Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Abstract

SummaryBackgroundSurgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.MethodsThis international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.FindingsBetween Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).InterpretationCountries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

The developing world of pre‐operative optimisation: a systematic review of Cochrane reviews

“…The index classifies countries as having low, middle, high or very high human development . In terms of utility, the HDI has been associated with the burden of peri‐operative mortality and surgical site infections . The HDI is a marker of country‐level socioeconomic status, and may not reflect the immediate socioeconomic environment of an individual in that country .…”

“…A higher baseline risk for morbidity and mortality in lower HDI countries suggests that pre‐operative optimisation interventions may cause a greater absolute risk reduction in these countries compared with higher HDI countries. Apart from the cost‐benefit for clinical practice, this may also translate to smaller sample size requirements for multinational trials that include lower HDI countries.…”

“… Differences in the population attributable fraction may alter the impact of interventions on morbidity and mortality; for example, infectious complications are thought to be responsible for a greater proportion of peri‐operative deaths in Africa than in high‐HDI countries , so that infection prevention strategies will have greater impact on peri‐operative mortality in Africa than in higher HDI countries. Differences in implementation or provider proficiency may alter the efficacy of a complex intervention . …”

“…For example, low‐HDI countries have 10 times the mortality rate of very high‐HDI countries for infants and children >5 years, and 40 times the maternal mortality rate (14 vs. 553 death per 100,000 live births) . In the peri‐operative setting, the GlobalSurg collaborative has shown HDI to be an independent predictor of both surgical site infection and postoperative mortality .…”

<p>Usefulness of Inflammation-Based Prognostic Scores for Predicting the Risk of Complications After Radical Resection of Colorectal Carcinoma</p>

“…Surgical site infection is the most common complication after surgery, with a high incidence and strong impact on the duration of hospitalization. 26 In a prospective study by Goulart et al 27 CAR was superior to white blood cell count and procalcitonin as an independent predictor of surgical site infection.…”