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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 82-86

Evaluation of post-surgical site infection wounds in a tertiary care hospital of Central India


1 Department of Surgery, Government Medical College, Nagpur, Maharashtra, India
2 Department of Plastic Surgery, Government Medical College, Nagpur, Maharashtra, India
3 Department of Surgical Gastro Department, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 Department of Surgery, Shri. Vasantrao Naik Government Medical College, Yavatmal, Maharashtra, India

Date of Submission01-Aug-2021
Date of Acceptance11-Oct-2021
Date of Web Publication11-May-2022

Correspondence Address:
Vinod N Rathod
Department of Surgery, Shri. Vasantrao Naik Government Medical College, Yavatmal, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/dypj.dypj_48_21

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  Abstract 

Introduction: Surgical site infections (SSIs) are one of the commonest hospital-acquired infections globally. Materials and Methods: A total of 2083 cases were included in the study; surgical sites were graded in accordance to the set of clinical criteria recommended by the CDC’s NNIS system. We graded the wounds on the basis of culture positive with respect to age and sex, pre-operative hospitalization, duration of surgery, duration of drain, hemoglobin levels, random blood sugar, and smoking. Results: The total males and females included were 1561 and 522, respectively. The age group of 40–50 years was the highest operated group, whereas the 12–21 age group was with least surgeries. The numbers of SSI were higher in subjects with longer pre-operative hospital stay. The occurrence of SSIs was higher in surgeries with longer duration. Patients with drain of longer duration had higher number of SSIs when compared with subjects with no drain in wounds. The hemoglobin pattern suggested that anemic subjects were more susceptible to SSIs when compared with non-anemic subjects. Diabetic patients were more prone to SSI when compared with non-diabetic subjects. Smokers were more prone to SSIs when compared with non-smokers. Conclusion: The study established a relationship between SSI and various factors, which would help clinicians in handling cases of post-operative SSIs.

Keywords: Culture positive, drain, surgical site infections, wounds


How to cite this article:
Hedaoo JB, Paramne AV, Raj N, Rathod VN. Evaluation of post-surgical site infection wounds in a tertiary care hospital of Central India. D Y Patil J Health Sci 2021;9:82-6

How to cite this URL:
Hedaoo JB, Paramne AV, Raj N, Rathod VN. Evaluation of post-surgical site infection wounds in a tertiary care hospital of Central India. D Y Patil J Health Sci [serial online] 2021 [cited 2022 May 27];9:82-6. Available from: http://www.dypatiljhs.com/text.asp?2021/9/3/82/345103




  Introduction Top


Hospital-acquired infections are a major worry for clinicians worldwide and are also major infections as per World Health Organization (WHO).[1] These infections affect a large population every year causing about 10% of cases to be hospitalized requiring medical attention.[2],[3] Surgical site infections (SSIs) contribute majorly, i.e., 25% in the total nosocomial infections globally.[4] About 5% of the total surgeries done globally every year suffer from SSIs.[5],[6],[7] In a study reported by us recently, we concluded that about 12% of the cases of total surgeries done were reported to suffer from SSIs.[8] The conditions in countries where there is shortage of resources and the hospital conditions are not up to the standards, the cases of SSIs are even higher.[9] SSIs are one of the major nosocomial infections and account for about 25% of the total nosocomial infections.[10]

Evaluation of wounds is an important predicting tool of the post-operative outcomes. Studies recently have focussed on factors such as operative time, co-morbidities, pre-operative risk factors, and use of antibiotics for prophylactic use.[11] These factors are helpful in deciding the strategies to be adopted for reducing the progression of SSIs. The present study screened a pool of about 2053 subjects reported for various surgeries and compared their wounds after surgeries. Here we accounted various factors for comparison of wounds such as age, sex, pre-operative hospitalization, duration of surgery, duration of drain, hemoglobin levels, prevalence of diabetic conditions (random blood sugar), and habits such as smoking.


  Materials and Methods Top


Study setting and subjects

The current work was conducted in the Surgery Department of Government Medical College, Nagpur, Maharashtra from the period June 2009 to November 2011. All the subjects enrolled in the study had undergone surgery in the department and were included after educating them about the study; informed consent was obtained prior to including them in the study. The study was approved from the Ethics Committee of Government Medical College. For the study, about 2083 subjects were included in the study undergone for operation and were under follow-up for any SSIs during the period June 2009 to January 2012.

Study design

The wounds were inspected in accordance to CDC’s NNIS system.[8] The wounds were classified according to the wound contamination class system as recommended by the American Centers for Disease Control (CDC) for inspection of SSI as clean contaminated, contaminated, clean, and dirty wounds. The wounds were inspected after 24 h at the time of dressing post-surgery; the swabs were verified for the cases of suspected SSIs.

Analysis of swabs and laboratory methods

The swabs (flocked swabs) were collected and were sent for analysis to the Department of Pathology of the hospital. All the swab samples were processed for culture in the MacConkey agar immediately after the swabs were received. The plates were maintained for 24 h at room temperature under aerobic conditions.

Statistical analyses

All the results were analyzed using GraphPad Software version 9 (GraphPad Prism, USA). The results were processed for mean, standard deviation, range, and standard error.


  Results Top


Age and sex factors on culture-positive wounds

In the current study, about 2083 subjects were enrolled; of them, about 1561 were males and 522 females. About 201 males (9.64%) and 49 females (2.35%) were reported for the presence of culture-positive wounds. When age groups for culture-positive infections were compared, it was observed that the age group 40–50 years males exceeded females in all the age groups. It was also recorded that the age group 12–21 years was the group with the least number of SSIs, i.e., 4.8%, which increased gradually with an increase in age of subjects to a significantly high rate of 24.7% in cases of age group above 70 years [Table 1].
Table 1: Comparison of wounds and culture-positive cases with age and sex

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Pre-operative hospitalization and culture-positive wounds

It was observed that the incidence of SSI increased significantly in subjects with a longer pre-operative hospital stay. Among the 1202 subjects (57.7%) who had a pre-operative hospitalization of up to 1 week, the infection rate was 6.3%. The rate of infection showed an increase to 15.9% in the 529 subjects (25.4%) hospitalized for 1–2 weeks before surgery. The rate further increased to 25.6% in the 352 (16.9%) subjects admitted for more than 2 weeks prior to surgery [Table 2].
Table 2: Comparison of wounds and culture-positive cases with pre-operative hospitalization

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Effect of duration of surgery on culture-positive wounds

The duration of surgeries in the present study suggested that in majority of the cases the time was 1–2 h. The infection rate showed a marked increase with longer durations of surgery. In 727 cases which took less than 1 h, 37 cases (5.1%) were infected. In 1026 cases which took 1–2 h, 103 cases (10%) were infected. Among the 330 cases which took more than 2 h, 110 cases (33.3%) were infected [Table 3].
Table 3: Comparison of wounds and culture-positive cases with duration of surgery

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Effect of duration of drain on culture-positive wounds

In this study, 1178 subjects had a drain of which 208 (17.7%) developed SSI. About 905 subjects did not have a drain of which only 42 (4.6%) developed SSI [Table 4]. The subjects having drain were further divided according to the duration of their drain as shown in the following chart into 1–3, 4–7, and more than 7 days, because of variations in the time interval in removal of the drain. All drains were removed once their purpose was served or when drain output was less than 50 mL per day. The drains put in to cover peri-operative bleeding or hematoma formation were removed in 1–3 days (e.g., thyroidectomy). In mastectomies, the drains put in to cover serous collections and leaks from intestinal anastomosis were removed in 4–7 days. The T-tubes, infected drains, and drains with output more than 50 mL for a week were removed after 7 days. The drains in the majority of cases were about 4–7 days. The infection rate showed a marked increase with longer durations of drain. In 424 cases which had drain for 1–3 days, 17 cases (4%) were infected. In 566 cases which had drain for 4–7 days, 108 cases (19%) were infected. Among the 288 cases which had drain for more than 7 days, 83 cases (44%) were infected [Table 5].
Table 4: Wounds of surgeries performed showing wounds with drain and no drain pattern

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Table 5: Comparison of wounds and culture positivity with duration of drain

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Effect of hemoglobin pattern, blood sugar levels, and smoking pattern on culture-positive wounds

In the present study, the hemoglobin pattern of about 222 anemics enrolled in the study was included, out of them 56 developed SSI (25.2%) whereas only 194 of the 1861 (10.4%) non-anemics developed SSI. Anemics were thus twice more likely to develop SSI. A total of 83 cases were enrolled as diabetics in the study, 44 developed SSI (53%), whereas only 206 of the 2000 (10.3%) non-diabetics developed SSI. Diabetics were thus five times more likely to develop SSI. In accounting the smoking patterns on SSI, about 235 smokers were enrolled in the study; of them 74 developed SSI (31.4%), whereas only 176 of the 1408 (12.5%) non-smokers developed SSI. Smokers were thus twice more likely to develop SSI [Table 6].
Table 6: Comparison of wounds and culture positivity with hemoglobin, random blood sugar, and smoking

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  Discussion Top


The present work is the first of its kind involving studies of post-operational SSIs based on culture positivity of wounds accounting for various factors for comparison such as age, sex, pre-operative hospitalization, duration of surgery, duration of drain, hemoglobin levels, prevalence of diabetic conditions (random blood sugar), and habits such as smoking. When the culture-positive wounds were compared for factors such as sex and age, it was observed that there were about 201 males (9.64%) and 49 females (2.35%), indicating a significantly increased number of males compared with females. The results were in accordance to the study published earlier which suggested males more prone to SSIs compared with females.[12] When the age-group-related comparison was made for culture-positive cases, it was noticed that the age group 40–50 years males exceeded females in all the age groups. It was also recorded that the age group 12–21 years was the group with the least number of SSIs, i.e., 4.8%, these results were in accordance to a study published earlier by Agodi et al.,[13] which suggested occurrence of SSI in age group of elderly subjects.

When the comparison of wounds is based on pre-operative hospitalization, it was observed that the incidence of SSI was on significantly higher side in subjects reported with longer pre-operative hospital stay. In our study, we observed that from the 1202 subjects (57.7%) who had a pre-operative hospitalization of up to 1 week showed infections in surgical wounds of 6.3%. The rate of infection increased to 15.9% in the 529 subjects (25.4%) hospitalized for 1–2 weeks before surgery. The rate further increased to 25.6% in the 352 (16.9%) subjects admitted for more than 2 weeks prior to surgery. The results clearly supported pre-operative hospitalization as one of the leading factors contributing to SSIs. However, results deferred to the earlier study which does not support pre-operative hospitalization as the leading factor for SSIs; however, this study does not rule out the pre-operative hospitalization.[14]

In studying the effect of duration of surgical procedure, it was observed that longer duration of operations increased the chances of SSIs. In total, 727 cases required less than 1 h, 37 cases (5.1%) were infected; in 1026 cases which took 1–2 h, 103 cases (10%) were infected. Among the 330 cases which took more than 2 h, 110 cases (33.3%) were infected. The outcomes were in agreement to earlier studies,[15] which clearly indicated that prolonged operation time led to increased risks of SSIs.

On evaluating the drain pattern, it was observed that about 1178 (56%) cases had drain in wounds, of which 208, i.e., 17.7%, developed SSI. The pattern clearly suggested that subjects with long duration drains led to more chances of SSIs. The findings were in agreement to earlier studies.[16] The study was also extended to compare chances of infections with pattern of hemoglobin, incidence of diabetes, and smoking habits. It was observed that subjects with reported anemic history developed more SSIs when compared with normal hemoglobin presenting subjects. From the total 222 anemic subjects in the study, 56 developed SSIs (25.2%) whereas only 194 of the 1861 (10.4%) non-anemics developed SSI, clearly suggesting anemic conditions responsible for SSIs. The outcomes were in agreement to findings reported earlier.[17] On evaluating the presence of diabetic conditions and SSIs, it was observed that diabetic subjects developed more chances of SSIs when compared with normal subjects. Out of the total 83 cases enrolled as diabetics in the study, 44 developed SSI (53%), while only 206 of the 2000 (10.3%) non-diabetics developed SSI; diabetic patients were thus five times more likely to develop SSI. The pattern of SSI in diabetic subjects was clearly in accordance to reports published by Martin et al.[18] The pattern of SSI in smokers and non-smokers was also studied; it was found that from the 235 smokers included in the study 74 developed SSI (31.4%), whereas only 176 of the 1408 (12.5%) non-smokers developed SSI. Smokers were thus twice more likely to develop SSI. The results were clearly in agreement to earlier study, which found that smoking habit is associated with development of SSI; also smoking on the day when surgery was done is associated with SSI.[19],[20]


  Conclusion Top


The present study which was undertaken in the department of surgery in a tertiary care hospital has given us pattern comparison of wounds for various factors.

It has also given us the idea of the relationship between SSI and factors such as age, sex, pre-operative hospitalization, duration of surgery, duration of drain, hemoglobin pattern, prevalence of diabetic conditions, and smoking habits. There was an increase in the incidence of infection in subjects with longer pre-operative hospitalization, longer duration of surgery, and longer duration of drain. Also, the anemics, diabetics, and smokers were more prone to SSIs when compared with normal. The study would definitely help clinicians in handling cases of post-operative SSIs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Aghdassi SJS, Schröder C, Gastmeier P Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany. Antimicrob Resist Infect Control 2019;8:95.  Back to cited text no. 12
    
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Agodi A, Quattrocchi A, Barchitta M, Adornetto V, Cocuzza A, Latino R, et al. Risk of surgical site infection in older patients in a cohort survey: Targets for quality improvement in antibiotic prophylaxis. Int Surg 2015;100:473-9.  Back to cited text no. 13
    
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Mujagic E, Marti WR, Coslovsky M, Soysal SD, Mechera R, von Strauss M, et al. Associations of hospital length of stay with surgical site infections. World J Surg 2018;42:3888-96.  Back to cited text no. 14
    
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Alp E, Altun D, Ulu-Kilic A, Elmali F What really affects surgical site infection rates in general surgery in a developing country? J Infect Public Health 2014;7:445-9.  Back to cited text no. 17
    
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Martin ET, Kaye KS, Knott C, Nguyen H, Santarossa M, Evans R, et al. Diabetes and risk of surgical site infection: A systematic review and meta-analysis. Infect Control Hosp Epidemiol 2016;37:88-99.  Back to cited text no. 18
    
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Nolan MB, Martin DP, Thompson R, Schroeder DR, Hanson AC, Warner DO Association between smoking status, preoperative exhaled carbon monoxide levels, and postoperative surgical site infection in patients undergoing elective surgery. JAMA Surg 2017;152: 476-83.  Back to cited text no. 19
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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