant difference between the groups according to the frequency of surgical procedures (Table 2).

Table (2):   Frequency of the surgical abdominal procedure among the study group.

     No significant difference between the groups according to the frequency of surgical procedures. Clean wound (Class I) was the most frequent in both groups. The results showed significant difference (P value >0.001) between the groups according to the frequency of surgical wound classification (Table 3).

Table (3):   Frequency of the surgical abdominal procedure according to the surgical wound classification among the study group

     There was a significant difference between the groups according to the fasting blood sugar results before the surgery (P value >0.001). The results showed significant difference between the groups after the surgery according to total leukocitic count, C. reactive protein and the fasting blood sugar results (P value >0.001). The results showed significant difference between the groups according to the grade and the frequency of inflammation (P value >0.001) (Table 4).

Table (4):   Frequency and the grade of the inflammation among the study groups

     There was insignificant difference between the groups according to the demographic data. (P value = 0.066) and significant difference in the frequency of surgical site infections in patient underwent urgent surgery (p value <0.001), open surgery (P value = 0.012), and patients with comorbidities (P value < 0.001) specially, malignancy and diabetic patient (39% and 29% respectively). There was no significant difference in the frequency of surgical site infection according to sex (Table 5).

Table (5):   Frequency of SSI among the study groups

     The result of the treatment followed with the infected site among the study groups after the abdominal procedure showed significant difference between the groups according to the treatment (P value = 0.001) (Table 6).

Table (6):   Treatment followed with the infected site among the study groups after the abdominal procedure

     The results showed that DM was the most frequent comorbidity (62.4%) in the comorbidity group (Figure 1).

Figure (1):      Frequency of Comorbidites in comorbidities group

     The results showed significant difference between the groups according to the culture results of the infected site swap among the study groups after the abdominal procedure (P value >0.001) (Figure 2).

Figure (2):  Distribution of culture results.

DISCUSSION

     Our study demonstrated that the surgical wounds according to the degree of contamination showed significant difference between the comorbidities group and the non-comorbidities group. Even higher rates are reported by prospective studies in developing countries. A longer duration, even of a clean operation, represents increased time at risk for contamination (Isik et al., 2015).

     Regarding the prevalence of SSI, the present study showed that SSI has higher significant prevalence in comorbidities group comparing to the non-comorbidities group. Our study showed that SSI occurred in 32% of comorbidities group with only 14% of non-comorbidities group. The rate of SSI varies greatly worldwide and from hospital to hospital. The present study found that the overall rate of SSI was 23%. This was similar with study conducted by Hafez et al. (2012) made in Egypt, in Alexandria, and reported that SSIs occurred in 17% of patients, while other study which took place at Cairo University found an SSI incidence to be 9% (Labib et al., 2012). Another international study took place in India found an SSI incidence of 12.6% (Goyal et al., 2015).

     Regarding age, the mean age in comorbidities group was 40.7+ 9.76 years in comparison to non-comorbidities group which was 40.1+ 11.99 years with no statistically significant difference in age between two groups. Regarding age the mean age in comorbidities group was 40.7+ 9.76 years in comparison to non-comorbidities group which was 40.1+ 11.99 years with no statistically significant difference in age between two groups. This finding was similar to that from a study conducted in DukeUniversity by Khairy et al. (2011) stating that increasing age independently predicted an increased risk of SSI until age 65 years. At ages >65 years, increasing age independently predicted a decreased risk of SSI.

     Our study showed that the superficial SSI was the highest prevalence in both groups with significant difference between the comorbidities and non-comorbidities groups. Labib et al. (2012) study showed that the entire infected group (100%) complained of redness, 68% complained of pain, meanwhile, 30% suffered from fever and 20% had discharge.

     Regarding laboratory finding there was a statistically significant difference in Laboratory finding post operation between both groups regarding TLC, CRP and FBs.

     Regarding the causative organism; Staph and stept was the most isolated micro-organisms which present in 10% of the comorbidities group and 5.1% of the non-comorbidities group.

     Labib et al. (2012) found that the most frequent SSI isolates detected were E. coli (29.8%), followed by Staph. aureus (17.1%). while the study done by Hemant et al. (2016) found that Pseudomonas infection was more prevalent followed by Klebsiella, then coagulase positive staphylococci, after that Escherichia coli, and diphtheroid infection.

     Isgren et al. (2017) reported that common bacterial isolates were Escherichia coli (59.5%), Enterococcus spp. (42.4%) and Staphylococcus spp. (25.4%). Penicillin resistant isolates accounted for 92% of isolates while 18% of isolates were gentamicin resistant.

     Alkaaki et al. (2019) stated that, the commonest organisms isolated from patients with SSI were gram-negative bacteria, namely extended-spectrum β-lactamase-producing E. coli. This finding is contrary to those in studies that revealed more gram-positive bacteria such as Staphylococcus aureus and coagulase-negative staphylococci (Sugiura et al., 2012 and Azoury et al., 2015).

CONCLUSION

     Surgical site infection is an important measure of the quality of patient care by surgeons, infection control practitioners, health planners and public. Although surgical site infections cannot be completely eliminated, a reduction in the infection rate to a minimal level could have significant benefits, by reducing postoperative morbidity and mortality, and wastage of health care resources. A pre-existing medical illness, the wound class, and wound contamination strongly predisposed to wound infection.

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